Performance of Self-Report to Establish Cancer Diagnoses in Disaster Responders and Survivors, World Trade Center Health Registry, New York, 2001-2007.

OBJECTIVE: Large-scale disasters may disrupt health surveillance systems, depriving health officials and researchers of timely and accurate information needed to assess disaster-related health effects and leading to use of less reliable self-reports of health outcomes. In particular, ascertainment of cancer in a population is ordinarily obtained through linkage of self-reported data with regional cancer registries, but exclusive reliance on these sources following a disaster may result in lengthy delays or loss of critical data. To assess the impact of such reliance, we validated self-reported cancer in a cohort of 59,340 responders and survivors of the World Trade Center disaster against data from 11 state cancer registries (SCRs). METHODS: We focused on residents of the 11 states with SCRs and on cancers diagnosed from September 11, 2001, to the date of their last survey participation. Medical records were also sought in a subset of 595 self-reported cancer patients who were not recorded in an SCR. RESULTS: Overall sensitivity and specificity of self-reported cancer were 83.9% (95% confidence interval [CI] 81.9, 85.9) and 98.5% (95% CI 98.4, 98.6), respectively. Site-specific sensitivities were highest for pancreatic (90.9%) and testicular (82.4%) cancers and multiple myeloma (84.6%). Compared with enrollees with true-positive reports, enrollees with false-negative reports were more likely to be non-Hispanic black (adjusted odds ratio [aOR] = 1.8, 95% CI 1.2, 2.9) or Asian (aOR=2.2, 95% CI 1.2, 4.1). Among the 595 cases not recorded in an SCR, 13 of 62 (21%) cases confirmed through medical records were reportable to SCRs. CONCLUSION: Self-report of cancer had relatively high sensitivity among adults exposed to the World Trade Center disaster, suggesting that self-reports of other disaster-related conditions less amenable to external validation may also be reasonably valid.

Defining care provided for breast cancer based on medical record review or Medicare claims: information from the Centers for Disease Control and Prevention Patterns of Care Study.

BACKGROUND: Description of care patterns is important as evidence-based guidelines increasingly dictate care. We explore the level of agreement between claims and record abstraction for guideline concordant multidisciplinary breast cancer care. METHODS: From the U.S. Centers for Disease Control and Prevention's National Program of Cancer Registries Patterns of Care study, in which medical record abstraction of breast cancer and treatment was accomplished, cases include breast cancer where Medicare claims were available. Components of care were breast-conserving surgery (BCS), mastectomy, node assessment, radiation (RT), and chemotherapy (CTX), including specific chemotherapeutic agents, and combinations. We compared Medicare claims with record abstraction, and measured concordance using the kappa statistic and sensitivity. RESULTS: The study sample consisted of 1762 women with stage 0 to 4 breast cancer. Level of agreement was excellent for surgery type (kappa = 0.84) and CTX (kappa = 0.89); agreement for RT therapy was slightly lower (kappa = 0.79). For standard multicomponent strategies, sensitivities and specificities were high; for example, 88.8%/93.5% for mastectomy plus nodes and 86.6%/95.4% for BCS plus nodes and RT. For selected, standard, multi-agent, adjuvant CTX regimens, sensitivities ranged from 66.3% to 68.8% (kappa 0.63-0.73). CONCLUSIONS: Medicare claims, compared with chart abstraction, is a reliable method for determining patterns of multicomponent care for breast cancer.

Examination of ancestral informative markers and self-reported race with tumor characteristics of breast cancer among Black and White women.

