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Age-related differences in breast cancer
mortality according to race/ethnicity,
insurance, and socioeconomic status
Yazmin San Miguel1, Scarlett Lin Gomez2,3, James D. Murphy1, Richard B. Schwab1, Corinne McDaniels-Davidson4,
Alison J. Canchola2, Alfredo A. Molinolo1, Jesse N. Nodora1,5 and Maria Elena Martinez1,5*


Background: We assessed breast cancer mortality in older versus younger women according to race/ethnicity,
neighborhood socioeconomic status (nSES), and health insurance status.

Methods: The study included female breast cancer cases 18 years of age and older, diagnosed between 2005 and
2015 in the California Cancer Registry. Multivariable Cox proportional hazards modeling was used to generate
hazard ratios (HR) of breast cancer specific deaths and 95% confidence intervals (CI) for older (60+ years) versus
younger (< 60 years) patients separately by race/ethnicity, nSES, and health insurance status.

Results: Risk of dying from breast cancer was higher in older than younger patients after multivariable adjustment,
which varied in magnitude by race/ethnicity (P-interaction< 0.0001). Comparing older to younger patients, higher
mortality differences were shown for non-Hispanic White (HR = 1.43; 95% CI, 1.36–1.51) and Hispanic women (HR =
1.37; 95% CI, 1.26–1.50) and lower differences for non-Hispanic Blacks (HR = 1.17; 95% CI, 1.04–1.31) and Asians/
Pacific Islanders (HR = 1.15; 95% CI, 1.02–1.31). HRs comparing older to younger patients varied by insurance status
(P-interaction< 0.0001), with largest mortality differences observed for privately insured women (HR = 1.51; 95% CI,
1.43–1.59) and lowest in Medicaid/military/other public insurance (HR = 1.18; 95% CI, 1.10–1.26). No age differences
were shown for uninsured women. HRs comparing older to younger patients were similar across nSES strata.

Conclusion: Our results provide evidence for the continued disparity in Black-White breast cancer mortality, which
is magnified in younger women. Moreover, insurance status continues to play a role in breast cancer mortality, with
uninsured women having the highest risk for breast cancer death, regardless of age.

Keywords: Mortality, Younger and older age, Breast cancer

According to American Cancer Society, the 10-year prob-
ability of developing breast cancer increases with age,
from 0.5% in women 30 years of age to 3.9% in those age
70 and the median age of diagnosis is 62 [1]. In 2015,

58.0% of all incident breast cancers in the United States
(U.S.) occurred in women over the age of 60 [2]. With a
rising number of older women in the U.S., understanding
the breast cancer burden, including survival outcomes in
these women is important. While different age cut-offs are
used to define younger versus older patients, it is well
recognized that women less than 40 years of age are mo

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Breast Cancer Knowledge, Attitude, and Screening Practices Breast Cancer Knowledge, Attitude, and Screening Practices
among Hispanic/Latino Women among Hispanic/Latino Women

Harrindra Seepersaud
Walden University

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Harrindra Seepersaud


Patients’ preferences for post-treatment breast
cancer follow-up in primary care vs. secondary
care: a qualitative study

Carriene Roorda MSc,* Geertruida H. de Bock PhD,† Christian Scholing MD MSc,‡
Klaas van der Meer MD PhD,§ Marjolein Y. Berger MD PhD,¶ Marlieke de Fouw MD MSc**
and Annette J. Berendsen MD PhD††
*Epidemiologist, PhD candidate, Department of General Practice, Department of Epidemiology, University of Groningen,

University Medical Center Groningen,†Epidemiologist, Professor in Oncological Epidemiology, Department of Epidemiology,

University of Groningen, University Medical Center Groningen, ‡Emergency Medicine Registrar, §Professor in General Practice

Medicine, Former Head of the Department of General Practice, ¶Professor in General Practice Medicine, Head of the Depart-

ment of General Practice, **Physician in Tropical Medicine and International Health and ††Assistant Professor, Department of

General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

Carriene Roorda MSc

Department of General Practice

University of Groningen

University Medical Center Groningen

P.O. Box 196

9700 AD Groningen

The Netherlands

E-mail: [email protected]

Accepted for publication

22 February 2014

Keywords: breast cancer, follow-up,

interviews, patients’ preferences,

primary care, qualitative study


Objective To explore patients’ preferences for follow-up in primary

care vs. secondary care.

Methods A cross-sectional design was employed, involving semi-

structured interviews with 70 female patients with a history of

early-stage breast cancer. Using descriptive content analysis, inter-

view transcripts were analysed independently and thematically by

two researchers.

