The association of race/ethnicity in male breast cancer survival within similar comorbidity cohorts.

BACKGROUND: Concomitant disease is associated with poor breast cancer survival in women and is more prevalent in racial/ethnic minority groups than individuals who are non-Hispanic White. The purpose of this study was to determine if race/ethnicity is associated with survival among men with breast cancer when stratifying analyses by level of comorbidity. METHODS: We used the California Cancer Registry to identify 1730 cases of men and 259,828 cases of women with breast cancer and documented Charlson Comorbidity Index (CCI). Kaplan-Meier survival and Cox regression analyses were used to compare breast cancer-specific survival and risk of mortality for African American/Black, Hispanic, and Asian/Pacific Islander men with White women and White men. RESULTS: When compared with White women, Black men with a CCI of 0 (hazard ratio [HR], 3.09; 95% CI, 1.10-1.16) and a CCI of 2+, (HR, 2.51; 95% CI, 1.42-4.42) had an increased risk of mortality when compared with White women. When compared with White men, African American men with a CCI of 0 (HR, 2.36; 95% CI, 1.45-3.85) and 2+ (HR, 2.44; 95% CI, 1.26-4.74) had an increased unadjusted risk of mortality, but these disparities were neutralized when controlling for sociodemographic and clinical factors. CONCLUSIONS: Black men with both low and high levels of concomitant disease have an increased risk of mortality when compared with both White men and women, but demographic and clinical factors are contributors to this disparity.

The influence of comorbidity on treatment and survival of triple-negative breast cancer.

Concomitant comorbidity is a key factor in treatment decision-making for breast cancer. The aim of this study was to determine how the Charlson Comorbidity Index (CCI) affected treatment and risk of mortality of women with TNBC, the subtype with the poorest prognosis. We accessed 20 177 cases of TNBC from the California Cancer Registry 2000-2015 with documented Charlson Comorbidity Index (CCI). Cox Regression was used to compute the adjusted risk of breast cancer-specific mortality for a CCI of 1 (low comorbidity) and 2+ (high comorbidity) vs a CCI of 0 (no comorbidity). Logistic regression was used to compute the association of CCI with treatment of mastectomy, lumpectomy + radiation, and chemotherapy. Analyses were conducted separately for each stage. Patients with high comorbidity CCI (2+) were less likely to receive systemic chemotherapy irrespective of Stage. High comorbidity was associated with higher breast-specific mortality in all stages of disease. High comorbidity did not have an effect on the use of lumpectomy and radiation of stage 1 breast cancer but was associated with reduced use in stages 2-4. Comorbidity was not associated with decreased risk of mastectomy except for patients with high comorbidity in stage 3. Concomitant comorbidity influences treatment decisions and breast cancer-specific mortality in patients with TNBC.

Differences in clinicopatholgic characteristics and risk of mortality between the triple positive and ER+/PR+/HER2- breast cancer subtypes.

PURPOSE: This study compared the demographic and clinicopathologic characteristics and risk of mortality between the triple positive (TP) and ER+/PR+/HER2- breast cancer subtypes. METHODS: Cases of first primary female invasive TP and ER+/PR+/HER2- breast cancer were obtained from the California Cancer Registry. Logistic regression analysis was used to compare differences in factors associated with the TP versus the ER+/PR+/HER2- subtype. Cox regression was used to compute the adjusted risk of breast cancer-specific mortality of the TP versus ER+/PR+/HER2-. RESULTS: The odds of TP versus ER+/PR+/HER2- were higher with advanced stage, high grade, low SES, ≤ 45 years of age (OR 1.48; CI 1.40-1.55), black (OR 1.11; CI 1.02-1.21), Asian/Pacific Islander (OR 1.15; CI 1.09-1.22), and uninsured (OR 1.42; CI 1.15-1.73). Unadjusted survival analysis indicated worse survival for the TP when compared with the ER+/PR+/HER2- subtype. However, adjusted risk of mortality for the TP subtype was not statistically significantly worse than the ER+/PR+/HER2- subtype. CONCLUSIONS: Young age, advanced stage and grade, low SES, black and API race, and lack of health insurance are more common in the TP subtype than in the ER+/PR+/HER2- subtype. However the risk of mortality between these two subtypes is similar.

Fourteen Year Follow-Up of Randomized Clinical Trials of Active Robotic-Assisted Total Hip Arthroplasty.