African American (AA) women have a higher mortality from breast cancer (BC) compared to European American (EA) women. This may be due to the higher proportion of AA women with tumors that are diagnosed at more advanced stages and are characterized as being estrogen receptor negative (ER-)/progesterone receptor negative (PR-). Our study sought to determine whether self-reported race and percent African ancestry were associated with BC tumor characteristics. In a multi-center, population-based case-control study of BC, we determined percent African ancestry using ancestry informative markers (AIM) among women self-reporting race as AA or Black. BC tumor characteristics were associated with self-reported race (including a 30 % reduction in ER+/PR+ tumors [95 % confidence interval [CI]: 0.6-0.9] and a 1.5-fold increased risk of high grade [95 % CI: 1.2-1.9] for AA women compared to EA women). AIMs among AA women were not associated with BC tumor characteristics (AA women with ≥95 % versus <80 % African ancestry, odds ratio [OR] = 1.0 for ER+/PR+ [95 % CI: 0.6-1.8] and OR = 0.9 for high-grade tumors [95 % CI: 0.6-1.4]). Similar findings were observed for BC stage. While BC subtypes were associated with self-reported race, BC subtypes were not associated with percent African ancestry. These study results suggest that subtle differences in percent African ancestry are less important than the overall presence of African ancestry in relation to BC tumor characteristics.

Self-reported skin rash or irritation symptoms among World Trade Center Health Registry participants.

OBJECTIVES: We described self-reported skin rash 2 to 3 and 5 to 6 years after 9/11 and examined its association with exposures to 9/11 dust/debris. METHODS: We analyzed a longitudinal study of New York City World Trade Center Health Registry participants who resided or worked in Lower Manhattan or worked in rescue/recovery in two surveys (W1 and W2). RESULTS: Among 42,025 participants, 12% reported post-9/11 skin rash at W1, 6% both times, 16% at W2. Among participants without posttraumatic stress disorder or psychological distress, W1 self-reported post-9/11 skin rash was associated with intense dust cloud exposure (adjusted odds ratio [OR] = 1.6; 95% confidence interval [CI] = 1.3 to 1.9), home/workplace damage (adjusted OR = 1.8; 95% CI, 1.4 to 2.3), and working more than 90 days (adjusted OR = 1.7; 95% CI, 1.3 to 2.2) or 31 to 90 days (adjusted OR = 1.6; 95% CI, 1.3 to 2.1) at the World Trade Center site. CONCLUSIONS: Post-9/11 skin rash may be related to acute and long-term exposure to dust, though subjectivity of skin symptoms may bias findings.

Estrogen-related genes and their contribution to racial differences in breast cancer risk.

Racial differences in breast cancer risk, including the risks of hormone receptor subtypes of breast cancer, have been previously reported. We evaluated whether variation in genes related to estrogen metabolism (COMT, CYP1A1, CYP1B1, CYP17A1, CYP19A1, ESR1, GSTM1, GSTP1, GSTT1, HSD17B1, SULT1A1, and UGT1A1) contributes to breast cancer risk and/or racial differences in risk within the CARE study, a multi-centered, population-based case-control study of breast cancer. Genetic variation was assessed as single nucleotide polymorphisms (SNPs), haplotypes, and SNP-hormone therapy (HT) interactions within a subset of 1,644 cases and 1,451 controls, including 949 Black women (493 cases and 456 controls), sampled from the CARE study population. No appreciable associations with breast cancer risk were detected for single SNPs or haplotypes in women overall. We detected SNP-HT interactions in women overall within CYP1B1 (rs1800440; p (het) = 0.003) and within CYP17A1 (rs743572; p (het) = 0.009) in which never users of HT were at a decreased risk of breast cancer, while ever users were at a non-significant increased risk. When investigated among racial groups, we detected evidence of an SNP-HT interaction with CYP1B1 in White women (p value = 0.02) and with CYP17A1 in Black women (p value = 0.04). This analysis suggests that HT use may modify the effect of variation in estrogen-related genes on breast cancer risk, which may affect Black and White women to a different extent.

Is ulcerative colitis associated with survival among older persons with colorectal cancer in the US? A population-based case-control study.

