Racial and ethnic disparities in breast cancer survival: critical appraisal of the data emerging from the randomized TAILORx.
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ABSTRACT:
SUBMITTER: Franceschini G
PROVIDER: S-EPMC9816834 | biostudies-literature | 2022 Dec
REPOSITORIES: biostudies-literature
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Racial and ethnic disparities in breast cancer survival: critical appraisal of the data emerging from the randomized TAILORx.
Franceschini Gianluca G Orlandi Armando A
Annals of translational medicine 20221201 23
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Project description:ImportanceWhether racial and ethnic disparities in locoregional recurrence (LRR) exist among patients with similar access to care treated in randomized clinical trials is unknown.ObjectiveTo examine racial and ethnic differences in LRR among patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (ERBB2 [formerly HER2 or HER2/neu])-negative, node-negative breast cancer enrolled in the Trial Assigning Individualized Options for Treatment (TAILORx).Design, setting, and participantsThis unplanned retrospective post hoc analysis examined a prospective multicenter clinical trial population of women with breast cancer enrolled between 2006 and 2010, with 9 years of follow-up. The TAILORx investigators randomized patients to treatment based on their Oncotype DX recurrence score, including endocrine therapy alone (recurrence score <11), endocrine therapy alone vs chemotherapy followed by endocrine therapy (recurrence score 11-25), or chemotherapy followed by endocrine therapy (recurrence score >25). Patients with unknown race and ethnicity or lack of follow-up were excluded from this analysis. Data analysis was performed between December 2021 and March 2022.Main outcome and measuresLocoregional recurrence was defined as ipsilateral in breast, skin, chest wall, or regional nodal recurrence without concurrent distant recurrence, and was stratified by racial and ethnic group. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards regression models were used for survival analyses.ResultsOf the 10 273 women enrolled in TAILORx, this analysis included 9369 with T1-2N0 HR-positive, ERBB2-negative breast cancer. Of these patients, 428 (4.6%) were Asian, 886 (9.4%) were Hispanic, 676 (7.2%) were non-Hispanic Black (hereinafter Black), and 7406 (78.8%) were non-Hispanic White (hereinafter White). Assigned treatment receipt was high, with a 9.3% (n = 870) crossover of treatment groups and a median endocrine therapy duration of longer than 60 months, ranging from 61.1 to 65.9 months, across racial and ethnic groups. A total of 6818 patients (72.6%) received radiation (6474 [96.1%] after breast-conserving surgery and 344 [13.0%] after mastectomy). At a median follow-up of 94.8 months (range, 1-138 months), 8-year LRR rates were 3.6% (95% CI, 1.6%-5.6%) in Asian patients, 3.9% (95% CI, 2.2%-5.4%) in Black patients, 3.1% in Hispanic patients (95% CI, 1.7%-4.5%), and 1.8% (95% CI, 1.5%-2.3%) in White patients (P < .001). In survival analyses adjusted for patient, tumor, and treatment factors, Asian race (hazard ratio, 1.91 [95% CI, 1.12-3.29]) and Black race (1.78 [1.15-2.77]) were independently associated with LRR. In adjusted survival analyses for breast cancer mortality, LRR was independently associated with increased breast cancer mortality (hazard ratio, 5.71 [95% CI, 3.50-9.31]).Conclusions and relevanceIn this post hoc analysis, racial and ethnic differences in LRR were observed among patients with T1-2N0 HR-positive, ERBB2-negative breast cancer despite high rates of treatment receipt in this clinical trial population, with the highest LRR rates in Asian and Black patients. Further study is needed to understand whether failure to rescue after LRR may contribute to racial disparities in breast cancer mortality.Trial registrationClinicalTrials.gov Identifier: NCT00310180.
