Racial disparities in breast cancer mortality in a multiethnic cohort in the Southeast.

BACKGROUND: Although much has been done to examine those factors associated with higher mortality among African American women, there is a paucity of literature that examines disparities among rural African Americans in South Carolina. The purpose of this investigation was to examine the association of race and mortality among breast cancer patients in a large cohort residing in South Carolina for which treatment regimens are standardized for all patients. METHODS: Subjects included 1209 women diagnosed with breast cancer between 2000 and 2002 at a large, local hospital containing a comprehensive breast center. Kaplan-Meier survival curves were calculated to determine survival rates among African American and European American women, stratified by disease stage or other prognostic characteristics. Adjusting for various characteristics, Cox multivariate survival models were used to estimate the hazard ratio (HR). RESULTS: The 5-year overall all-cause mortality survival proportion was ∼78% for African American women and ∼89% for European American women, P < 0.01. In analyses of subpopulations of women with identical disease characteristics, African American women had significantly higher mortality than European American women for the same type of breast cancer disease. In multivariate models, African American women had significantly higher mortality than European American women for both breast cancer-specific death (HR, 2.41; 95% confidence interval [CI], 1.21-4.79) and all-cause mortality (HR, 1.42; 95% CI, 1.06-1.89). CONCLUSIONS: African American women residing in rural South Carolina had lower survival for breast cancer even after adjustment for disease-related prognostic characteristics. These findings support health interventions among African American breast cancer patients aimed at tertiary prevention strategies or further down-staging of disease at diagnosis.

Sustained remission with the kinase inhibitor sorafenib in stage IV metastatic adrenocortical carcinoma.

OBJECTIVE: To report our experience using kinase inhibition therapy with sorafenib in a patient with advanced adrenocortical carcinoma. METHODS: We describe the clinical, laboratory, and radiologic findings of the study patient and discuss the clinical course with sorafenib therapy. RESULTS: A 56-year-old woman presented with rapid development of virilization, cushingoid features, hypertension, weight gain, and abdominal distension. An 8-cm left adrenal lesion was found on computed tomography, removed surgically, and confirmed as adrenal carcinoma on pathologic examination. Postoperative scanning revealed metastases to both lungs and the liver that were confirmed by fine-needle biopsy, thus establishing stage IV disease. Treatment with the adrenolytic agent mitotane failed to halt disease progression. A trial of sorafenib resulted in regression and eventual resolution of bilateral metastatic lung lesions, reduction in size of the hepatic lesion, normalization of androgen hypersecretion, and marked clinical improvement. The radiologic and biochemical remission on sorafenib has continued for 28 months. CONCLUSION: Multiple kinase inhibitors such as sorafenib provide targeted oncologic treatment and may be effective in treating advanced adrenal cancer.

Breast cancer disparities in South Carolina: early detection, special programs, and descriptive epidemiology.

A discrepancy exists between mortality and incidence rates between African-American and European-American women in South Carolina. The relationship between tumor grade and the estrogen/ progesterone receptor status is different in African-American and European-American women. African-American women with breast cancer should be encouraged to participate in clinical trials, with the goal of identifying biological factors that might facilitate the detection of tumors at an earlier stage and the development of more effective therapies. The most important of our goals is to design studies to reduce the incidence of the disease and interventions to improve survival and quality of life. The importance of participation in research cannot be overstated. Reproductive factors such as early pregnancy and multiple pregnancies are strongly related to breast cancer risk, however, promotion of these factors as a "prevention strategy," clearly does not lead to cogent, comprehensive public health messages. Data from ecological and migrant studies point clearly to other factors that may be important such as diet. Additional research around primary prevention strategies is needed. In addition, yearly mammograms (secondary prevention) are recommended for women over 50 years old or those with relatives who have developed breast cancer. The Best Chance Network, as a provider of screenings to low-income, uninsured women, has helped to narrow the racial gap in screening that otherwise might exist (see Figures 3 and 4) to a large extent. The determination for timing of surgery after diagnosis needs additional consideration. For example, factors such as effective screening in younger women, timing of screening and surgery in relationship to the ovulatory cycle, and season of screening and surgery may have a great impact on outcomes and may offer some insight into the process of carcinogenesis and therapeutic efficacy. Research into this area is so novel that the impact on possible ethnic disparities is completely unknown. The South Carolina Cancer Disparities Community Network (SCCDCN) has identified the following areas as potential research foci: Identification of small media interventions as an effective strategy to motivate targeted populations, especially those least likely to seek screening for breast cancer and those least likely to participate in research programs (African-Americans). Utilization of breast cancer survivors, self-identified as community natural helpers, can share their experiences with their church congregation. A replication of such a program in South Carolina has great potential because of the strong presence of the church, especially in rural parts of the state. Programs that closely integrate religion with screening women for breast cancer are promising in this state. Development of a mammography registry whereby information on all mammography procedures would be collected within a single database system (much like a central cancer registry). This would aid in identifying population groups that could be targeted for special programs and in the examination and exploration of the most appropriate modalities of detection. Such a resource could also be a useful tool to encourage screening. Thus, this focus area has the potential to benefit epidemiologic and health promotion research on many different levels. Additional breast cancer screening methods should not be overlooked as a potential research focus. Mammography is not the only valid screening method for breast cancer. Magnetic resonance imaging has shown some promise for screening among women with a genetic predisposition for cancer. Another promising avenue is thermography. Because detection rates may depend on age, ethnicity, and breast mammographic characteristics, women for whom regular screening methods do not detect their cancers (e.g. older age, African-American ethnicity, dense breasts) must be identified and other screening methods promoted within these populations. The above-mentioned mammography registry would support this type of research.

