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Socioeconomic disparities in breast cancer survival: relation to stage at diagnosis, treatment and race
Xue Yu
BMC Cancer , 2009, DOI: 10.1186/1471-2407-9-364
Abstract: Women diagnosed with breast cancer during 1998-2002 in the 13 SEER cancer registry areas were followed-up to the end of 2005. The association between an area-based measure of SES and cause-specific five-year survival was estimated using Cox regression models. Six models were used to assess the extent to which SES differences in survival were explained by clinical and demographical factors. The base model estimated the hazard ratio (HR) by SES only and then additional adjustments were made sequentially for: 1) age and year of diagnosis; 2) stage at diagnosis; 3) first course treatment; 4) race; and 5) rural/urban residence.An inverse association was found between SES and risk of dying from breast cancer (p < 0.0001). As area-level SES falls, HR rises (1.00 → 1.05 → 1.23 → 1.31) with the two lowest SES groups having statistically higher HRs. This SES differential completely disappeared after full adjustment for clinical and demographical factors (p = 0.20).Stage at diagnosis, first course treatment and race explained most of the socioeconomic disparity in breast cancer survival. Targeted interventions to increase breast cancer screening and treatment coverage in patients with lower SES could reduce much of socioeconomic disparity.Previous studies have documented substantial disparities in breast cancer survival in relation to socioeconomic status (SES) as measured either at the individual [1,2] or area levels [3-6] in the United States, with women in lower SES groups showing poorer survival. Factors that may mediate these disparities include differences in the stage at diagnosis, access to and quality of care delivered and other correlates of low SES [7]. Women with less education and those who are unemployed, reside in a poor area, or are uninsured or under-insured are more likely to be diagnosed at later stages [8-10], and are less likely to receive optimal cancer care [11,12]. Race has been reported to be related with breast cancer survival independently of SES [5,
The influence of nativity and neighborhoods on breast cancer stage at diagnosis and survival among California Hispanic women
Theresa HM Keegan, Thu Quach, Sarah Shema, Sally L Glaser, Scarlett L Gomez
BMC Cancer , 2010, DOI: 10.1186/1471-2407-10-603
Abstract: We studied 37,695 Hispanic women diagnosed from 1988 to 2005 with invasive breast cancer from the California Cancer Registry. Nativity was based on registry data or, if missing, imputed from case Social Security number. Neighborhood variables were developed from Census data. Stage at diagnosis was analyzed with logistic regression, and survival, based on vital status determined through 2007, was analyzed with Cox proportional hazards regression.Compared to US-born Hispanics, foreign-born Hispanics were more likely to be diagnosed at an advanced stage of breast cancer (adjusted odds ratio (OR) = 1.14, 95% confidence interval (CI): 1.09-1.20), but they had a somewhat lower risk of breast cancer specific death (adjusted hazard ratio (HR) = 0.94, 95% CI: 0.90-0.99). Living in low SES and high enclave neighborhoods was associated with advanced stage of diagnosis, while living in a lower SES neighborhood, but not Hispanic enclave, was associated with worse survival.Identifying the modifiable factors that facilitate this survival advantage in Hispanic immigrants could help to inform specific interventions to improve survival in this growing population.For United States (US) Hispanic (also known as Latina) women, breast cancer is the most commonly diagnosed cancer and the leading cause of cancer death [1]. However, within this population group, breast cancer patterns differ by nativity. Hispanic women who are foreign-born (representing approximately 40% of this large and growing minority group [2,3]) have lower rates of breast cancer incidence [4-6] and mortality [7,8] than those who are US-born; however, despite these lower rates, foreign-born Hispanics have a higher likelihood of late stage disease at breast cancer diagnosis and lower likelihood of receiving guideline-concordant treatment compared to US-born Hispanics [9]. Furthermore, foreign-born Hispanics also tend to live in Hispanic enclaves (neighborhoods with other Hispanics or Hispanic immigrants) [10,11], which a
