Among U.S. women, breast cancer is the most commonly diagnosed cancer (excluding skin cancers) and the second leading cause of cancer death, following lung cancer. In 2012, an estimated 226,870 new cases of invasive breast cancer and 39,510 breast cancer deaths are expected to occur among U.S. women. Breast cancer rates vary largely by race/ethnicity and socioeconomic status (SES), and geographic region. Death rates are higher in African American women than in whites, despite their lower incidence rates. Historically, breast cancer was recognized as a disease of western countries. However, over the past 20 years, breast cancer incidence and mortality rates have been increasing rapidly in economically less developed regions. According to 2008 GLOBOCAN estimates, half of the new worldwide breast cancer cases (1.38 million) and 60 % of the breast cancer deaths (458,000) occurred in developing countries. This chapter reviews breast cancer incidence and mortality patterns among women in the U.S. and worldwide, and the possible explanations for these patterns.

Breast Cancer Statistics

Background Studies have documented the underrepresentation of women and blacks in clinical trials, and their recruitment is now federally mandated. However, little is known about the level of participation of elderly patients. We determined the rates of enrollment of patients 65 years of age or older in trials of treatment for cancer. Methods We analyzed data on 16,396 patients consecutively enrolled in 164 Southwest Oncology Group treatment trials between 1993 and 1996 according to sex, race (black or white), and age under 65 years or 65 or older. These rates were compared with the corresponding rates in the general population of patients with cancer, derived from the 1990 U.S. Census and from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program for the period from 1992 through 1994. Fifteen types of cancer were included in the analysis. Results The overall proportions of women and blacks enrolled in Southwest Oncology Group trials were similar to or the same as the estimat...

https://www.nejm.org/doi/pdf/10.1056/NEJM199912303412706

Underrepresentation of patients 65 years of age or older in cancer-treatment trials.

ContextDespite the importance of diversity of cancer trial participants with
regard to race, ethnicity, age, and sex, there is little recent information
about the representation of these groups in clinical trials.ObjectiveTo characterize the representation of racial and ethnic minorities,
the elderly, and women in cancer trials sponsored by the National Cancer Institute.Design, Setting, and PatientsCross-sectional population-based analysis of all participants in therapeutic
nonsurgical National Cancer Institute Clinical Trial Cooperative Group breast,
colorectal, lung, and prostate cancer clinical trials in 2000 through 2002.
In a separate analysis, the ethnic distribution of patients enrolled in 2000
through 2002 was compared with those enrolled in 1996 through 1998, using
logistic regression models to estimate the relative risk ratio of enrollment
for racial and ethnic minorities to that of white patients during these time
periods.Main Outcome MeasureEnrollment fraction, defined as the number of trial enrollees divided
by the estimated US cancer cases in each race and age subgroup.ResultsCancer research participation varied significantly across racial/ethnic
and age groups. Compared with a 1.8% enrollment fraction among white patients,
lower enrollment fractions were noted in Hispanic (1.3%; odds ratio [OR] vs
whites, 0.72; 95% confidence interval [CI], 0.68-0.77; P<.001) and black (1.3%; OR, 0.71; 95% CI, 0.68-0.74; P<.001) patients. There was a strong relationship between age and
enrollment fraction, with trial participants 30 to 64 years of age representing
3.0% of incident cancer patients in that age group, in comparison to 1.3%
of 65- to 74-year-old patients and 0.5% of patients 75 years of age and older.
This inverse relationship between age and trial enrollment fraction was consistent
across racial and ethnic groups. Although the total number of trial participants
increased during our study period, the representation of racial and ethnic
minorities decreased. In comparison to whites, after adjusting for age, cancer
type, and sex, patients enrolled in 2000 through 2002 were 24% less likely
to be black (adjusted relative risk ratio, 0.76; 95% CI, 0.65-0.89; P<.001). Men were more likely than women to enroll in
colorectal cancer trials (enrollment fractions: 2.1% vs 1.6%, respectively;
OR, 1.30; 95% CI, 1.24-1.35; P<.001) and lung
cancer trials (enrollment fractions: 0.9% vs 0.7%, respectively; OR, 1.23;
95% CI, 1.16-1.31; P<.001).ConclusionsEnrollment in cancer trials is low for all patient groups. Racial and
ethnic minorities, women, and the elderly were less likely to enroll in cooperative
group cancer trials than were whites, men, and younger patients, respectively.
The proportion of trial participants who are black has declined in recent
years.

https://jamanetwork.com/journals/jama/articlepdf/198896/JOC32348.pdf

Participation in Cancer Clinical Trials: Race-, Sex-, and Age-Based Disparities

This guideline from the USPSTF is based on current evidence on mammography, digital breast tomography, and supplemental screening for breast cancer. The recommendations apply to asymptomatic women ...