| S-EPMC10099173 | biostudies-literature
Project description:ImportanceBlack women in the United States have higher breast cancer (BC) mortality rates than White women. The combined role of multiple factors, including body mass index (BMI), age, and tumor subtype, remains unclear.ObjectiveTo assess the association of race and ethnicity with survival among clinical trial participants with early-stage BC (eBC) according to tumor subtype, age, and BMI.Design, setting, and participantsThis cohort study analyzed survival data, as of November 12, 2021, from participants enrolled between 1997 and 2010 in 4 randomized adjuvant chemotherapy trials: Cancer and Leukemia Group B (CALGB) 9741, 49907, and 40101 as well as North Central Cancer Treatment Group (NCCTG) N9831, legacy groups of the Alliance of Clinical Trials in Oncology. Median follow-up was 9.8 years.ExposuresNon-Hispanic Black and Hispanic participants were compared with non-Hispanic White participants within subgroups of subtype (hormone receptor positive [HR+]/ERBB2 [formerly HER2] negative [ERBB2-], ERBB2+, and HR-/ERBB2-), age (<50, 50 to <65, and ≥65 years), and BMI (<18.5, 18.5 to <25.0, 25.0 to <30.0, and ≥30.0).Main outcomes and measuresRecurrence-free survival (RFS) and overall survival (OS).ResultsOf 9479 participants, 436 (4.4%) were Hispanic, 871 (8.8%) non-Hispanic Black, and 7889 (79.5%) non-Hispanic White. The median (range) age was 52 (19.0-89.7) years. Among participants with HR+/ERBB2- tumors, non-Hispanic Black individuals had worse RFS (hazard ratio [HR], 1.49; 95% CI, 1.04-2.12; 5-year RFS, 88.5% vs 93.2%) than non-Hispanic White individuals, although the global test for association of race and ethnicity with RFS was not significant within any tumor subtype. There were no OS differences by race and ethnicity in any subtype. Race and ethnicity were associated with OS in young participants (age <50 years; global P = .008); young non-Hispanic Black participants (HR, 1.34; 95% CI, 1.04-1.71; 5-year OS, 86.6% vs 92.0%) and Hispanic participants (HR, 1.62; 95% CI, 1.16-2.29; 5-year OS, 86.2% vs 92.0%) had worse OS than young non-Hispanic White participants. Race and ethnicity were associated with RFS in participants with BMIs of 25 to less than 30, with non-Hispanic Black participants having worse RFS (HR, 1.81; 95% CI, 1.23-2.68; 5-year RFS, 83.2% vs 87.3%) than non-Hispanic White participants.Conclusions and relevanceIn this cohort study, racial and ethnic survival disparities were identified in patients with eBC receiving standardized initial care, and potentially at-risk subgroups, for whom focused interventions may improve outcomes, were found.
| S-EPMC10600583 | biostudies-literature
Project description:BackgroundYoung adults diagnosed with colorectal cancer (CRC) comprise a growing, yet understudied, patient population. We estimated 5-year relative survival of early-onset CRC and examined disparities in survival by race-ethnicity in a population-based sample.MethodsWe used the National Cancer Institute's Surveillance, Epidemiology, and End Results program of cancer registries to identify patients diagnosed with early-onset CRC (20-49 years of age) between January 1, 1992, and December 31, 2013. For each racial-ethnic group, we estimated 5-year relative survival, overall and by sex, tumor site, and stage at diagnosis. To illustrate temporal trends, we compared 5-year relative survival in 1992-2002 vs 2003-2013. We also used Cox proportional hazards regression models to examine the association of race-ethnicity and all-cause mortality, adjusting for age at diagnosis, sex, county type (urban vs rural), county-level median household income, tumor site, and stage at diagnosis.ResultsWe identified 33,777 patients diagnosed with early-onset CRC (58.5% White, 14.0% Black, 13.0% Asian, 14.5% Hispanic). Five-year relative survival ranged from 57.6% (Black patients) to 69.1% (White patients). Relative survival improved from 1992-2002 to 2003-2013 for White patients only; there was no improvement for Black, Asian, or Hispanic patients. This pattern was similar by sex, tumor site, and stage at diagnosis. In adjusted analysis, Black (adjusted hazard ratio [aHR], 1.42; 95% confidence interval [CI], 1.36-1.49), Asian (aHR, 1.06; 95% CI, 1.01-1.12), and Hispanic (aHR, 1.16; 95% CI, 1.10-1.21) race-ethnicity were associated with all-cause mortality.ConclusionOur study adds to the well-documented disparities in CRC in older adults by demonstrating persistent racial-ethnic disparities in relative survival and all-cause mortality in patients with early-onset CRC.