BACKGROUND: Active robotic total hip arthroplasty (THA) has been used clinically for over 20 years, but long-term results have never been studied. The aims of this study are to determine whether active robotic THA improves clinical outcomes and results in fewer revisions over a long-term follow-up. METHODS: Patients from 2 US Food and Drug Administration clinical trials (1994-1998 and 2001-2006) who had undergone THA using either an active robotic system or a traditional manual technique were examined to determine if any differences existed in radiographic analysis and patient pain and function using the University of California, Los Angeles; visual analog scale; Health Status Questionnaire (HSQ) pain; HSQ role physical; HSQ physical functioning; Harris pain scores; and the total Western Ontario and McMaster Universities Osteoarthritis Index scores at a mean follow-up of 14 years. RESULTS: The ROBODOC group had statistically significant higher HSQ pain and Harris pain scores and lower Western Ontario and McMaster Universities Osteoarthritis Index scores. There was no statistically significant difference in probability of a revision for wear between the groups (χ2 = 1.80; P = .179), and no revisions for loosening in either group. CONCLUSION: Prior studies have demonstrated improved implant fit and alignment with the use of this active robot system. This long-term study now shows no failures for stem loosening at a mean follow-up of 14 years and small but potentially important improvements in clinical outcomes in the robot group.

Risk of mortality of node-negative, ER/PR/HER2 breast cancer subtypes in T1, T2, and T3 tumors.

PURPOSE: The purpose of this study was to assess differences in breast cancer-specific mortality within tumors of the same size when breast cancer was defined using the three tumor markers estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). METHODS: We identified 104,499 cases of node-negative primary female invasive breast cancer from the California Cancer Registry. Tumor size was categorized as T1a, T1b, T1c, T2, and T3. Breast cancer was defined using ER, PR, and HER2. Kaplan-Meier Survival analysis was conducted and Cox Regression was used to compute the adjusted risk of mortality for the ER+/PR+/HER2+, ER-/PR-/HER2- (TNBC), and ER-/PR-/HER2+ (HER2-overexpressing) subtypes when compared with the ER+/PR+/HER2-. Separate models were computed for each tumor size. RESULTS: Unadjusted survival analysis showed that for all tumor sizes, the ER+/PR+ subtypes regardless of HER status have better breast cancer-specific survival than ER-/PR- subtypes. Subtype was not an important factor for risk of mortality for T1a tumors. The ER+/PR+/HER2+ subtype was only a risk for mortality in T1b tumors that were unadjusted for treatment. For all other tumor sizes, the ER+/PR+/HER2+ had the same mortality as the ER+/PR+/HER2- subtype regardless of adjustment for treatment. The HER2-overexpressing subtype had a higher risk of mortality than the ER+/PR+/HER2- subtype except for T1b tumors that were adjusted for treatment. For all tumor sizes, the TNBC had higher hazard ratios than all other subtypes. CONCLUSIONS: T1a tumors have the same risk of mortality regardless of ER/PR/HER2 subtype, and ER and PR negativity plays a stronger role in survival than HER2 positivity for tumors of all size.

Risk factors associated with the triple-negative breast cancer subtype within four race/ethnicities.

PURPOSE: The ER-/PR-/HER2- or triple-negative (TNBC) subtype is more prevalent among women who are young, black, Hispanic, and of lower SES. The purpose of this study is to determine if young age and low SES are associated with TNBC within four mutually exclusive race/ethnicities. METHODS: The study identified 19,283 cases of TNBC and 89,089 of ER+/PR+/HER2- from the California Cancer Registry. Logistic regression analyses were conducted separately for whites, blacks, Hispanics, and Asian/Pacific Islanders (API) to compute the adjusted odds ratios (OR) for age and SES for the TNBC versus the ER+/PR+/HER2- subtype. RESULTS: White (OR=1.37;1.23-1.53) and Hispanic and women (OR=1.35;1.17-1.56) 30-39 had increased odds of the TNBC when compared with women 50-59 of the same race/ethnicity. Black women under 40 had the same odds, and black women 40-49 had lower odds of the TNBC as black women 50-59. White, black, and Hispanic women 70 and older had decreased or the same odds of the TNBC as 50 to 59-year-old women. API women had a similar risk of TNBC at all ages. Lower SES was associated with increased risk of TNBC only for white and Hispanic women. The odds of TNBC were no worse for API women with lower SES than API women with higher SES. SES was not statistically significant for black women. CONCLUSIONS: When assessing the odds of TNBC within a single race/ethnicity, young age and low SES are risk factors only for white and Hispanic women, but not for black and API women.