BACKGROUND: While ulcerative colitis (UC) is a risk factor for colorectal cancer, the association of UC with survival after colorectal cancer has not been studied in an older population. AIMS: The objective of our study was to compare the survival of colorectal cancer between persons with and without UC. METHODS: All cases of colorectal cancer (CRC) in persons 67 and older residing in a SEER catchment area and enrolled in the Medicare between 1993 and 1999 were assessed. We identified diagnosis of UC using ICD-9 codes on Medicare outpatient, office, and inpatient claims in the 2 years prior to the date of diagnosis. We used Cox proportional hazards model and Kaplan-Meier curves to compare survival between individuals with UC and CRC (UC-CRC) and sporadic CRC RESULTS: We identified 47,543 cases of colorectal cancer. Cases with UC-CRC tend to be diagnosed at earlier stages compared to sporadic CRC (42 vs. 37% local (TNM stage 1 and 2) and 11 vs. 17% distant spread (TNM stage 4), respectively; P value = 0.04). Controlling for age, gender, race and stage, diagnosis of UC did not affect the 3-year survival for CRC. CONCLUSIONS: Colorectal cancers tend to be diagnosed at earlier stages among persons with UC, but there is no difference in 3-year survival rates for colorectal cancer among individuals with and without UC.

Mortality among survivors of the Sept 11, 2001, World Trade Center disaster: results from the World Trade Center Health Registry cohort.

BACKGROUND: The Sept 11, 2001 (9/11) World Trade Center (WTC) disaster has been associated with several subacute and chronic health effects, but whether excess mortality after 9/11 has occurred is unknown. We tested whether excess mortality has occurred in people exposed to the WTC disaster. METHODS: In this observational cohort study, deaths occurring in 2003-09 in WTC Health Registry participants residing in New York City were identified through linkage to New York City vital records and the National Death Index. Eligible participants were rescue and recovery workers and volunteers; lower Manhattan area residents, workers, school staff and students; and commuters and passers-by on 9/11. Study participants were categorised as rescue and recovery workers (including volunteers), or non-rescue and non-recovery participants. Standardised mortality ratios (SMR) were calculated with New York City rates from 2000-09 as the reference. Within the cohort, proportional hazards were used to examine the relation between a three-tiered WTC-related exposure level (high, intermediate, or low) and total mortality. FINDINGS: We identified 156 deaths in 13,337 rescue and recovery workers and 634 deaths in 28,593 non-rescue and non-recovery participants. All-cause SMRs were significantly lower than that expected for rescue and recovery participants (SMR 0·45, 95% CI 0·38-0·53) and non-rescue and non-recovery participants (0·61, 0·56-0·66). No significantly increased SMRs for diseases of the respiratory system or heart, or for haematological malignancies were found. In non-rescue and non-recovery participants, both intermediate and high levels of WTC-related exposure were significantly associated with mortality when compared with low exposure (adjusted hazard ratio 1·22, 95% CI 1·01-1·48, for intermediate exposure and 1·56, 1·15-2·12, for high exposure). High levels of exposure in non-rescue and non-recovery individuals, when compared with low exposed non-rescue and non-recovery individuals, were associated with heart-disease-related mortality (adjusted hazard ratio 2·06, 1·10-3·86). In rescue and recovery participants, level of WTC-related exposure was not significantly associated with all-cause mortality (adjusted hazard ratio 1·25, 95% CI 0·56-2·78, for high exposure and 1·03, 0·52-2·06, for intermediate exposure when compared with low exposure). INTERPRETATION: This exploratory study of mortality in a well defined cohort of 9/11 survivors provides a baseline for continued surveillance. Additional follow-up is needed to establish whether these associations persist and whether a similar association over time will occur in rescue and recovery participants. FUNDING: US Centers for Disease Control and Prevention (National Institute for Occupational Safety and Health, Agency for Toxic Substances and Disease Registry, and National Center for Environmental Health); New York City Department of Health and Mental Hygiene.

Use of complementary and alternative medicine among men with prostate cancer in a rural setting.