| S-EPMC9835097 | biostudies-literature
Project description:BackgroundWomen of color with breast cancer are less likely to undergo post-mastectomy reconstruction compared with White women, but it is unclear whether their perioperative outcomes are worse. The goal of this study was to investigate differences in preoperative comorbidities and postoperative complications by race/ethnicity among women with breast cancer undergoing postmastectomy reconstruction.Study designData were collected from the National Inpatient Sample database of the Healthcare Cost and Utilization Project from 2012 to 2016. Patient demographics, types of reconstruction, comorbid conditions, Charlson-Deyo Combined Comorbidity (CDCC) scores, length of stay (LOS), and perioperative complications were abstracted. Multivariate linear and logistic regression were performed to model LOS and likelihood of postoperative complications, respectively.ResultsCompared with White women (n = 19,730), Black women (n = 3,201) underwent autologous reconstruction more frequently (40.7% vs 28.3%), had more perioperative comorbidities (eg diabetes: 12.9% vs 5.8%), higher CDCC scores (% CDCC ≥ 4: 5.5% vs 2.7%), and longer LOS (median 3 vs 2 days, all p < 0.001). Being Black (vs White: +0.13 adjusted days, 95% CI 0.06 to 0.19) was also associated with longer LOS and an increased likelihood of surgical complications (vs White: odds ratio 1.24, 95% CI 1.09 to 1.42, both p < 0.01), but this association did not persist when outcomes were limited to microsurgical complications.ConclusionDisparities in postmastectomy breast reconstruction between Black and White women extend beyond access to care and include perioperative factors and outcomes. These findings suggest an important opportunity to mitigate inequities in reconstruction through perioperative health optimization and improved access to and co-management with primary care.
| S-EPMC9347225 | biostudies-literature
Project description:Background Recent guidelines have emphasized the use of medical management, early diagnosis, and a multidisciplinary team to effectively treat patients with critical limb ischemia (CLI). Previous literature briefly highlighted the current racial disparities in its intervention. Herein, we analyze the trend over a 14-year time period to investigate whether the disparities gap in CLI management is closing. Methods and Results The National Inpatient Sample was queried between 2005 and 2018 for hospitalizations involving CLI. Nontraumatic amputations and revascularization were identified. Utilization trends of these procedures were compared between races (White, Black, Hispanic, Asian and Pacific Islander, Native American, and Other). Multivariable regression assessed differences in race regarding procedure usage. There were 6 904 562 admissions involving CLI in the 14-year study period. The rate of admissions in White patients who received any revascularization decreased by 0.23% (P<0.001) and decreased by 0.25% (P=0.025) for Asian and Pacific Islander patients. Among all patients, the annual rate of admission in White patients who received any amputation increased by 0.21% (P<0.001), increased by 0.19% (P=0.001) for Hispanic patients, and increased by 0.19% (P=0.012) for the Other race patients. Admissions involving Black, Hispanic, Asian and Pacific Islander, or Other race patients had higher odds of receiving any revascularization compared with White patients. All races had higher odds of receiving major amputation compared with White patients. Conclusions Our analysis highlights disparities in CLI treatment in our nationally representative sample. Non-White patients are more likely to receive invasive treatments, including major amputations and revascularization for CLI, compared with White patients.