Trends in Breast Cancer Incidence Rates by Age and Stage at Diagnosis in Gharbiah, Egypt, over 10 Years (1999–2008)  [PDF]
Kelly A. Hirko,Amr S. Soliman,Ahmed Hablas,Ibrahim A. Seifeldin,Mohamed Ramadan,Mousumi Banerjee,Joe B. Harford,Robert M. Chamberlain,Sofia D. Merajver
Journal of Cancer Epidemiology , 2013, DOI: 10.1155/2013/916394
Abstract: Background. This study was undertaken to evaluate trends in breast cancer incidence in Egypt from 1999 to 2008 and to make projections for breast cancer occurrence for the years 2009–2015. Patients and Methods. We utilized joinpoint regression and average annual percent change (AAPC) measures with 95% confidence intervals (CI) to describe the trends in breast cancer incidence rates from the Gharbiah Cancer Registry by age and stage at diagnosis and to estimate expected breast cancer caseloads for 2009–2015. Results. From 1999 to 2008, the AAPC in breast cancer incidence rates in Gharbiah significantly increased among women 50 years and older and among localized tumors (AAPC %, 95% CI, 3.1% to 8.0%). Our results predict a significant increase in breast cancer caseloads from 2009 to 2015 among women aged 30–39 (AAPC %, 95% CI, 0.9% to 1.1%) and among women aged 40–49 years (AAPC %, 95% CI, 1.0% to 2.6%). Conclusion. These results have important implications for allocating limited resources, managing treatment needs, and exploring the consequences of prior interventions and/or changing risk factors in Egypt and other developing countries at the same stages of demographic and health transitions. 1. Introduction Breast cancer rates are increasing in developing countries, including Egypt, and are largely attributed to aging of the population, delay in time of first pregnancy, decrease in number of children and in breastfeeding, and a move toward high-calorie Western diets [1–4]. Although breast cancer incidence rates in Egypt are substantially lower than the rates in the United States and other developed countries [5–7], breast cancer is the most common cancer among women in Egypt [8]. Furthermore, the current demographic trends favor the likelihood that breast cancer will become an even greater public health concern in Egypt in the future. Trends in the stage at diagnosis of breast cancer in the Gharbiah registry have not been reported, and this information is critical for evaluation of downstaging efforts. Detailed information on trends of breast cancer by stage of diagnosis may promote the reduction of disparities in the presentation of disease by focusing limited resources on the susceptible populations and can aid in our overall understanding of the etiology of breast cancer in a setting that differs in regard to its risk factor profile as compared to many developed countries. The specific aim of this study was to examine trends in breast cancer incidence by age, stage, and hormone receptor status in the Gharbiah registry from 1999 to 2008. Further, we
Stage of diagnosis: the impact of awareness campaigns on breast cancer  [PDF]
Bouchbika Z,Serhier Z,Sahraoui S,Bennani-Othmani M
Pratiques et Organisation des Soins , 2012,
Abstract: Summary Aim: Breast cancer is the most common cancer of women. In our context approximately 60% of cases are diagnosed in advanced stages due to late diagnosis. Since the creation of the Lalla Salma Association to Fight Against Cancer (ALSC) in 2005, awareness raising campaigns on breast cancer have been conducted to promote early diagnosis and screening. The main objective of our study is to evaluate the impact of awareness campaigns on breast cancer organized by the Lalla Salma Association Against Cancer on the evolution of the distribution by stage at diagnosis. Methods: In our study we included 1162 patients, of which 574 were recruited in 2004 (before any awareness campaign) and 588 in 2009 (after the first national awareness campaigns on cancer in general and breast cancer). Results: The percentage of patients who consulted with a delay of less than three months has increased significantly in 2009 (p < 0.001), which could be the cause of the significant increase in localized stages diagnosed in 2009: 56.4% in 2004 versus 68.6% in 2009 (p < 0.001). This has resulted in a significant increase in the rate of conservative treatment carried out during 2009: 16.5% in 2004 versus 25.2% in 2009 (p < 0.001). Conclusion: Promotion of early diagnosis of breast cancer (breast self / clinical examination medical) in Morocco seen the hospital data showing that breast cancer is still currently diagnosed at a late stage is essential and indispensable in the coming years. Prat Organ Soins. 2012;43(4):269-275