UNLABELLED: The purpose of this study was to examine the prevalence and predictors of complementary and alternative medicine (CAM) use among rural patients with localized prostate cancer. The study also examined the participants' disclosure of CAM use to their physicians. Baseline and 6-month follow-up data were taken from a study examining the factors that influence treatment choice and quality of life among men diagnosed with and being treated for localized prostate cancer residing in rural southwest Georgia (N = 321). A total of 291 participants were interviewed at baseline and 6-month follow-up. FINDINGS: At baseline, 26.4% reported ever using CAM. Among them, dietary supplements were the most commonly used (75%), and 56% of patients did not disclose their CAM use to their physicians. At 6-month follow-up, 11% of the study sample reported using CAM since starting treatment (half of these were new users). The proportions of CAM users who reported taking dietary supplements after treatment were significantly lower than the corresponding proportions before treatment. CAM use after treatment was more common among those who selected surgery and watchful waiting. While 44% of the sample disclosed using CAM to their doctors before treatment, 61% after treatment began (P = 0.05). We found that CAM use after cancer treatment in this population was markedly less common than in nationally reported data for cancer patients. In line with national patterns, younger and more educated rural patients were significantly more likely to have ever used CAM and to use it after treatment.

Developing a claim-based version of the ACE-27 comorbidity index: a comparison with medical record review.

OBJECTIVES: The adult comorbidity evaluation (ACE-27) is a medical record-based comorbidity index that predicts survival among various types of cancer patients. The purpose of this study was to compare the medical record-based ACE-27 instrument to a newly developed administrative claim-based ACE-27 measure. STUDY DESIGN AND SETTING: Cross-sectional study of 4,300 breast and prostate cancer patients from the Centers for Disease Control and Prevention Patterns of Care Study. RESULTS: Comorbidities with the highest concordance were diabetes (sensitivity=84.6%, κ=0.58 for breast cancer patients; sensitivity=0.764, κ=0.54 for prostate cancer patients), and hypertension (sensitivity=78.5%, κ=0.32 for breast cancer patients; sensitivity=69.6%, κ=0.28 for prostate cancer patients). Diseases with fair or moderate agreement in one or both cancer sites include congestive heart failure, arrhythmia, hypertension, respiratory diseases, hepatic disease, renal disease, dementia, and neuromuscular disease. For overall indices, agreement was fair but with high sensitivities in the collapsed indices, and the highest sensitivities in the lowest level of decompensation. CONCLUSIONS: The ACE-27 comorbidity score derived from administrative claims data provides a tool to examine the relationship between comorbidity, cancer diagnosis, and outcomes in future epidemiologic research, particularly when medical record review is logistically impossible. The classification of most comorbidities into 2 or 3 levels of severity within a claim-based measure is a major development. Future research should be directed toward refining the measure with a longer review period or different paradigms for diagnosis identification, and testing the predictive ability of the measure in terms of survival, complications, or other outcomes of care.

Crohn's disease and small bowel adenocarcinoma: a population-based case-control study.

BACKGROUND: Although Crohn's disease (CD) is thought to predispose to adenocarcinomas of the small bowel, the association has not been well studied in an older population. AIMS: The objective of our study was to evaluate the association of CD with small bowel cancer in a population-based case-control study. METHODS: All cases of small bowel cancer in persons 67 and older in the Surveillance, Epidemiology and End Results catchment area and in the Medicare claims data base were compared with cancer-free controls residing in the same geographic area. We used multivariable logistic regression models adjusted for demographic and other factors. RESULTS: We identified 923 cases of small bowel cancer and 142,273 controls. Although we found a strong association between CD and small bowel cancer (OR = 12.07; 95% CI: 6.07-20.80; P < 0.001), the prevalence of CD in patients with small bowel cancer was low (1.6%). CONCLUSIONS: Although CD is a significant risk factor for small bowel cancers among individuals older than 67, the absolute risk is small. IMPACT: Older individuals with CD can be reassured that although there is an association between CD and small bowel cancer, the absolute risk remains small.