/pdf/screening-for-breast-cancer-u-s-preventive-services-task-4hi5mt179k.pdf

Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement

Summary Background Cancer survival varies widely between countries. The CONCORD study provides survival estimates for 1·9 million adults (aged 15–99 years) diagnosed with a first, primary, invasive cancer of the breast (women), colon, rectum, or prostate during 1990–94 and followed up to 1999, by use of individual tumour records from 101 population-based cancer registries in 31 countries on five continents. This is, to our knowledge, the first worldwide analysis of cancer survival, with standard quality-control procedures and identical analytic methods for all datasets. Methods To compensate for wide international differences in general population (background) mortality by age, sex, country, region, calendar period, and (in the USA) ethnic origin, we estimated relative survival, the ratio of survival noted in the patients with cancer, and the survival that would have been expected had they been subject only to the background mortality rates. 2800 life tables were constructed. Survival estimates were also adjusted for differences in the age structure of populations of patients with cancer. Findings Global variation in cancer survival was very wide. 5-year relative survival for breast, colorectal, and prostate cancer was generally higher in North America, Australia, Japan, and northern, western, and southern Europe, and lower in Algeria, Brazil, and eastern Europe. CONCORD has provided the first opportunity to estimate cancer survival in 11 states in USA covered by the National Program of Cancer Registries (NPCR), and the study covers 42% of the US population, four-fold more than previously available. Cancer survival in black men and women was systematically and substantially lower than in white men and women in all 16 states and six metropolitan areas included. Relative survival for all ethnicities combined was 2–4% lower in states covered by NPCR than in areas covered by the Surveillance Epidemiology and End Results (SEER) Program. Age-standardised relative survival by use of the appropriate race-specific and state-specific life tables was up to 2% lower for breast cancer and up to 5% lower for prostate cancer than with the census-derived national life tables used by the SEER Program. These differences in population coverage and analytical method have both contributed to the survival deficit noted between Europe and the USA, from which only SEER data have been available until now. Interpretation Until now, direct comparisons of cancer survival between high-income and low-income countries have not generally been available. The information provided here might therefore be a useful stimulus for change. The findings should eventually facilitate joint assessment of international trends in incidence, survival, and mortality as indicators of cancer control. Funding Centers for Disease Control and Prevention (Atlanta, GA, USA), Department of Health (London, UK), Cancer Research UK (London, UK).

https://www.thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(08)70179-7.pdf

Cancer survival in five continents: a worldwide population-based study (CONCORD)

Background : The National Cancer Institute (NCI)-sponsored clinical trials cooperative groups place more than 25 000 American patients in treatment trials every year. Equal access and proportional representation of all races/ethnicities is desired. Purpose : Our objectives were to evaluate the inclusion of African-Americans, Hispanics, and non-Hispanic whites in NCI-sponsored treatment trials and to determine if there is proportional racial/ethnic representation. Methods : During the period of January 1, 1991, through June 30, 1994, 99 495 cancer patients were enrolled in clinical trials and declared themselves as non-Hispanic black, non-Hispanic white, or Hispanic (of any race). In the analysis, participants in NCI treatment trials were subdivided into three age groups : birth to 19 years, 20-49 years, and 50 or more years. The racial/ethnic composition of each of these age groups was compared with the racial/ethnic makeup of the American population with cancer. Estimates of the number of incident cancer cases per year were made for each racial/ethnic group within each age group using data from the Surveillance, Epidemiology, and End Results (SEER) Program and the 1990 Census. The percentage of all cancer patients who were in each racial/ethnic group were compared with the population that entered clinical trials. Comparisons are also made separately for patients with leukemia and breast, colorectal, lung, and prostate cancers. Results : Among patients 0-19 years old, 20-49 years old, and 50 years old or older there is relatively proportional representation of non-Hispanic blacks, Hispanics, and non-Hispanic whites in trials. It is noted that more than 70% of cancer patients aged 0-19 years are estimated to enter cooperative group clinical trials compared with 4.0% of cancer patients aged 20-49 years and 1.5% of patients aged 50 years or older. Conclusions : Accrual of American cancer patients to NCI-sponsored treatment trials generally parallels the incident burden of disease among non-Hispanic African-Americans, Hispanics, and non-Hispanic whites. Implications : This study shows that the NCI clinical trials are, as a whole, racially/ethnically representative of the American population and suggests that there is equal access to NCI clinical trials.

/pdf/representation-of-african-americans-hispanics-and-whites-in-386gv07ayi.pdf

Representation of African-Americans, Hispanics, and Whites in National Cancer Institute Cancer Treatment Trials

PURPOSE: Hormone receptor expression (presence-positive or absence-negative) may reflect different stages of one disease or different breast cancer types. Determining whether hormone receptor expression represents one or more breast cancer phenotypes would have important paradigmatic and practical implications. METHODS: Breast cancer records were obtained from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database. The study included 19,541 non-Hispanic white women with node-negative breast cancer. Standard tumor cell characteristics and breast cancer-specific survival were analyzed by independent estrogen receptor (ER+ and ER−), independent progesterone receptor (PR+ and PR−), and joint ERPR expression (ER+PR+, ER+PR−, ER−PR+, and ER−PR−). RESULTS: Age frequency density plots by hormone receptor expression showed two overlapping breast cancer populations with early-onset and/or late-onset etiologies. Independent ER+ and PR+ phenotype were associated with smaller tumor...