Findings Patients expressed the strongest preference for annual vis-

its (31/68), a schedule with a decreasing frequency over time (27/

68), and follow-up > 10 years, including lifelong follow-up (20/64).
The majority (56/61) preferred to receive follow-up care from the

same care provider over time, for reasons related to a personal

doctor–patient relationship and the physician’s knowledge of the
patient’s history. About 75% (43/56) preferred specialist follow-up

to other follow-up models. However, primary care-based follow-up

would be accepted by 57% (39/68) provided that there is good

communication between GPs and specialists, and sufficient knowl-

edge among GPs about follow-up. Perceived benefits of primary

care-based follow-up referred to the personal nature

Understanding the Breast Cancer Experience of Survivors:
a Qualitative Study of AfricanAmericanWomen in Rural Eastern
North Carolina

Essie Torres1 & Crystal Dixon2 & Alice R. Richman3

Published online: 16 April 2015
# American Association for Cancer Education 2015

Abstract The purpose of this study is to gain an in-depth
understanding of African American breast cancer survivors’
experiences, barriers and facilitators in accessing breast cancer
treatment, and challenges in adherence to follow-up care. We
conducted seven focus groups with 32 African American
women with breast cancer in three rural counties in eastern
North Carolina during August–November 2013. Surveys
were also utilized to gather basic demographic and breast
health history information. Thematic analysis was performed
using the immersion crystallization approach. Several com-
mon areas of life affected by breast cancer included faith and
support networks, psychosocial well-being, and quality of
care issues. Faith in God was an important coping mechanism
essential to all women in the study and a critical facilitator in
survivorship. Support networks consisted of family, church-
family, friends, and co-workers. The concept of fear included
the discovery of breast cancer and fear of death, negative side
effects of treatment, and social stigma of having breast cancer.
Factors that influenced provider-patient relationship were age
of provider, perceived lack of empathy, and providers leaving
during treatment. Participants also expressed their lack of
knowledge regarding a number of the side effects they were
experiencing during and after their treatment. Results of this
study contribute to the assessment of potential coping

mechanisms used by African American breast cancer survi-
vors (i.e., spirituality, positive attitudes, and support networks)
that can potentially be effective and have a positive impact on
the adjustment of life for survivors.

Keywords African American . Breast cancer . Eastern North


Breast cancer is the most commonly diagnosed cancer and the
second most common cause of cancer death among African
American women [1, 2]. Although breast cancer mortality
rates have been steadily decreasing, African American women
have the highest death rate and shortest survival of any racial
and ethnic group in the USA for breast cancers [1, 2]. The
overall 5-year survival rate for breast cancer diagnosis from
2002 to 2008 among African American women was 78 %,
compared to 90 % among Caucasian women [1, 2]. When
looking at the burden of female breast cancer in North
Carolina 2004–2008, the average crude incidence rate for
breast cancer in eastern North Carolina (ENC) was 11 %
greater (expressed as a ratio) compared to the rest of North
Carolina (RNC) (201.5 per 100,000 women compared to
181.4 per 100,000 women) [3]. Similarly, the average crude
mortality rate fo

The role of country of birth, and genetic and self-identified ancestry,
in obesity susceptibility among African and Hispanic Americans

Abhishek Vishnu,1,2 Gillian M Belbin,2,3 Genevieve L Wojcik,4 Erwin P Bottinger,2 Christopher R Gignoux,5

Eimear E Kenny,2,4,6,7 and Ruth JF Loos1,2,8

1The Genetics of Obesity and Related Metabolic Disease Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA; 2The Charles Bronfman
Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; 3Department of Genetics and Genomic Sciences, Icahn
School of Medicine at Mount Sinai, New York, NY, USA; 4Department of Biomedical Data Science, School of Medicine, Stanford University, Palo Alto, CA,
USA; 5Division of Biomedical Informatics and Personalized Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora,
CO, USA; 6The Icahn Institute of Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; 7The Center of Statistical
Genetics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; and 8The Mindich Child Health and Development Institute, Icahn School of Medicine
at Mount Sinai, New York, NY, USA