The effect of race and rural residence on prostate cancer treatment choice among men in Georgia.

OBJECTIVE: To analyze differences for prostate cancer by race and in rural areas. METHODS: We studied 516 men younger than 75 years old with incident prostate cancer during 2005-08 in 33 counties in Southwest Georgia (SWGA), a rural area of 700,000 (40% African American). Treatment data were abstracted from medical records, and interviews conducted with 314 men. We also compared treatments in SWGA vs. Atlanta in 2005. RESULTS: External radiation plus brachytherapy was the most common treatment in SWGA (31%), followed by external radiation alone (27%), and surgery (18%). Patients in SWGA had higher odds of external radiation vs. surgery than men in Atlanta (OR 2.66, 95% CI 1.85-3.81). African Americans had higher odds of choosing treatment other than surgery, compared with whites (OR 2.04, 95% CI 1.57-2.63), more so in SWGA (OR 3.51, 95% CI 1.92-6.41) than Atlanta (OR 1.76, 95% CI 1.32-2.35) (P = .05). Poor communication with their physician was reported by 13% of men in SWGA, more among African Americans than whites (OR 3.95, 95% CI 1.52-10.30), and more among those who had no treatment vs. some treatment (OR 5.77, 95% CI 1.88-11.46). CONCLUSIONS: In both rural and urban Georgia, white men with prostate cancer had surgery more frequently than African Americans, although data suggest this may be caused more by income differences than race. Rural patients as opposed to urban patients were more likely to receive external radiation and less likely to receive brachytherapy alone or surgery. Poor communication with a physician, particularly prevalent among African Americans, was associated with choosing no treatment in SWGA.

Is inflammatory bowel disease an important risk factor among older persons with colorectal cancer in the United States? A population-based case-control study.

BACKGROUND: While ulcerative colitis (UC) and Crohn's disease (CD) are thought to predispose to colorectal cancer (CRC), the association has not been well studied in an older population. AIMS: The objective of our study was to evaluate the association of ulcerative colitis and Crohn's disease and colorectal cancer in a population-based, case-control study. We also wished to estimate the incidence rates of colorectal cancer among older individuals with UC/CD. METHODS: All cases of colorectal cancer in persons 67 and older in the SEER catchment area and in the Medicare claims database were compared with cancer-free controls residing in the same geographic area. We used multivariable logistic regression models adjusted for demographic and other factors. RESULTS: We identified 47,543 cases of CRC and 142,273 controls. We found a modest association between UC and CRC (OR 1.93; 95% CI 1.54-2.49; P-value<0.001) and a significant, albeit modest, association between CD and CRC (OR 1.45; 95% CI 1.08-1.91; P-value 0.01). We found the incidence of CRC to be 8.2 per 10,000 person-years (95% CI 6.5-10.1/10,000 person-years) among those with UC/CD, and 6.1 per 10,000 person-years (95% CI 4.6-7.8/10,000 person-years) among those without UC/CD, resulting in an incidence rate ratio of 1.34. CONCLUSIONS: Among older persons ulcerative colitis and Crohn's disease are modest risk factors for CRC, and the incidence rate ratio for CRC is modest, suggesting that risk of CRC in patients with IBD may be lower than previously thought.

Genome-wide copy number alterations in subtypes of invasive breast cancers in young white and African American women.

