Survival differences in breast cancer among racial/ethnic groups: a population-based study.

In women, breast cancer is the most frequent solid tumor and the second leading cause of cancer death. Differences in survival of breast cancer have been noted among racial/ethnic groups, but the reasons are unclear. This report presents the characteristics and the survival experience of four racial/ethnic groups and evaluates the effects of stage, age, histology, and treatment on survival time. The distributions of prognostic factors and treatment among racial/ethnic groups are compared using female breast cancer patients from two population-based registries in Southern California. The main end points are observed survival time and survival by cause of death. The Cox model is used to estimate the relative risk of death in three minority groups compared with non-Hispanic whites, while controlling for several covariates. Breast cancer cases included in this study were 10,937 non-Hispanic whites, 185 blacks, 875 Hispanics, and 412 Asians. The median follow-up period was 76 months (range: 48-132). The median age at diagnosis was 64 years among non-Hispanic whites, 55 years among Hispanics (p = 0.001), 52 years among blacks (p = 0.001), and 50 years among Asians (p = 0. 001). There was more localized disease among non-Hispanic whites (61. 4%) than among blacks (50.8%) and Hispanics (52.2%), but not compared to Asians (59.7%). After controlling for stage, age, histology, treatment, and registry, overall survival significantly differed between non-Hispanic whites and blacks [relative risk (RR) = 2.27, 95% confidence interval (95% CI) 1.82-2.84) and between non-Hispanic whites and Hispanics (RR = 1.18, 95% CI 1.04-1.34). The same results were found for breast cancer death in blacks (RR = 2.32, 95% CI 1.76-3.07) and Hispanics (RR = 1.28, 95% CI 1.10-1.50). We found no difference between Asians and non-Hispanic whites in overall and cancer-related survival. These results show that stage of disease, age at diagnosis, histologic features and treatment for breast cancer differed among racial/ethnic groups. Moreover, black women, in particular, and Hispanic women with breast cancer had a higher risk of death compared to non-Hispanic white women, even after controlling for prognostic factors. These findings underline the necessity of improved screening and access to appropriate treatment among minority women for breast cancer.

Impact of guidelines to alter antitetanus prophylaxis practices and reduce costs in the emergency department.

The objective of this study was to assess the impact of an intervention to modify antitetanus prophylaxis of open wounds. This prospective, before-and-after study was conducted in an emergency department of a large metropolitan hospital. Consecutive patients with open wounds were managed according to the World Health Organization (WHO) guidelines before an intervention, then according to new guidelines afterwards. Locally developed guidelines were introduced and backed up by a teaching program, with emphasis on reducing unwarranted human tetanus immunoglobulins and costs. Serum tetanus antitoxins level was measured in postintervention patients mainly to verify the soundness of the intervention, eventually to complete patients' protection during follow-up, and to derive more reliable recommendations for the future. Main outcome measures included the number of treatments conforming to each set of guidelines, the rate of tetanus immunoglobulin prescriptions, and the cost of each strategy. Two groups of 389 and 459 patients were included. Treatment conforming to guidelines increased from 60% to 79%, undertreatment decreased from 31% to 19%, and overtreatment decreased from 9% to 2% (P < 0.001). Tetanus immunoglobulin prescriptions decreased from 23% to 1% (P < 0.001). On the basis of antitoxins level, 60% of 367 postintervention patients were correctly treated, 29% were overtreated, and 11% were undertreated. Nevertheless, with the WHO guidelines, only 49% would have been correctly treated, 39% would have been overtreated (29% with immunoglobulins), and 12% would have been undertreated (P < 0.001). Costs decreased from $32 to $24 per patient. New guidelines resulted in improved tetanus prophylaxis at reduced costs in an emergency department. Because they rely on immunization history, however, guidelines currently in use are misleading. More reliable recommendations, including a test for tetanus antibody status in some cases, are needed.

Outcome of cord-blood transplantation from related and unrelated donors. Eurocord Transplant Group and the European Blood and Marrow Transplantation Group.

BACKGROUND: Cord-blood banks have increased the use of cord-blood transplantation in patients with hematologic disorders. We have established a registry containing information on the outcome of cord-blood transplantation. METHODS: We sent questionnaires to 45 transplantation centers for information on patients receiving cord-blood transplants from 1988 to 1996. Reports on 143 transplantations, performed at 45 centers, were studied, and the responses were analyzed separately according to whether the donor was related or unrelated to the recipient. RESULTS: Among 78 recipients of cord blood from related donors, the Kaplan-Meier estimate of survival at one year was 63 percent. Younger age, lower weight, transplants from HLA-identical donors, and cytomegalovirus-negative serologic results in the recipient were favorable prognostic factors. Graft-versus-host-disease of at least grade II occurred at estimated rates of 9 percent in 60 recipients of HLA-matched cord blood and 50 percent in 18 recipients of HLA-mismatched cord blood. Neutrophil engraftment was associated with an age of less than six years (P = 0.02) and a weight of less than 20 kg (P = 0.02), and it occurred in 85 percent of patients receiving 37 million or more nucleated cells per kilogram of body weight. Among 65 patients who received cord blood from unrelated donors, the Kaplan-Meier estimate of survival at one year was 29 percent. Cytomegalovirus-negative serologic status in these recipients was associated with improved survival (P = 0.03) and was the most important predictor of graft-versus-host disease (P = 0.04). Neutrophil recovery occurred in 94 percent of the patients who received 37 million or more nucleated cells per kilogram from unrelated donors. CONCLUSIONS: Cord blood is a feasible alternative source of hematopoietic stem cells for pediatric and some adult patients with major hematologic disorders, particularly if the donor and the recipient are related.