Racial disparities in female breast cancer in South Carolina: clinical evidence for a biological basis.

OBJECTIVE: Racial disparities in breast cancer outcomes are well documented: African-American (AA) women have markedly poorer survival than do European-American (EA) women. A growing literature suggests that AA women have, on average, tumors of more aggressive histopathology, even if discovered early. We investigated this in our South Carolina population. METHODS: Tumor registry data for 1687 AA and EA women with breast cancers newly diagnosed during 2000-2002 at the two Palmetto Health hospitals in Columbia, SC, were reviewed. RESULTS: Corresponding to our regional population, 31% of cancers were in AA women. In both racial groups, 19% were in situ. Among women with invasive cancers, AA women had significantly earlier age at diagnosis than did EA women. Fewer AA women had lobular carcinoma (p = 0.001) or Her-2 over-expressing disease (7 versus 19%, p = 0.001). Significantly more AA women had high-grade cancer, larger tumors, axillary metastases and ER negative/PR negative tumors. After controlling for T-stage, AA women were significantly more likely to have high-grade and/or ER negative disease. Detection of invasive cancers by screening mammogram was less frequent in AA women (40 versus 53%, p < 0.000), and in small ER negative cancers. CONCLUSIONS: At diagnosis, breast cancers in AA women tend to have the hallmarks of more aggressive and less treatable disease, even in small tumors, a pattern resembling that of breast cancers in younger EA women. Whatever the causes, these observations suggest breast cancer is biologically different in AA women. This may contribute substantially to the poorer outcomes in African-American women.

Breast cancer care: changing community standards.

A community hospital-based program was developed to improve breast cancer care in the community. A consensus was developed for what should be optimal care; a database was established to document the care being delivered in the community; and the data were analyzed to document changes in practice patterns over time. The major clinical benefits to patients included a significant improvement in needle biopsy rates, decreased utilization of second operative procedures, increased breast conservation surgery, conformity to guidelines for adjuvant chemotherapy administration, and a sizable increase in discovery of small breast cancers by screening mammography.

Can hyperbaric oxygen therapy reduce breast cancer treatment-related lymphedema? A pilot study.

OBJECTIVE: Arm lymphedema after surgery or radiation for breast cancer is common, causing pain and limitation of activities. Previous reports of hyperbaric oxygen (HBO) therapy for breast edema led us to consider the use of HBO therapy for arm lymphedema. METHODS: Ten healthy postmenopausal women (age 58 +/- 5.7 years) with persistent (9.4 years +/- 9.1 years) arm lymphedema following breast cancer surgery and radiation (n = 10) plus chemotherapy (n = 7) received 20 HBO treatments (90 minutes at 2.0 ATA five times a week for 4 weeks). End points included changes in upper extremity volume, platelet counts, plasma levels of vascular endothelial growth factor (VEGF), and lymph angiogenic-associated vascular endothelial growth factor-C (VEGF-C). Lymphedema volume (LV) was defined as the volume of the unaffected arm subtracted from the volume of the affected arm. RESULTS: We observed a 38% average reduction in hand lymphedema (-7.4 ml, 11.6 SD, range -30-+8 ml, p = 0.076, 95% confidence interval -15.7-0.9 ml) at the end of HBO, which was independent of changes in body weight. For those who benefited (n = 8), the reduction was persistent from the end of treatment to a final measurement an average of 14.2 months after the last HBO treatment. However, total LV did not change significantly. VEGF-C increased from baseline (p = 0.004) before treatment 20, suggesting HBO had begun to stimulate this growth factor. CONCLUSIONS: Future studies should explore the effects of a greater number of HBO treatments on lymphedema, with more patients.

The use of FISH on breast core needle samples for the presurgical assessment of HER-2 oncogene status.

HER-2 status has been used in breast carcinoma as a prognostic marker to predict drug response and to select patients for trastuzumab treatment. Since immunohistochemistry (IHC) is thought to be less reliable, HER-2 testing with FISH is preferred. The analysis of HER-2 is usually performed on formalin-fixed paraffin tissue sections obtained from surgery. The use of paraffin sections is very time consuming and labor intensive. The objectives of this study were to (1) develop a simple and quick FISH protocol using touch imprints of breast core needle biopsies, eliminating the deparaffinization and pretreatment; and (2) make the HER-2 status available at the presurgical multidisciplinary treatment planning conference. A total of 50 core samples of breast carcinoma were obtained from image-guided core needle biopsy. Both FISH and IHC data were available for 46 cases. Forty-four of 46 cases (95.7%) were consistent. Two IHC 2+ cases were nonamplified (ratios of 0.99 and 1.09). It is expected that, in the near future, additional molecular markers will be used before surgery when the overall treatment plan is being developed. We conclude that HER-2 gene analysis by FISH on breast touch imprints is easily done and is a useful and reliable technique.