Background: African Americans (AAs) and Hispanic/Latinos
(HLs) have higher risk of obesity than European Americans,
possibly due to differences in environment and lifestyle, but also
reflecting differences in genetic background.
Objective: To gain insight into factors contributing to BMI (in
kg/m2) and obesity risk (BMI ≥ 30) among ancestry groups, we
investigate the role of self-reported ancestry, proportion of genetic
African ancestry, and country of birth in 6368 self-identified AA
and 7569 HL participants of the New York–based BioMe Biobank.
Methods: AAs and HLs are admixed populations that trace their
genetic ancestry to the Americas, Africa, and Europe. The proportion
of African ancestry (PAA), quantified using ADMIXTURE, was
higher among self-reported AA (median: 87%; IQR: 79–92%) than
among HL (26%; 15–41%) participants. Approximately 18% of AA
and 59% of HL participants were non–US-born.
Results: Because of significant differences between sexes
(PPAA∗sex interaction = 4.8 × 10−22), we considered women and men
separately. Among women, country of birth and genetic ancestry
contributed independently to BMI. US-born women had a BMI 1.99
higher than those born abroad (P = 7.7 × 10−25). Every 10% increase
in PAA was associated with a BMI 0.29 higher (P = 7.1 × 10−10).
After accounting for PAA and country of birth, the contribution
of self-reported ancestry was small (P = 0.046). The contribution
of PAA to higher BMI was significantly more pronounced among
US-born (0.35/10%PAA, P = 0.003) than among non–US-born
(0.26/10%PAA, P = 0.01) women (PPAA∗sex interaction = 0.004). In
contrast, among men, only US-born status influenced BMI. US-born
men had a BMI 1.33 higher tha

Disparities in breast cancer incidence, mortality, and quality of
care among African American and European American women in
South Carolina

Marsha E Samson, MSPH, MHSA1,2, Nancy G Porter, MS1,2, Deborah M. Hurley, MSPH3,
Swann A Adams, PhD1,2,4, and Jan M. Eberth, PhD1,2

1Cancer Prevention and Control Program, Arnold School of Public Health, University of South
Carolina, Columbia SC

2 Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of
South Carolina, Columbia SC

3 SC Central Cancer Registry, Department of Health & Environmental Control, Columbia, SC

4 College of Nursing, University of South Carolina, Columbia, SC


Breast cancer is the most frequently diagnosed cancer among women and the second-leading

cause of cancer death in United States women. African Americans and other minorities in the

United States suffer lower survival and worse prognosis than European Americans despite

European Americans having a much higher incidence of the disease. Adherence to breast cancer

treatment–quality measures is limited, particularly when the data are stratified by race/ethnicity.

We aimed to examine breast cancer incidence and mortality trends in South Carolina by race and

explore possible racial disparities in the quality of breast cancer treatment received in South

Carolina. African Americans have high rates of mammography and clinical breast exam

screenings yet suffer lower survival compared to European Americans. For most treatment-quality

metrics, South Carolina fairs well in comparison to the United States as a whole; however, South

Carolina hospitals overall lag behind SC COC-accredited hospitals for all measured quality

indicators including needle biopsy utilization, breast-conserving surgeries, and timely use of

radiation therapy. Accreditation may a have a major role in increasing the standard of care related

to breast cancer diagnosis and treatment. These descriptive findings may provide significant

insight for future interventions and policies aimed at eliminating racial/ethnic disparities in health

outcomes. Further risk-reduction approaches are necessary to reduce minority group mortality

rates, especially among African-American women.


Breast cancer is the most frequently diagnosed cancer among women and the second-leading

cause of cancer death in United States (US) women. The Surveillance, Epidemiology, and

End Results (SEER) program estimates that over 230,000 new cases of breast cancer will be

diagnosed in 2015, and 40,000 women will die from breast cancer in 2014.[1] However,

large racial disparities exist within these statistics. African Americans (AAs) and other



Combining quantitative and qualitative
breast density measures to assess breast
cancer risk
Karla Kerlikowske1,2,3*, Lin Ma3, Christopher G. Scott4, Amir P. Mahmoudzadeh5, Matthew R. Jensen4,
Brian L. Sprague6, Louise M. Henderson7, V. Shane Pankratz8, Steven R. Cummings9, Diana L. Miglioretti10,11,
Celine M. Vachon4 and John A. Shepherd5


Background: Accurately identifying women with dense breasts (Breast Imaging Reporting and Data System
[BI-RADS] heterogeneously or extremely dense) who are at high breast cancer risk will facilitate discussions of
supplemental imaging and primary prevention. We examined the independent contribution of dense breast
volume and BI-RADS breast density to predict invasive breast cancer and whether dense breast volume combined
with Breast Cancer Surveillance Consortium (BCSC) risk model factors (age, race/ethnicity, family history of breast
cancer, history of breast biopsy, and BI-RADS breast density) improves identifying women with dense breasts at
high breast cancer risk.

Methods: We conducted a case-control study of 1720 women with invasive cancer and 3686 control subjects. We
calculated ORs and 95% CIs for the effect of BI-RADS breast density and Volpara™ automated dense breast volume
on invasive cancer risk, adjusting for other BCSC risk model factors plus body mass index (BMI), and we compared
C-statistics between models. We calculated BCSC 5-year breast cancer risk, incorporating the adjusted ORs
associated with dense breast volume.