Tumor variants by hormone receptor expression in white patients with node-negative breast cancer from the surveillance, epidemiology, and end results database.

African American women are more likely than any other racial or ethnic group to present with a later stage of breast cancer at initial diagnosis. Delay in breast cancer detection is a critical factor in diagnosis at a later stage. Available data indicate a delay of 3 months or more is a significant factor in breast cancer mortalty. Numerous factors have been reported as contributing to delay in time to seek medical care including religiosity, spirituality, and fatalistic beliefs. This study examined the influence of religiosity, spirituality, and cancer fatalism on delay in diagnosis and breast cancer stage in African American women with self-detected breast symptoms. A descriptive correlation, retrospective methodology using an open-ended questionnaire and three validated measurement scales were used: the Religious Problem Solving Scale (RPSS), the Religious Coping Activity Scale (RCAS) subscale measuring spiritually based coping, and the modified Powe Fatalism Inventory (mPFI). A convenience sample of 129 women ages between 30 and 84 years who self-reported detecting a breast symptom before diagnosis of breast cancer within the preceding 12 months were included in the study. Outcome variables were time to seek medical care and breast cancer stage. Other variables of interest included marital status, income, education, insurance status, and to whom the women spoke about their breast symptoms. Data were analyzed using descriptive statistics, logistic regression analysis, Pearson r correlations, Mann-Whitney U analysis, and Chi Square analysis. Participants were found to be highly religious and spiritual but not fatalistic. While most women delayed more than 3 months in seeking medical care, no associations were found between the three predictor variables and time to seek medical care. The median delay in time from self detection of a breast symptom to seeking medical care was 5.5 months. Women who were less educated, unmarried, and talked to God only about their breast change were significantly more likely to delay seeking medical care. An association was found between disclosing a breast symptom to God only and delay in seeking medical care. In contrast, women who had told a person about their breast symptom were more likely to seek medical care sooner. African American women who delayed seeking medical care for longer than 3 months were more likely to present with a later stage of breast cancer than women who sought care within 3 months of symptom discovery.

Religiosity, spirituality, and cancer fatalism beliefs on delay in breast cancer diagnosis in african american women

BACKGROUND:

Diffuse large B-cell lymphoma (DLBCL) is often cured with standard chemoimmunotherapy, but there is great heterogeneity in presentation and outcomes.



METHODS:

By using Surveillance, Epidemiology, and End Results (SEER) data from 13 registries across the United States, the authors examined differences in incidence and survival for DLBCL by race. International Classification of Diseases for Oncology, third edition histology codes 9678, 9679, 9680, and 9684 were used to identify cases.



RESULTS:

From 1992 to 2007, 38,522 cases of DLBCL were recorded in SEER. Sixty-five percent of black patients compared with 37% of white patients presented at age ≤60 years, 52% of blacks compared with 44% of whites presented with stage III/IV disease, and 31% of black versus 24% of white patients presented with B symptoms (all P 60, advanced stage, and B symptoms at diagnosis were predictors of worse survival (P < .001).



CONCLUSIONS:

Black patients with DLBCL in the United States present at younger age, more advanced stage, and have inferior survival. Epidemiological studies that examine the biological variants of DLBCL in concert with race are needed to elucidate the etiology of these disparities. Cancer 2011;. © 2010 American Cancer Society.

Racial differences in the presentation and outcomes of diffuse large B-cell lymphoma in the United States.

Improvements in technology have led to a number of tests that can be used to suggest that a patient has a cancer. Advances in cancer biology and medical imaging have led to a number of cancer screening tests. Cancer screening is commonly advocated, but its complexity is often lost in guidelines that have sound-bite quality. It is commonly viewed as of no harm, when in fact there are harms associated with every known screening test. Indeed, many screening experts believe a screening test should only be used when the potential for benefit clearly outweighs the potential for harm. Cancer screening principles are classically within the realm of the epidemiologist. As more screening tests are developed, these principles have become more relevant to the practicing clinician. What is known and what is unknown about screening is distinctly different from what is believed by the public and many practicing clinicians. Many tests have both screening and diagnostic uses, and it is only the context in which these are used that determines whether they are screening or diagnostic. A screening test is done on asymptomatic individuals who receive the test principally because they are of the age or sex at risk for the cancer. A diagnostic test is done on an individual because of clinical suspicion of disease.

Otis W. Brawley

Papers

Representation of African-Americans, Hispanics, and Whites in National Cancer Institute Cancer Treatment Trials

Tumor variants by hormone receptor expression in white patients with node-negative breast cancer from the surveillance, epidemiology, and end results database.

Religiosity, spirituality, and cancer fatalism beliefs on delay in breast cancer diagnosis in african american women

Racial differences in the presentation and outcomes of diffuse large B-cell lymphoma in the United States.

Cancer screening in theory and in practice