Genomic copy number alterations (CNA) are common in breast cancer. Identifying characteristic CNAs associated with specific breast cancer subtypes is a critical step in defining potential mechanisms of disease initiation and progression. We used genome-wide array comparative genomic hybridization to identify distinctive CNAs in breast cancer subtypes from 259 young (diagnosed with breast cancer at <55 years) African American (AA) and Caucasian American (CA) women originally enrolled in a larger population-based study. We compared the average frequency of CNAs across the whole genome for each breast tumor subtype and found that estrogen receptor (ER)-negative tumors had a higher average frequency of genome-wide gain (P < 0.0001) and loss (P = 0.02) compared to ER-positive tumors. Triple-negative (TN) tumors had a higher average frequency of genome-wide gain (P < 0.0001) and loss (P = 0.003) than non-TN tumors. No significant difference in CNA frequency was observed between HER2-positive and -negative tumors. We also identified previously unreported recurrent CNAs (frequency >40%) for TN breast tumors at 10q, 11p, 11q, 16q, 20p, and 20q. In addition, we report CNAs that differ in frequency between TN breast tumors of AA and CA women. This is of particular relevance because TN breast cancer is associated with higher mortality and young AA women have higher rates of TN breast tumors compared to CA women. These data support the possibility that higher overall frequency of genomic alteration events as well as specific focal CNAs in TN breast tumors might contribute in part to the poor breast cancer prognosis for young AA women.

Breast cancer risk and ovariectomy, hysterectomy, and tubal sterilization in the women's contraceptive and reproductive experiences study.

Removal or impairment of ovaries before menopause may affect a woman's breast cancer risk by altering her cumulative exposure to ovarian hormones. The Women's Contraceptive and Reproductive Experiences Study, a population-based, multicenter case-control study of incident invasive breast cancer, recruited women aged 35-64 years (4,490 cases and 4,611 controls) who provided data on ovariectomy, hysterectomy, and tubal sterilization during in-person interviews. Controls were frequency-matched to cases by age, race, and study site. Unconditional logistic regression analysis was used. Women who had not undergone premenopausal reproductive surgery were the referent group. Bilateral ovariectomy was associated with reduced breast cancer risk overall (odds ratio (OR) = 0.59, 95% confidence interval (CI): 0.50, 0.69) and among women <45 years of age (ORs ranged from 0.31 to 0.52), but not among those who were older at surgery. It was also associated with a reduced risk for estrogen and progesterone receptor-positive tumors (OR = 0.63, 95% CI: 0.52, 0.75) but not receptor-negative tumors. Hysterectomy with ovarian conservation (OR = 0.83, 95% CI: 0.72, 0.96) and hysterectomy with partial ovary removal (OR = 0.73, 95% CI: 0.59, 0.91) were also associated with lower risk. No association with breast cancer risk was observed with tubal sterilization only or partial ovariectomy without hysterectomy. Reproductive organ surgeries may alter ovarian hormone levels, thereby affecting breast cancer risk.

A case-control study of body mass index and breast cancer risk in white and African-American women.

OBJECTIVE: Large body size has been associated with decreased risk of breast cancer in premenopausal women but with increased risk in postmenopausal women. Limited information is available about African-American women and differences by estrogen and progesterone receptor status. METHODS: We analyzed data from the Women's Contraceptive and Reproductive Experiences Study among 3,997 white and African-American breast cancer case patients diagnosed in 1994 to 1998 and 4,041 control participants ages 35 to 64 years. We calculated multivariate odds ratios (OR) as measures of relative risk of breast cancer associated with self-reported body mass index (BMI) at age 18 and 5 years before diagnosis (recent BMI). RESULTS: Risk tended to decrease with increasing BMI at age 18 years in all women [OR(BMI > or = 25 kg/m(2) versus < 20 kg/m(2)) = 0.76; 95% confidence interval (CI), 0.63-0.90; P(trend) = 0.005] and with recent BMI in premenopausal women (OR(BMI > or = 35 kg/m(2) versus < 25 kg/m(2)) = 0.81; 95% CI, 0.61-1.06; P(trend) = 0.05), unmodified by race. Among postmenopausal white but not African-American women, there was an inverse relation between recent BMI and risk. High recent BMI was associated with increased risk of estrogen receptor- and progesterone receptor-positive tumors among postmenopausal African-American women (OR(BMI > or = 35 kg/m(2) versus < 25 kg/m(2)) = 1.83; 95% CI, 1.08-3.09; P(trend) = 0.03). CONCLUSION: Among women at age 35 to 64 years, BMI at age 18 years is inversely associated with risk of breast cancer, but association with recent BMI varies by menopause status, race, and hormone receptor status. IMPACT: Our findings indicate that studies of BMI and breast cancer should consider breast cancer subtypes.