Results: Compared with women with BI-RADS scattered fibroglandular densities and second-quartile dense breast
volume, women with BI-RADS extremely dense breasts and third- or fourth-quartile dense breast volume (75% of
women with extremely dense breasts) had high breast cancer risk (OR 2.87, 95% CI 1.84–4.47, and OR 2.56, 95% CI
1.87–3.52, respectively), whereas women with extremely dense breasts and first- or second-quartile dense breast
volume were not at significantly increased breast cancer risk (OR 1.53, 95% CI 0.75–3.09, and OR 1.50, 95% CI 0.82–2.
73, respectively). Adding continuous dense breast volume to a model with BCSC risk model factors and BMI
increased discriminatory accuracy compared with a model with only BCSC risk model factors (C-statistic 0.639, 95%
CI 0.623–0.654, vs. C-statistic 0.614, 95% CI 0.598–0.630, respectively; P < 0.001). Women with dense breasts and
fourth-quartile dense breast volume had a BCSC 5-year risk of 2.5%, whereas women with dense breasts and first-
quartile dense breast volume had a 5-year risk ≤ 1.8%.

Conclusions: Risk models with automated dense breast volume combined with BI-RADS breast density may better
identify women with dense breasts at high breast cancer risk than risk models with either measure alone.

Keywords: Breast density, Breast cancer risk, Dense volume

* Correspondence:


Breast cancer (BC) is a heterogeneous disease featuring distinct histological, molecular

and clinical phenotypes. Although traditional classification systems utilising

clinicopathological and few molecular markers are well-established and validated they

remain insufficient to reflect the diverse biological and clinical heterogeneity of BC.

Advancements in high-throughput molecular techniques and bioinformatics have

contributed to the improved understanding of BC biology, refinement of molecular

taxonomies and the development of novel prognostic and predictive molecular assays.

Application of such technologies is already underway, and is expected to change the way

we manage BC. Despite the enormous amount of work that has been carried out to develop

and refine BC molecular prognostic and predictive assays, molecular testing is still in

evolution. Pathologists should be aware of the new technology and be ready for the

challenge. In this review, we provide an update on the application of molecular techniques

with regard to BC diagnosis, prognosis and outcome prediction. Current contribution of the

emerging technology to our understanding of BC is also highlighted.



Historically breast cancer (BC) was classified based on clinicopathological features mainly

tumour stage, and grade. Other morphological features such as histological type,

proliferation status and lymphovascular invasion are also recognised as important

morphological prognostic variables that reflect tumour biology (1, 2). Over time,

knowledge about BC biology has significantly increased and led to the understanding that

BC represents a heterogeneous group of tumours and that tumour behaviour and response

to therapy is determined by the underlying bi

PU39CH07_Hiatt ARI 10 February 2018 9:7

Annual Review of Public Health

Environmental Determinants
of Breast Cancer
Robert A. Hiatt1 and Julia Green Brody2
1Department of Epidemiology and Biostatistics and Helen Diller Family Comprehensive
Cancer Center, University of California, San Francisco, California 94158, USA;
email: [email protected]
2Silent Spring Institute, Newton, Massachusetts 02460, USA; email: [email protected]

Annu. Rev. Public Health 2018. 39:113–33

First published as a Review in Advance on
January 12, 2018

The Annual Review of Public Health is online at

Copyright c© 2018 Robert A. Hiatt & Julia Green
Brody. This work is licensed under a Creative
Commons Attribution 4.0 International License,
which permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited. See credit lines of
images or other third-party material in this article
for license information


epidemiology, toxicology, chemical toxicants, social determinants,
endocrine, disrupting chemicals


In the United States, breast cancer is the most common invasive malignancy
and the second most common cause of death from cancer in women. Re-
productive factors, estrogen, and progesterone have major causal roles, but
concerns about other potential causes in the external environment continue
to drive research inquiries and stimulate calls for action at the policy level.
The environment is defined as anything that is not genetic and includes so-
cial, built, and chemical toxicant aspects. This review covers the scope of
known and suspected environmental factors that have been associated with
breast cancer and illustrates how epidemiology, toxicology, and mechanistic
studies work together to create the full picture of environmental effects on
this malignancy. Newer approaches to risk-related evaluations may allow this
field to move forward and more clearly delineate actionable environmental
causes of this most common of cancers in women.