Regional Variation in Disparities in Breast Cancer Specific Mortality Due to Race/Ethnicity, Socioeconomic Status, and Urbanization.

PURPOSE: Disparities in breast cancer mortality due to race/ethnicity, area socioeconomic status (SES), and urbanization have been documented. This study examined if disparities in the risk of breast cancer specific mortality due to race/ethnicity, SES, and urbanization varied within diverse regions of California. METHODS: We identified 163,569 cases of first primary female invasive breast cancer from the California Cancer Registry diagnosed between January, 2000 and December, 2013. Cox regression was used to compute hazard ratios (HR) and 95 % confidence intervals for race/ethnicity, SES, and urbanization within eight regions of California. RESULTS: Blacks had an increased risk of mortality in the San Francisco Bay Area (SFBA) (HR = 1.37; 1.22-1.55), Desert Sierra (HR = 1.27; 1.08-1.49), San Diego/Orange (HR = 1.43; 1.19-1.71), and Los Angeles (LA) (HR = 1.31; 1.20-1.44). Japanese (HR = 0.62; 0.47-0.81), Chinese (HR = 0.71; 0.58-0.87), and Filipino (HR = 0.81; 0.69-0.95) women had a decreased risk of mortality in LA. Southeast Asians had a decreased risk in San Diego/Orange (HR = 0.72; 0.57-0.90) and in the SFBA (HR = 0.81; 0.67-0.98). Hispanics had a decreased risk (HR = 0.73; 0.57-0.93) and American Indians had an increased risk (HR = 2.32; 1.08-4.98) in the Tri-County region. SES was a significant risk factor for mortality in all regions except the North and Tri-County. Urbanization was a statistically significant factor for mortality only in LA (HR = 1.32; 1.08-1.60). CONCLUSIONS: Disparities in breast cancer mortality, due to race/ethnicity, SES, and urbanization vary by region which suggests that further research is warranted concerning the role of geographic regions and neighborhoods in cancer outcomes.

Determinants of recovery from a 161-km ultramarathon.

The primary study objective was to identify determinants of short-term recovery from a 161-km ultramarathon. Participants completed 400 m runs at maximum speed before the race and on days 3 and 5 post-race, provided a post-race blood sample for plasma creatine kinase (CK) concentration, and provided lower body muscle pain and soreness ratings (soreness, 10-point scale) and overall muscular fatigue scores (fatigue, 100-point scale) pre-race and for 7 days post-race. Among 72 race finishers, soreness and fatigue had statistically returned to pre-race levels by 5 days post-race; and 400 m times at days 3 and 5 remained 26% (P = 0.001) and 12% (P = 0.01) slower compared with pre-race, respectively. CK best modelled soreness, fatigue and per cent change in post-race 400 m time. Runners with the highest CKs had 1.5 points higher (P < 0.001) soreness and 11.2 points higher (P = 0.006) fatigue than runners with the lowest CKs. For the model of 400 m time, a significant interaction of time with CK (P < 0.001) indicates that higher CKs were linked with a slower rate of return to pre-race 400 m time. Since post-race CK was the main modifiable determinant of recovery following the ultramarathon, appropriate training appears to be the optimal approach to enhance ultramarathon recovery.

The Influence of Socioeconomic Status on Racial/Ethnic Disparities among the ER/PR/HER2 Breast Cancer Subtypes.

Background. The eight ER/PR/HER2 breast cancer subtypes vary widely in demographic and clinicopathologic characteristics and survival. This study assesses the contribution of SES to the risk of mortality for blacks, Hispanics, Asian/Pacific Islanders, and American Indians when compared with white women for each ER/PR/HER2 subtype. Methods. We identified 143,184 cases of first primary female invasive breast cancer from the California Cancer Registry between 2000 and 2012. The risk of mortality was computed for each race/ethnicity within each ER/PR/HER2 subtype. Models were adjusted for tumor grade, year of diagnosis, and age. SES was added to a second set of models. Analyses were conducted separately for each stage. Results. Race/ethnicity did not contribute to the risk of mortality for any subtype in stage 1 when adjusted for SES. In stages 2, 3, and 4, race/ethnicity was associated with risk of mortality and adjustment for SES changed the risk only in some subtypes. SES reduced the risk of mortality by over 45% for American Indians with stage 2 ER+/PR+/HER2- cancer, but it decreased the risk of mortality for blacks with stage 2 triple negative cancer by less than 4%. Conclusions. Racial/ethnic disparities do not exist in all ER/PR/HER2 subtypes and, in general, SES modestly alters these disparities.