Assessment of a commercial searchable population directory as a means of selecting controls for case-control studies.

We explored the feasibility of using SalesGenie, a commercially available database, as a potential alternative to traditional methods of selecting controls for population-based case-control studies. An attractive feature of this particular database is that it permits a search within specific age ranges, geographic locations, and household income. Information on 1,068 cases reported to the California Cancer Registry between 2001 and 2005 was entered manually into the SalesGenie Web-based search engine. The frequency of Registry-to-SalesGenie matches was then compared with the frequency of matching the registry data to the California Department of Motor Vehicles (DMV) records. Our findings indicate that the SalesGenie database is currently less comprehensive than DMV records. Nevertheless, Web-based population data sources may provide a potential alternative for population-based studies when used in conjunction with other methods, particularly in states where DMV records are not accessible to researchers.

The epidemiology of triple-negative breast cancer, including race.

OBJECTIVE: Predictors of intrinsic breast cancer subtypes, including the triple-negative (TN) subtype, are largely unknown. We evaluated whether anthropometrics, demographics, and reproductive history were associated with distinct breast cancer subtypes. METHODS: Invasive breast tumors from a population-based case-control study of 476 (116 black and 360 white) Atlanta women aged 20-54, diagnosed between 1990 and 1992, were centrally reviewed and immunohistochemically analyzed for estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2); then grouped [TN (ER-PR-HER2-); ER-PR-HER2+; ER/PR+HER2+; ER/PR+HER2- (case-only reference group)]. Data were from interviews and anthropometric measurements; adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression, including both case-only and case-control comparisons. RESULTS: From the case-only analyses and compared with the ER/PR+HER2- subtype, women with TN tumors were more likely to be obese than normal/underweight [OR = 1.89 (95% CI = 1.22, 2.92)]. Regardless of HER2 status, ER-PR- tumors were associated with black race, young age at first birth, having a recent birth, and being overweight. CONCLUSIONS: Distinct breast cancer subtypes have unique sociodemographic, anthropometric and reproductive characteristics and possibly different pathways for development.

Cancer outcomes research in a rural area: a multi-institution partnership model.

Whereas, most cancer research data come from high-profile academic centers, little is known about the outcomes of cancer care in rural communities. We summarize the experience of building a multi-institution partnership to develop a cancer outcomes research infrastructure in Southwest Georgia (SWGA), a primarily rural 33-county area with over 700,000 residents. The partnership includes eight institutions: the Emory University in Atlanta, the Centers for Disease Control and Prevention (CDC), the Georgia Comprehensive Center Registry (the Registry), the Southwest Georgia Cancer Coalition (the Coalition), and the four community cancer centers located within the SWGA region. The practical application of the partnership model, its organizational structure, and lessons learned are presented using two specific examples: a study evaluating treatment decisions and quality of life among prostate cancer patients, and a study of treatment discontinuation among prostate, breast, lung, and colorectal cancer patients. Our partnership model allowed us to (1) use the Coalition as a link between Atlanta-based researchers and local community; (2) collaborate with the area cancer centers on day-to-day study activities; (3) involve the Registry personnel and resources to identify eligible cancer cases and to perform data collection; and (4) raise community awareness and sense of study ownership through media announcements organized by the Coalition. All of the above activities were performed in consultation with the funding institution (CDC) and its project directors who oversee several other studies addressing similar research questions throughout the country. Our partnership model may provide a useful framework for cancer outcomes research projects in rural communities.

Secular trends in mortality from common cancers in the United States by educational attainment, 1993-2001.

