Risk of death after cancer diagnosis; shift in stage of breast cancer diagnosis

To explore the association between SES and mortality, Tim Byers, M.D. of the University of Colorado Denver and colleagues from seven states conducted the Breast, Colon, and Prostate Cancer Data Quality and Patterns of Care (POC) Study, a collaborative inquiry by seven state cancer registries within the National Program of Cancer Registries. The researchers documented compete information on cancer stage, treatment received, and 5-year mortality rates from multiple medical record sources for 13,598 cancer cases diagnosed in seven states in 1997, including 4,844 women with breast cancer, 4,332 men with prostate cancer, and 4,422 men and women with colorectal cancer. They also determined the socioeconomic status of the neighborhood of each patient by using the neighborhood-specific income and education data from the 2000 U.S. census.

Their analysis revealed that for all three types of cancers, individuals of low socioeconomic status had more advanced stages of cancer and received less aggressive treatment. For example, women of low socioeconomic status were less likely to receive radiation treatment after a lumpectomy or to receive anti-estrogen therapy when diagnosed with an estrogen receptor positive (ER+) tumor. Men with prostate cancer who were living in areas of low socioeconomic status were less likely to have been treated by prostatectomy or radiation compared to men from areas of high socioeconomic status. Chemotherapy was also less likely to be used for low socioeconomic status men and women with colorectal cancer.

For all three types of cancer, patients who lived in low SES neighborhoods were more likely to die in the five years following their cancer diagnosis than were patients in higher SES neighborhoods. A substantial proportion of this difference seemed to be due to the combined effects of this less intensive treatment and to a later stage of cancer at the time of diagnosis. While African Americans and Hispanics were more likely than non-Hispanic whites to have lived in areas of low socioeconomic status, the investigators say that the low SES factor was apparent for all racial and ethnic groups. Disparities related to socioeconomic status were not as apparent among patients aged 65 and older, perhaps because nearly everyone over age 65 is provided access to cancer screening and treatment via Medicare, regardless of their socioeconomic status.

"These findings support the need to focus on socioeconomic status as an important underlying factor in cancer disparities by race and ethnicity," the authors concluded. "We need better information on how access to health care contributes to differences in cancer outcomes by socioeconomic status in order to address the root causes of racial and ethnic cancer disparities in the United States," they added.

Article: "The impact of socioeconomic status on survival after cancer in the United States: Findings from the National Program of Cancer Registries Patterns of Care Study." Tim Byers, Holly J. Wolf, Katrina R. Bauer, Susan Bolick-Aldrich, Vivien W. Chen, Jack L. Finch, John P. Fulton, Maria J. Schymura, Tiefu Shen, Scott Van Heest, and Xiang Yin. CANCER; Published Online: June 23, 2008 (DOI: 10.002/cncr.23567); Print Issue Date: August 1, 2008.

OUTREACH INITIATIVES LEAD TO SHIFT IN STAGE OF BREAST CANCER DIAGNOSIS IN AFRICAN AMERICAN WOMEN

A new study indicates that community education outreach and internal navigation programs lead to a significant shift in stage at diagnosis of breast cancer among African American women, with a doubling in the proportion of cases caught at the earliest stage and a nearly reciprocal drop in the proportion of cancers at most advanced stage. The research suggests that initiatives aimed at raising awareness and utilization of breast cancer screening may improve breast cancer survival rates for African American women, who have a higher risk of death from the disease compared to whites. The study is published in the August 1, 2008 issue of CANCER, a peer-reviewed journal of the American Cancer Society.

A disproportionate number of deaths from breast cancer occur in African American women, a disparity attributed to later stage of disease at diagnosis and diagnosis at an earlier age. Treatment differences may also contribute to the higher risk of mortality.

To assess the effectiveness of outreach programs on breast cancer stage among African American women, Sheryl Gabram, M.D., an Emory University surgical oncologist and director of the AVON Comprehensive Breast Center at the Georgia Cancer Center for Excellence at Grady Memorial Hospital in Atlanta, reported on a program implemented in 2001 with two components: Community Health Advocacy and Patient Navigation. The Community Health Advocacy component includes public educational programs that encourage mammography screening, teach the importance of breast self exams, and instruct individuals to see a trained healthcare provider. The Patient Navigation component involves breast cancer survivors who communicate directly with all patients who have been diagnosed with breast cancer in the AVON Breast Center. Patient Navigators (PNs) encourage patients to follow-up with recommended medical care and access needed resources such as finances, transportation, and support services.

Between 2001 and 2004, the program conducted a total of 1,148 community interventions for more than 10,000 participants. During that same time period, a total of 487 patients were identified, diagnosed, and treated for breast cancer at the AVON Comprehensive Breast Center (89 percent African American, 5 percent Caucasian, 2 percent Hispanic, and 4 percent other race/ethnicity). Dr. Gabram and her team found that there was a doubling in the proportion of Stage 0 non-invasive breast cancers (from 12.4 percent to 25.8 percent) over the study period, while the proportion of women diagnosed with Stage IV invasive breast cancers dropped from 16.8 percent to 9.4 percent.

"This reciprocal deviation of Stage 0 versus Stage IV cancers has implications on prognosis, and ultimately outcome for these women if recommended treatment guidelines are followed," the authors wrote. They, along with leadership from Emory University's Rollins School of Public Health team, are currently conducting studies to see if the Patient Navigation program successfully influences patients to accept treatment recommendations and to adhere to appointments after they are diagnosed with breast cancer. (Research has revealed that many patients with breast cancer refuse or do not receive appropriate therapy.)

The authors concluded that programs with Community Health Advocates (CHAs) who encourage mammography screening and stress the importance of early diagnosis should be jointly emphasized with the efforts of the Patient Navigators (PNs) who encourage acceptance of and adherence to treatment standards.

Article: "Effects of an outreach and internal navigation program on breast cancer diagnosis in an urban cancer center with a large African-American population." Sheryl G.A. Gabram, Mary Jo B. Lund, Jessica Gardner, Nadjo Hatchett, Harvey L. Bumpers, Joel Okoli, Monica Rizzo, Barbara J Johnson, Gina B Kirkpatrick, and Otis W. Brawley. CANCER; Published Online: June 23, 2008 (DOI: 10.002/cncr.23568); Print Issue Date: August 1, 2008.

American Cancer Society

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Risk of death after cancer diagnosis; shift in stage of breast cancer diagnosis