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The Journal of Nutrition

Nutritional Epidemiology

Dietary Modifications, Weight Loss, and
Changes in Metabolic Markers Affect Global
DNA Methylation in Hispanic, African American,
and Afro-Caribbean Breast Cancer Survivors1,2

Lissette Delgado-Cruzata,3,8 Wenfei Zhang,4 Jasmine A McDonald,5 Wei Yann Tsai,4 Cristina Valdovinos,5

Laura Falci,5 Qiao Wang,3 Katherine D Crew,5–7 Regina M Santella,3,6 Dawn L Hershman,5–7

and Heather Greenlee5,6*

Departments of 3Environmental Health Sciences, 4Biostatistics, and 5Epidemiology, Mailman School of Public Health, 6Herbert Irving

Comprehensive Cancer Center, and 7Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY;

and 8Department of Sciences, John Jay College of Criminal Justice, City University of New York, New York, NY


Background: Lower levels of global DNA methylation in tissue and blood have been associated with increased cancer

risk. Conversely, cross-sectional analyses of healthier lifestyle patterns have been associated with higher levels of

global DNA methylation.

Objective: In this trial, we explored the associations between changes in lifestyle modifications (diet, weight loss),

metabolic markers, and global epigenetic biomarkers in white blood cells.

Methods: Study participants were Hispanic, African American, and Afro-Caribbean overweight and sedentary female breast

cancer survivors (n = 24) who participated in a larger randomized, crossover, pilot study of a 6-mo weight loss intervention and

who had available blood specimens. Anthropometric measures, a food-frequency questionnaire, and peripheral blood were

collected at baseline, 6 mo, and 12 mo. Plasma samples were analyzed for metabolic markers (insulin, glucose). We

measured DNA methylation of long interspersed nucleotide element 1 (LINE-1) and satellite 2 by pyrosequencing and

MethyLight, respectively, and global DNA methylation by the luminometric methylation assay (LUMA).

Results: DNA methylation of LINE-1 was statistically significantly elevated at 6 mo [75.5% vs. 78.5% (P < 0.0001)] and 12 mo [75.5%

vs. 77.7%(P<0.0001)], comparedtobaseline.Overa12-moperiod,changesinpercentagebodyfatandplasmaglucoseconcentrations

were positively associated with LINE-1 DNA methylation (b = 0.19, P = 0.001) and LUMA DNA methylation levels (b = 0.24, P = 0.02),

respectively. Similarly, 12-mo changes in dietary measures such as vegetable (b = 0.009, P = 0.048), protein (b = 0.04, P = 0.001), and

total caloric (b = 0.05, P = 0.01) intake were positively associated with changes in LUMA DNA methylation, as was intake of fruit

positively associated with changes in LINE-1 DNA methylation (b = 0.004, P = 0.02).

Conclusions: Our hypothesis-generating resul

Cancer Statistics for African Americans, 2016:
Progress and Opportunities in Reducing Racial Disparities

Carol E. DeSantis, MPH1; Rebecca L. Siegel, MPH2; Ann Goding Sauer, MPH3;
Kimberly D. Miller, MPH4; Stacey A. Fedewa, MPH5; Kassandra I. Alcaraz, PhD, MPH6;

Ahmedin Jemal, DVM, PhD7

In this article, the American Cancer Society provides the estimated number of new cancer cases and deaths for blacks in the

United States and the most recent data on cancer incidence, mortality, survival, screening, and risk factors for cancer. Inci-

dence data are from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American

Association of Central Cancer Registries, and mortality data are from the National Center for Health Statistics. Approximately

189,910 new cases of cancer and 69,410 cancer deaths will occur among blacks in 2016. Although blacks continue to have

higher cancer death rates than whites, the disparity has narrowed for all cancers combined in men and women and for lung and

prostate cancers in men. In contrast, the racial gap in death rates has widened for breast cancer in women and remained level

for colorectal cancer in men. The reduction in overall cancer death rates since the early 1990s translates to the avoidance of

more than 300,000 deaths among blacks. In men, incidence rates from 2003 to 2012 decreased for all cancers combined (by

2.0% per year) as well as for the top 3 cancer sites (prostate, lung, and colorectal). In women, overall rates during the corre-

sponding time period remained unchanged, reflecting increasing trends in breast cancer combined with decreasing trends in

lung and colorectal cancer rates. Five-year relative survival is lower for blacks than whites for most cancers at each stage of

diagnosis. The extent to which these disparities reflect unequal access to health care versus other factors remains an active

area of research. Progress in reducing cancer death rates could be accelerated by ensuring equitable access to prevention,

early detection, and high-quality treatment. CA Cancer J Clin 2016;66:290-308. VC 2016 American Cancer Society.

Keywords: cancer statistics, health disparities, incidence, mortality, survival, risk factors, trends