| S-EPMC10547355 | biostudies-literature
Project description:AbstractLittle is known about the impact of recent advances in acute myeloid leukemia (AML) treatment on racial/ethnic disparities in survival outcomes. We performed a retrospective cohort study of patients with newly diagnosed AML using data from a nationwide electronic health record-derived deidentified database. Patients were categorized based on their diagnosis date relative to venetoclax approval, as pre-novel therapy era (Pre era; 2014-2018; n = 2998) or post-novel therapy era (Post era; 2019-2022; n = 2098). Patients in the Post era were older and had more comorbidities than Pre era. Non-Hispanic Black (NHB) and Hispanic patients were younger and more likely to have lower socioeconomic status than non-Hispanic White (NHW) patients, with no differences in the distributions of key disease features. After accounting for age and comorbidity, overall survival (OS) was higher in patients in Post era than Pre era (adjusted hazard ratio [aHR], 0.90; 95% confidence interval [CI], 0.83-0.96). In Pre era, NHB had a 22% higher hazard of death than NHW (aHR, 1.22; 95% CI, 1.04-1.43), whereas worse OS was not observed for NHB in Post era (aHR, 0.86; 95% CI, 0.69-1.08; predicted 2-year survival, 45.3% vs 39.9%). Utilization of novel therapeutics in frontline therapy did not differ by race/ethnicity. Among patients receiving venetoclax-based induction, particularly those without TP53, RAS, or FLT3-ITD mutations, results suggested higher OS for NHB than NHW patients (aHR, 0.67; 95% CI, 0.45-1.01). Additional studies are needed to elucidate factors contributing to these observed survival differences and to inform strategies to optimize outcomes for all patients with AML.
| S-EPMC11821405 | biostudies-literature
Project description:BackgroundThird-variable effect refers to the effect from a third-variable that explains an observed relationship between an exposure and an outcome. Depending on whether there is a causal relationship from the exposure to the third variable, the third-variable is called a mediator or a confounder. The multilevel mediation analysis is used to differentiate third-variable effects from data of hierarchical structures.Data collection and analysisWe developed a multilevel mediation analysis method to deal with time-to-event outcomes and implemented the method in the mlma R package. With the method, third-variable effects from different levels of data can be estimated. The method uses multilevel additive models that allow for transformations of variables to take into account potential nonlinear relationships among variables in the mediation analysis. We apply the proposed method to explore the racial/ethnic disparities in survival among patients diagnosed with breast cancer in California between 2006 and 2017, using both individual risk factors and census tract level environmental factors. The individual risk factors are collected by cancer registries and the census tract level factors are collected by the Public Health Alliance of Southern California in partnership with the Virginia Commonwealth University's Center on Society and Health. The National Cancer Institute work group linked variables at the census tract level with each patient and performed the analysis for this study.ResultsWe found that the racial disparity in survival were mostly explained at the census tract level and partially explained at the individual level. The associations among variables were depicted. Conclusion: The multilevel mediation analysis method can be used to differentiate mediation/confounding effects for factors originated from different levels. The method is implemented in the R package mlma.
| S-EPMC9232182 | biostudies-literature
Project description:BackgroundLimited studies have investigated racial/ethnic survival disparities for breast cancer defined by estrogen receptor (ER) and progesterone receptor (PR) status in a multiethnic population.MethodsUsing multivariable Cox proportional hazards models, we assessed associations of race/ethnicity with ER/PR-specific breast cancer mortality in 10,366 California women diagnosed with breast cancer from 1993 to 2009. We evaluated joint associations of race/ethnicity, health care, sociodemographic, and lifestyle factors with mortality.ResultsAmong women with ER/PR+ breast cancer, breast cancer-specific mortality was similar among Hispanic and Asian American women, but higher among African American women [HR, 1.31; 95% confidence interval (CI), 1.05-1.63] compared with non-Hispanic White (NHW) women. Breast cancer-specific mortality was modified by surgery type, hospital type, education, neighborhood socioeconomic status (SES), smoking history, and alcohol consumption. Among African American women, breast cancer-specific mortality was higher among those treated at nonaccredited hospitals (HR, 1.57; 95% CI, 1.21-2.04) and those from lower SES neighborhoods (HR, 1.48; 95% CI, 1.16-1.88) compared with NHW women without these characteristics. Breast cancer-specific mortality was higher among African American women with at least some college education (HR, 1.42; 95% CI, 1.11-1.82) compared with NHW women with similar education. For ER-/PR- disease, breast cancer-specific mortality did not differ by race/ethnicity and associations of race/ethnicity with breast cancer-specific mortality varied only by neighborhood SES among African American women.ConclusionsRacial/ethnic survival disparities are more striking for ER/PR+ than ER-/PR- breast cancer. Social determinants and lifestyle factors may explain some of the survival disparities for ER/PR+ breast cancer.ImpactAddressing these factors may help reduce the higher mortality of African American women with ER/PR+ breast cancer.