Diagnosis delay in Libyan female breast cancer
Eramah Ermiah, Fathi Abdalla, Abdelbaset Buhmeida, Entesar Larbesh, Seppo Pyrh?nen, Yrj? Collan
BMC Research Notes , 2012, DOI: 10.1186/1756-0500-5-452
Abstract: 200 women, aged 22 to 75 years with breast cancer diagnosed during 2008–2009 were interviewed about the period from the first symptoms to the final histological diagnosis of breast cancer. This period (diagnosis time) was categorized into 3 periods: <3 months, 3–6 months, and >6 months. If diagnosis time was longer than 3 months, the diagnosis was considered delayed (diagnosis delay). Consultation time was the time taken to visit the general practitioner after the first symptoms. Retrospective preclinical and clinical data were collected on a form (questionnaire) during an interview with each patient and from medical records.The median of diagnosis time was 7.5 months. Only 30.0% of patients were diagnosed within 3 months after symptoms. 14% of patients were diagnosed within 3–6 months and 56% within a period longer than 6 months. A number of factors predicted diagnosis delay: Symptoms were not considered serious in 27% of patients. Alternative therapy (therapy not associated with cancer) was applied in 13.0% of the patients. Fear and shame prevented the visit to the doctor in 10% and 4.5% of patients, respectively. Inappropriate reassurance that the lump was benign was an important reason for prolongation of the diagnosis time. Diagnosis delay was associated with initial breast symptom(s) that did not include a lump (p?<?0.0001), with women who did not report monthly self examination (p?<?0.0001), with old age (p?=?0.004), with illiteracy (p?=?0.009), with history of benign fibrocystic disease (p?=?0.029) and with women who had used oral contraceptive pills longer than 5 years (p?=?0.043). At the time of diagnosis, the clinical stage distribution was as follows: 9.0% stage I, 25.5% stage II, 54.0% stage III and 11.5% stage IV.Diagnosis delay was associated with bigger tumour size (p <0.0001), with positive lymph nodes (N2, N3; p?<?0.0001), with high incidence of late clinical stages (p?<?0.0001), and with metastatic disease (p?<?0.0001).Diagnosis delay is very seri
Age at Diagnosis and Breast Cancer Survival in Iran  [PDF]
Fatemeh Asadzadeh Vostakolaei,Mireille J. M. Broeders,Nematollah Rostami,Jos A. A. M. van Dijck,Ton Feuth,Lambertus A. L. M. Kiemeney,André L. M. Verbeek
International Journal of Breast Cancer , 2012, DOI: 10.1155/2012/517976
Abstract: Background. Tumour characteristics are the most important prognostic factors in breast cancer. Patient-related factors such as young age at diagnosis, obesity, and smoking behaviour may also modify disease outcome. Due to the absence of a unique definition for “young age breast cancer” and the resulting variation in disease management, findings on the association between young age and prognosis of breast cancer are controversial. Methods. This study included 1500 patients with a primary diagnosis of breast cancer in six Iranian hospitals from 5 provinces. We modelled the relative excess risk (RER) of breast cancer death to age at diagnosis and tumour characteristics. Results. Excess risks of death were observed for stage IV disease and poorly differentiated tumours: RER of 4.3 (95% CI: 1.05–17.65) and 3.4 (95% CI: 1.17–9.87), respectively. “Older” patients, particularly those aged 50 and over, presented more often with advanced and poorly differentiated tumours ( ). After adjustment for stage, histological grade, Her-2 expression, estrogen and progesterone receptors, and place of residency, breast cancer mortality was not significantly different across age groups. Conclusion. We conclude that there is no prognostic effect of age at diagnosis of breast cancer among breast cancer patients treated at cancer centres in different parts of Iran; young and relatively old women have similar risks of dying from breast cancer. 