BACKGROUND: Death rates for the four major cancer sites (lung, breast, prostate, and colon and rectum) have declined steadily in the United States among persons aged 25-64 years since the early 1990s. We used national data to examine these trends in relation to educational attainment. METHODS: We calculated age-standardized death rates for each of the four cancers by level of education among 25- to 64-year-old non-Hispanic white and non-Hispanic black men and women for 1993 through 2001 using data on approximately 86% of US deaths from the National Center for Health Statistics, education level as recorded on the death certificate, and population data from the US Bureau of Census Current Population Survey. Annual percent changes in age-adjusted death rates were estimated using weighted log-linear regression models. All statistical tests were two-sided. RESULTS: Death rates for each cancer decreased statistically significantly from 1993 to 2001 in people with at least 16 years of education in every sex and race stratum except lung cancer in black women, for whom death rates were stable. For example, colorectal cancer death rates among white men, black men, white women, and black women with at least 16 years of education decreased by 2.4% (P < .001), 4.8% (P = .011), 3.0% (P < .001), and 2.6% (P = .030) annually, respectively. By contrast, among people with less than 12 years of education, a statistically significant decrease in death rates from 1993 through 2001 was seen only for breast cancer in white women (1.4% per year; P = .029). Death rates among persons with less than 12 years of education over the same time interval increased for lung cancer in white women (2.4% per year; P < .001) and for colon cancer in black men (2.7% per year; P < .001) and were stable for the remaining race/sex/site strata. Temporal trends generally followed an educational gradient in which the slopes of the decreases in death rate became steeper with higher educational attainment. CONCLUSION: The recent declines in death rates from major cancers in the United States mainly reflect declines in more highly educated individuals.

Cancer mortality in the United States by education level and race.

BACKGROUND: Although both race and socioeconomic status are well known to influence mortality patterns in the United States, few studies have examined the simultaneous influence of these factors on cancer incidence and mortality. We examined relationships among race, education level, and mortality from cancers of the lung, breast, prostate, colon and rectum, and all sites combined in contemporary US vital statistics. METHODS: Age-adjusted cancer death rates (with 95% confidence intervals [CIs]) were calculated for 137,708 deaths among 119,376,196 individuals aged 25-64 years, using race and education information from death certificates and population denominator data from the US Bureau of the Census, for 47 states and Washington, DC, in 2001. Relative risk (RR) estimates were used to compare cancer death rates in persons with 12 or fewer years of education with those in persons with more than 12 years of education. RESULTS: Educational attainment was strongly and inversely associated with mortality from all cancers combined in black and white men and in white women. The all-cancer death rates were nearly identical for black men and white men with 0-8 years of education (224.2 and 223.6 per 100,000, respectively). The estimated relative risk for all-cancer mortality comparing the three lowest (< or = 12 years) with the three highest (> 12 years) education categories was 2.38 (95% CI = 2.33 to 2.43) for black men, 2.24 (95% CI = 2.23 to 2.26) for white men, 1.43 (95% CI = 1.41 to 1.46) for black women, and 1.76 (95% CI = 1.75 to 1.78) for white women. For both men and women, the magnitude of the relative risks comparing the three lowest educational levels with the three highest within each race for all cancers combined and for lung and colorectal cancers was higher than the magnitude of the relative risks associated with race within each level of education, whereas for breast and prostate cancer the magnitude of the relative risks associated with race was higher than the magnitude of the relative risks associated with level of education within each racial group. Among the most important and novel findings were that black men who completed 12 or fewer years of education had a prostate cancer death rate that was more than double that of black men with more schooling (10.5 versus 4.8 per 100,000 men; RR = 2.17, 95% CI = 1.82 to 2.58) and that, in contrast with studies of mortality rates in earlier time periods, breast cancer mortality rates were higher among women with less education than among women with more education (37.0 and 31.1 per 100,000, respectively, for black women and 25.2 versus 18.6 per 100,000, respectively, for white women). CONCLUSION: Cancer death rates vary considerably by level of education. Identifying groups at high risk of death from cancer by level of education as well as by race may be useful in targeting interventions and tracking cancer disparities.