| S-EPMC7867638 | biostudies-literature
Project description:BackgroundFor many childhood cancers, survival is lower among non-Hispanic blacks and Hispanics in comparison with non-Hispanic whites, and this may be attributed to underlying socioeconomic factors. However, prior childhood cancer survival studies have not formally tested for mediation by socioeconomic status (SES). This study applied mediation methods to quantify the role of SES in racial/ethnic differences in childhood cancer survival.MethodsThis study used population-based cancer survival data from the Surveillance, Epidemiology, and End Results 18 database for black, white, and Hispanic children who had been diagnosed at the ages of 0 to 19 years in 2000-2011 (n = 31,866). Black-white and Hispanic-white mortality hazard ratios and 95% confidence intervals, adjusted for age, sex, and stage at diagnosis, were estimated. The inverse odds weighting method was used to test for mediation by SES, which was measured with a validated census-tract composite index.ResultsWhites had a significant survival advantage over blacks and Hispanics for several childhood cancers. SES significantly mediated the race/ethnicity-survival association for acute lymphoblastic leukemia, acute myeloid leukemia, neuroblastoma, and non-Hodgkin lymphoma; SES reduced the original association between race/ethnicity and survival by 44%, 28%, 49%, and 34%, respectively, for blacks versus whites and by 31%, 73%, 48%, and 28%, respectively, for Hispanics versus whites ((log hazard ratio total effect - log hazard ratio direct effect)/log hazard ratio total effect).ConclusionsSES significantly mediates racial/ethnic childhood cancer survival disparities for several cancers. However, the proportion of the total race/ethnicity-survival association explained by SES varies between black-white and Hispanic-white comparisons for some cancers, and this suggests that mediation by other factors differs across groups.
| S-EPMC6234050 | biostudies-literature
Project description:Background: We studied the effect of race and ethnicity on disease characteristics and survival in gastrointestinal neuroendocrine tumors. Methods: The Surveillance, Epidemiology, and End Results database was used to select patients with non-pancreatic gastrointestinal neuroendocrine tumors diagnosed between 2004 and 2015. Trends in survival were evaluated among three groups: Hispanic, non-Hispanic White, and non-Hispanic Black. Kaplan-Meier and Cox regression methods were performed to calculate overall survival and cause-specific survival after adjusting for patient and tumor characteristics. Results: A total of 26,399 patients were included in the study: 65.1% were non-Hispanic White, 19.9% were non-Hispanic Black, and 15% were Hispanic. Non-Hispanic White patients were more likely to be male (50.0%, p < 0.001), older than 60 years (48.0%, p < 0.001), and present with metastatic disease (17.7%, p < 0.001). Non-Hispanic White patients had small intestine neuroendocrine tumors, while Hispanic and non-Hispanic Black patients had rectum neuroendocrine tumors as the most common primary site. Hispanic patients had better overall survival, while non-Hispanic Black patients had better cause-specific survival versus non-Hispanic White patients. This finding was confirmed on multivariable analysis where Hispanic patients had improved overall survival compared to non-Hispanic White patients (Hazard ratio (HR): 0.89 (0.81-0.97)), whereas non-Hispanic Black patients had better cause-specific survival compared to non-Hispanic White patients (HR: 0.89 (0.80-0.98)). Conclusions: Race/ethnicity is an independent prognostic factor in patients with gastrointestinal neuroendocrine tumors.
| S-EPMC7602558 | biostudies-literature