1. Background Tumour characteristics such as size, tumour grade, receptor status, and lymph node involvement are known to be the most important prognostic factors in breast cancer [1, 2]. Patient-related factors such as obesity, cigarette smoking, alcohol consumption, and age may modify disease outcome [3–6]. The prognostic value of age at diagnosis is particularly controversial due to the fact that there is no worldwide consensus on age boundaries for the definition of “young” age breast cancer. In the literature, the cut-off point of young age varies and has been set at age, 30, 35, 40, and 45. As a consequence, variation in disease management may occur in patients of similar age. Most reports on risks of young age breast cancer come from western countries with small proportions of young patients [7–13]. Some of these studies suggested that negative prognostic influence of young age is thought to be related to the less favourable tumour characteristics as presented by young women. However, neither the worse influence in its own nor the factors that have been suggested to explain the influence of young age are universally accepted. In
Estimation of age- and stage-specific Catalan breast cancer survival functions using US and Catalan survival data
Ester Vilaprinyo, Montserrat Rué, Rafael Marcos-Gragera, Montserrat Martínez-Alonso
BMC Cancer , 2009, DOI: 10.1186/1471-2407-9-98
Abstract: Cubic splines were used to smooth data and obtain continuous hazard rate functions. After, we fitted a Poisson model to derive hazard ratios. The model included time as a covariate. Then the hazard ratios were applied to US survival functions detailed by age and stage to obtain Catalan estimations.We started estimating the hazard ratios for Catalonia versus the USA before and after the introduction of screening. The hazard ratios were then multiplied by the age- and stage-specific breast cancer hazard rates from the USA to obtain the Catalan hazard rates. We also compared breast cancer survival in Catalonia and the USA in two time periods, before cancer control interventions (USA 1975–79, Catalonia 1980–89) and after (USA and Catalonia 1990–2001). Survival in Catalonia in the 1980–89 period was worse than in the USA during 1975–79, but the differences disappeared in 1990–2001.Our results suggest that access to better treatments and quality of care contributed to large improvements in survival in Catalonia. On the other hand, we obtained detailed breast cancer survival functions that will be used for modeling the effect of screening and adjuvant treatments in Catalonia.Mortality from breast cancer has been decreasing in the majority of industrialized countries since the beginning of the 1990s. Extended use of mammography screening and improvements in adjuvant therapies have been indicated as the causes of this decline. Adjuvant therapies are drugs, usually chemotherapy or hormonotherapy, used as additional treatments for patients with cancers that are thought to have spread beyond their original sites.On one hand, screening with mammography may reduce breast cancer mortality, because more tumors are detected at earlier stages where survival time is longer. On the other hand, concurrently with mammography use, the introduction of adjuvant therapies also may have increased the survival time at all stages of the disease and modified the survival functions.Based on a col
Diagnosis delay of breast cancer and its associated factors in Malaysian women
Bachok Norsa'adah, Krishna G Rampal, Mohd A Rahmah, Nyi N Naing, Biswa M Biswal
BMC Cancer , 2011, DOI: 10.1186/1471-2407-11-141
Abstract: This study had a cross-sectional design. Respondents had histologically confirmed breast cancer and were registered at five medical centres between 2005 and 2007. All breast cancer patients who attended hospital clinics at the East Coast were included. Patients at Kuala Lumpur hospitals were selected by systematic sampling. A standardised questionnaire was developed to interview respondents. We measured the time from the first recognition of symptoms to the first general practitioners' consultation and to the histological diagnosis of breast cancer. Diagnosis delay was defined when there was more than 6 months from the recognition of symptoms to the histological diagnosis. Multiple logistic regression was used for analysis.In total, 328 respondents were included. The mean (standard deviation) age was 47.9 (9.4) years. Most respondents were of Malay ethnicity, were married housewives with a median family income of RM1500 a month. Most respondents had ductal carcinoma (89.3%) and the stage distribution was as follows: 5.2% stage I, 38.7% stage II, 44.8% stage III and 11.3% stage IV. The median time to consultation was 2 months and the median time to diagnosis was 5.5 months. The frequency of diagnosis