Longitudinal assessment of the effect of age and experience on performance in 161-km ultramarathons.

PURPOSE: This work longitudinally assesses the influence of aging and experience on time to complete 161-km ultramarathons. METHODS: From 29,331 finishes by 4066 runners who had completed 3 or more 161-km ultramarathons in North America from 1974 through 2010, independent cohorts of men (n = 3,092), women (n = 717), and top-performing men (n = 257) based on age-group finish place were identified. Linear mixed-effects regression was used to assess the effects of aging and previous 161-km finish number on finish time adjusted for the random effects of runner, event, and year. RESULTS: Men and women up to 38 y of age slowed by 0.05-0.06 h/y with advancing age. Men slowed 0.17 h/y from 38 through 50 y and 0.23 h/y after 50 y. Women slowed 0.20-0.23 h/y with advancing age from 38 y. Top-performing men under 38 y did not slow with increasing age but slowed by 0.26 and 0.39 h/y from 38 through 50 y and after 50 y, respectively. Finish number was inversely associated with finish time for all 3 cohorts. A 10th or higher finish was 1.3, 1.7, and almost 3 h faster than a first finish for men, women, and top-performing men, respectively. CONCLUSIONS: High-level performances in 161-km ultramarathoners can be sustained late into the 4th decade of life, but subsequent aging is associated with declines in performance. Nevertheless, the adverse effects of aging on performance can be offset by greater experience in these events.

Breast Cancer Survival Defined by the ER/PR/HER2 Subtypes and a Surrogate Classification according to Tumor Grade and Immunohistochemical Biomarkers.

Introduction. ER, PR, and HER2 are routinely available in breast cancer specimens. The purpose of this study is to contrast breast cancer-specific survival for the eight ER/PR/HER2 subtypes with survival of an immunohistochemical surrogate for the molecular subtype based on the ER/PR/HER2 subtypes and tumor grade. Methods. We identified 123,780 cases of stages 1-3 primary female invasive breast cancer from California Cancer Registry. The surrogate classification was derived using ER/PR/HER2 and tumor grade. Kaplan-Meier survival analysis and Cox proportional hazards modeling were used to assess differences in survival and risk of mortality for the ER/PR/HER2 subtypes and surrogate classification within each stage. Results. The luminal B/HER2- surrogate classification had a higher risk of mortality than the luminal B/HER2+ for all stages of disease. There was no difference in risk of mortality between the ER+/PR+/HER2- and ER+/PR+/HER2+ in stage 3. With one exception in stage 3, the ER-negative subtypes all had an increased risk of mortality when compared with the ER-positive subtypes. Conclusions. Assessment of survival using ER/PR/HER2 illustrates the heterogeneity of HER2+ subtypes. The surrogate classification provides clear separation in survival and adjusted mortality but underestimates the wide variability within the subtypes that make up the classification.

A Comparison of In-person, Telephone, and Secure Messaging for Type 2 Diabetes Self-Management Support.

Ongoing interaction between diabetes educators and patients is necessary for making and sustaining behavior changes essential for glycemic control and subsequently reducing the complications of diabetes. PURPOSE: The purpose of this study was to determine the feasibility of diabetes self-management support (DSMS) delivered via telephone or secure message and to compare clinical outcomes (A1C, LDL), behavioral goal achievement, and health maintenance task completion. METHODS: In sum, 150 persons with type 2 diabetes who completed diabetes self-management education self-selected DSMS methods: 1 in-person visit (n = 47), 3 brief visits by phone (n = 44), or 3 by secure message (n = 59) through electronic health record. DSMS included evaluation of goal achievement, barriers and facilitators, problem solving, and review of health maintenance exams. Self-reported data were collected at 9 months. RESULTS: There were no significant differences among groups in main outcomes between baseline and 9-month follow-up. Behavioral goals were achieved by 59% of in-person participants, 73% phone, and 77% secure message. Sixty-two completed the intervention per protocol: fewer online than in-person or phone groups. Mean attempts to contact participants was significantly greater in the secure message group. Phone contact was significantly longer than secure message. CONCLUSIONS: Telephone and secure message was feasible for providing DSMS. Three brief contacts by phone or secure message resulted in similar outcomes when compared to an in-person visit. Secure messaging required less staff time, but increased patient engagement is needed.

Adapting the Group Lifestyle Balance™ Program for Weight Management Within a Large Health Care System Diabetes Education Program.

PURPOSE: The purpose of this translation study was to evaluate the feasibility and effectiveness of an adapted Group Lifestyle Balance (GLB) intervention for weight management implemented through an existing diabetes education program within a large health care delivery system for overweight/obese individuals with diabetes, prediabetes, or neither condition. METHODS: Adults with BMI ≥ 25 kg/m2 participated in an adapted GLB intervention designed to be appropriate regardless of diabetes status. Effectiveness was based on changes in weight and minutes of physical activity between baseline and completion of the 12-week core. Differences between subjects based on diabetes status were also examined. RESULTS: A total of 111 subjects with diabetes, prediabetes, and no diabetes completed baseline survey data and attended at least 9 of the 12 core sessions from April 2010 through December 2011. All achieved significant weight loss, and the proportion of subjects who reported exercising at least 150 minutes/week increased. CONCLUSIONS: The adapted GLB intervention for weight management implemented through an existing diabetes education program in a large health care system was feasible and effective in the population, regardless of participants' diabetes status.

Disparities in race/ethnicity and socioeconomic status: risk of mortality of breast cancer patients in the California Cancer Registry, 2000-2010.

BACKGROUND: Racial disparities in breast cancer survival have been well documented. This study examines the association of race/ethnicity and socioeconomic status (SES) on breast cancer-specific mortality in a large population of women with invasive breast cancer. METHODS: We identified 179,143 cases of stages 1-3 first primary female invasive breast cancer from the California Cancer Registry from January, 2000 through December, 2010. Cox regression, adjusted for age, year of diagnosis, grade, and ER/PR/HER2 subtype, was used to assess the association of race/ethnicity on breast cancer-specific mortality within strata of stage and SES. Hazard ratios (HR) and 95% confidence intervals were reported. RESULTS: Stage 1: There was no increased risk of mortality for any race/ethnicity when compared with whites within all SES strata. Stage 2: Hispanics (HR = 0.85; 0.75, 0.97) in the lowest SES category had a reduced risk of mortality.. Blacks had the same risk of mortality as whites in the lowest SES category but an increased risk of mortality in the intermediate (HR = 1.66; 1.34, 2.06) and highest (HR = 1.41; 1.15, 1.73) SES categories. Stage 3: Hispanics (HR = 0.74; 0.64, 0.85) and APIs (HR = 0.64; 0.50, 0.82) in the lowest SES category had a reduced risk while blacks had similar mortality as whites. Blacks had an increased risk of mortality in the intermediate (HR = 1.52; 1.20, 1.92) and highest (HR = 1.53; 1.22, 1.92) SES categories. CONCLUSIONS: When analysis of breast cancer-specific mortality is adjusted for age and year of diagnosis, ER/PR/HER2 subtype, and tumor grade and cases compared within stage and SES strata, much of the black/white disparity disappears. SES plays a prominent role in breast cancer-specific mortality but it does not fully explain the racial/ethnic disparities and continued research in genetic, societal, and lifestyle factors is warranted.

Utilizing clinical support staff and electronic health records to increase tobacco use documentation and referrals to a state quitline.

The purpose of this study was to determine if incorporation of a workflow in the electronic health record (EHR) that empowered medical assistants (MA) to become tobacco-cessation promoters, would increase tobacco documentation and referral for cessation counseling. MAs in three primary care centers were trained to ask every patient, at every visit, about tobacco use then document this status in the EHR. Patients ready to quit were electronically referred to the quitline for tobacco cessation counseling. Documentation of tobacco status, ongoing verification of tobacco use, and chief complaint recording was compared before and after the intervention. Logistic regression analysis indicated that after adjusting for differences between care centers, there were increased odds in initial documentation (OR = 1.52; 95% CI = 1.42 - 1.62) and ongoing verification (OR = 2.86; 95% CI = 1.42 - 1.62) in 2010 in comparison with 2009. Recording of tobacco cessation as the chief complaint in current smokers increased 91% (OR = 1.91; 95% CI = 1.56 - 2.34). Documentation and referrals for smoking cessation can be increased in organizations using EHR by empowering MAs to promote tobacco cessation and providing electronic referral options.