delay of more than 3 months was 72.6% and delay of more than 6 months occurred in 45.5% of the cases. The factors associated with diagnosis delay included the use of alternative therapy (odds ratio (OR) 1.77; 95% confidence interval (CI): 1.06, 2.94), breast ulcer (OR 5.71; 95% CI: 1.59, 20.47), palpable axillary lymph nodes (OR 2.19; 95% CI: 1.23, 3.90), false-negative diagnostic test (OR 5.32; 95% CI: 2.32, 12.21), non-cancer interpretation (OR 1.68; 95% CI: 1.01, 2.78) and negative attitude toward treatment (OR 2.09; 95% CI: 1.15, 3.82).Delays in consultation and diagnosis are serious problems in Malaysia. Diagnosis delay was influenced by complex interactions between many factors. Breast awareness and education are required to promote early detection, diagnosis and t
Pathways to breast cancer diagnosis and treatment: exploring the social relations of diagnostic delay
Angus, Jan;Paszat, Lawrence;McKeever, Patricia;Trebilcock, Anne;Shivji, Farzina;Edwards, Beth;
Texto & Contexto - Enfermagem , 2007, DOI: 10.1590/S0104-07072007000400002
Abstract: in epidemiological studies, inequitable access to breast cancer care aligns with such variables as income, age, education, ethnicity and residential location. these variables correspond to structural patterns of advantage and disadvantage, which in turn may constrain or facilitate timely access to care. the purpose of this study was to understand the complexities of women's pathways to diagnosis. thirty-five women from diverse backgrounds and who had clinically detectable breast symptoms at time of diagnosis participated in semi-structured interviews. all were receiving or completing treatment when they participated. data were analyzed using the strategies of induction, comparison and abduction. all of the participants described a variety of activities involved in seeking care for breast cancer. the findings illustrate how the social relations of health care, rather than simply patient or provider delay, may contribute barriers to timely diagnosis. we illustrate how women's widely differing social and material contexts offer opportunities and barriers to access.
Breast implants following mastectomy in women with early-stage breast cancer: prevalence and impact on survival
Gem M Le, Cynthia D O'Malley, Sally L Glaser, Charles F Lynch, Janet L Stanford, Theresa HM Keegan, Dee W West
Breast Cancer Research , 2005, DOI: 10.1186/bcr974
Abstract: We analyzed data from the Surveillance, Epidemiology and End Results Breast Implant Surveillance Study conducted in San Francisco–Oakland, in Seattle–Puget Sound, and in Iowa. This population-based, retrospective cohort included women younger than 65 years when diagnosed with early or unstaged first primary breast cancer between 1983 and 1989, treated with mastectomy. The women were followed for a median of 12.4 years (n = 4968). Breast implant usage was validated by medical record review. Cox proportional hazards models were used to estimate hazard rate ratios for survival time until death due to breast cancer or other causes for women with and without breast implants, adjusted for relevant patient and tumor characteristics.Twenty percent of cases received postmastectomy breast implants, with silicone gel-filled implants comprising the most common type. Patients with implants were younger and more likely to have in situ disease than patients not receiving implants. Risks of breast cancer mortality (hazard ratio, 0.54; 95% confidence interval, 0.43–0.67) and nonbreast cancer mortality (hazard ratio, 0.59; 95% confidence interval, 0.41–0.85) were lower in patients with implants than in those patients without implants, following adjustment for age and year of diagnosis, race/ethnicity, stage, tumor grade, histology, and radiation therapy. Implant type did not appear to influence long-term survival.In a large, population-representative sample, breast implants following mastectomy do not appear to confer any survival disadvantage following early-stage breast cancer in women younger than 65 years old.Over the past 30 years, an estimated 1.5–2 million women have received breast implants in the United States [1]. Starting in the 1980s, widespread public health concern arose regarding their potential adverse health effects [2]. Numerous epidemiologic investigations have focused on systemic complications, particularly cancer and connective tissue disease, but have found no s
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