Disparities in receipt of adjuvant radiation therapy after breast-conserving surgery among the cancer-reporting regions of California.

BACKGROUND: Incidence and mortality of breast cancer vary according to demographic factors such as age, race/ethnicity, socioeconomic status (SES), and geographic region. This study assesses the variation of these factors in the use of adjuvant radiation therapy (RT) after breast-conserving surgery (BCS) among 8 regions of California. METHODS: The authors identified 85,574 cases of first primary female invasive breast cancer with complete data diagnosed between January 1, 2000 and December 31, 2007. Logistic regression was used to determine the association between race/ethnicity, age, SES, and receipt of RT after BCS within each of the regions of California. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed. RESULTS: Age was a significant predictor of receipt of RT after BCS in all regions. In Los Angeles (LA), lower SES was associated with decreasing odds of RT. Racial disparities were evident only in LA, where black (OR, 0.85; 95% CI, 0.74-0.97) and Hispanic (OR, 0.86; 95% CI, 0.78-0.96) women were about 15% less likely to receive RT than white women. CONCLUSIONS: Racial disparities in the receipt of RT after BCS exist only in LA, where African American and Hispanic women are less likely to receive this form of adjuvant treatment. Lower SES was also associated with a reduced likelihood of receipt of RT in LA. Women age 70 years and older are less likely to receive RT after BCS in all regions of California.

Influence of temperature and performance level on pacing a 161 km trail ultramarathon.

BACKGROUND: Even pacing has been recommended for optimal performances in running distances up to 100 km. Trail ultramarathons traverse varied terrain, which does not allow for even pacing. PURPOSE: This study examined differences in how runners of various abilities paced their efforts in the Western States Endurance Run (WSER), a 161 km trail ultramarathon in North America, under hot vs cooler temperatures. METHOD: Temperatures in 2006 (hot) and 2007 (cooler) ranged from 7-38°C and 2-30°C, respectively. Arrival times at 13 checkpoints were recorded for 50 runners who finished the race in both years. After stratification into three groups based on finish time in 2007 (<22, 22-24, 24-30 h), paired t tests were used to compare the difference in pace across checkpoints between the years within each group. The χ2 test was used to compare differences between the groups on the number of segments run slower in the hot vs cooler years. RESULTS: For all groups, mean pace across the entire 161 km race was slower in 2006 than in 2007 (9:23 ± 1:13 min/km vs 8:42 ± 1:15 min/km, P < .001) and the pace was slower from the start of the race when temperatures were still relatively cool. Overall, the <22 h cohort ran slower in 2006 than 2007 over 12 of the 14 segments examined, the 22-24 h cohort was slower across 10 of the segments, and the >24 h cohort was slower across only 6 of the segments χ(2)2 = 6.00, P = .050). Comparable pacing between the 2 y corresponded with onset of nighttime and cooling temperatures. CONCLUSIONS: Extreme heat impairs all runners' ability to perform in 161 km ultramarathons, but faster runners are at a greater disadvantage compared with slower competitors because they complete a greater proportion of the race in the hotter conditions.

Variation in breast cancer subtypes with age and race/ethnicity.

BACKGROUND: Both age and race have been identified as independent predictors of breast cancer subtype but the association of age with subtype within each race is not well understood. This study assesses the association of age with the eight breast cancer subtypes as defined by ER/PR/HER2 among white, African-American, Hispanic, and Asian/Pacific Islander women. METHODS: This study included 69,358 women with primary invasive breast cancer. Logistic regression was used to assess the association of age with each of the ER/PR/HER2 subtypes for each race adjusted for socioeconomic status, stage, grade, and tumor size. RESULTS: The odds of African-American women having a triple-negative tumor were not statistically significantly increased for women under 46 when compared to the African-American women aged 46-69 (OR=0.96; 95% CI=0.80-1.16). A similar pattern was observed for the ER-/PR-/HER2+ subtype. Hispanic women under age 46 (OR=0.83; 95% CI=0.71-0.97) and over age 70 (OR=0.71; 95% CI=0.57-0.89) were less likely to have the ER-/PR-/HER2+ subtype. Asian/Pacific Islander women under age 46 also had reduced odds (OR=0.67; 95% CI=0.55-0.82) of the ER-/PR-/HER2+ subtype. CONCLUSIONS: The ER/PR/HER2 subtypes vary with age and differences in this variation depend on race. It is important to define breast cancer using the ER/PR/HER2 subtype and the significance of age and race should not be overlooked.

Breast cancer subtypes as defined by the estrogen receptor (ER), progesterone receptor (PR), and the human epidermal growth factor receptor 2 (HER2) among women with invasive breast cancer in California, 1999-2004.

Breast cancer research examining either molecular profiles or biomarker subtypes has focused on the estrogen receptor negative/progesterone receptor negative/human epidermal growth factor receptor 2 negative (ER-/PR-/HER2-) and ER-/PR-/HER2+ subtypes. Less is known about the epidemiology or clinical outcome of the other subtypes. This study examines the eight combinations of ER/PR/HER2 in patients with invasive breast cancer. The 5-year relative survival and the distribution among demographic, socioeconomic, and tumor characteristics of each of the subtypes are examined. Using the California Cancer Registry, 61,309 women with primary invasive breast cancer were classified according to ER/PR/HER2 status. Five-year relative survival was computed for the eight subtypes. Bivariate analyses were used to assess the distribution of cases across all subtypes. Multivariate logistic regression was used to compute the adjusted odds of having one of the five subtypes with the best and worst survival. Survival varied from 96% (ER+/PR+/HER2-) to 76% (ER-/PR-/HER2+ and ER-/PR-/HER2-). The four subtypes with the poorest survival were all ER negative. Women who were younger than age 50, non-Hispanic black or Hispanic, of the lowest SES groups, and had stage IV tumors that were undifferentiated were overrepresented in ER-/PR-/HER2+ and triple negative (ER-/PR-/HER2-) subtypes. Asian Pacific Islanders had increased odds (OR = 1.41; 95% confidence interval [CI] = 1.26-1.57) of having the ER-/PR-/HER2+ subtype. Stage III tumors (OR = 1.25; 95% CI = 1.08-1.44) and stage IV tumors (OR = 1.58; 95% CI = 1.27-1.98) had higher odds than stage I tumors of being ER-/PR-/HER2+. Stage IV tumors (OR = 0.54; 95% CI = 0.44-0.67) strongly decreased the odds of the ER-/PR-/HER2- subtype. Poorly differentiated and undifferentiated tumors were over 20 times as likely as well-differentiated tumors of being ER-/PR-/HER2- or ER-/PR-/HER2+. There are considerable differences in survival, demographics, and tumor characteristics among the eight subtypes. We recommend reporting breast cancer as an ER/PR/HER2 subtype and precisely documenting demographic and tumor characteristics.

The role of human epidermal growth factor receptor 2 in the survival of women with estrogen and progesterone receptor-negative, invasive breast cancer: the California Cancer Registry, 1999-2004.

BACKGROUND: Breast cancers that are negative for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) (triple negative [TN]) have been associated with high-grade histology, aggressive clinical behavior, and poor survival. It has been determined that breast cancers that are negative for ER and PR but positive for HER2 (double negative [DN]) share features with TN breast cancers. In this report, the authors quantified the contribution of HER2 as well as demographic and tumor characteristics to the survival of women with TN tumors, DN tumors, and other breast cancers (OBC). METHODS: In total, 61,309 women who were diagnosed with invasive breast cancer between 1999-2004 were identified in the California Cancer Registry. Demographic and tumor characteristics of women with TN tumors were compared with those from women with DN tumors and women with OBC. A compound proportional hazards regression analysis (PHPH) (a generalization of the Cox proportional hazards model) was used to model these characteristics. RESULTS: Women with TN tumors were younger, African American, Hispanic, and of lower socioeconomic status (SES), whereas women with DN tumors were slightly older; African American, and Asian/Pacific Islander. Women with TN and DN tumors presented with larger, higher grade, and higher stage than women with OBC. Survival among women with TN tumors was poorer compared with that among women with OBC but was nearly the same as that of women with DN tumors. Results of the regression analysis indicated that disease stage, tumor grade, SES, and race/ethnicity were significant risk factors for survival. Negative ER and PR status was associated with an increased risk of death. There was a small but significant difference in both long-term and short-term survival patients who had TN tumors compared with patients who had DN tumors. CONCLUSIONS: Patients with TN tumors shared many clinical, demographic, and tumor features and had survival that was very similar survival to that of patients with DN tumors, and survival for both groups contrasted greatly with survival for patients with OBC. Disease stage, tumor grade, SES, race/ethnicity, negative ER and PR status, rather than negative HER2 status, were risk factors for survival.