Black Women's Health Study Research Articles

Abstract 5252: Prospective cohort study of physical activity and lung cancer risk in the Black Women's Health Study

Abstract Background: Lung cancer is the second most common site of cancer among Black women. Black women have higher incidence rates of lung cancer despite having a lower smoking prevalence than their White counterparts. These differences are not well understood but may be due to differences in smoking behavior and other potential lung cancer risk factors (e.g., physical activity). Lower reported physical activity levels among Black women compared to White women could contribute to observed lung cancer disparities. Previous studies have shown a 20-50% lower risk of lung cancer among those who are physically active but overall, findings are equivocal. To our knowledge, no previous studies have examined the relationship between physical activity and lung cancer risk in Black women and few studies have examined the associations of physical activity with lung cancer risk stratified by smoking status. Objective: The objective of this study is to evaluate the association between physical activity over time and lung cancer incidence in the Black Women's Health Study, and determine if tobacco use modifies this association. Methods: In this ongoing prospective cohort of Black women (analytic cohort n=46217), 291 cases of lung cancer were diagnosed between 1995 (baseline) and 2013. Questionnaire data, collected at baseline and updated every other year thereafter, were used to calculate recreational physical activity (walking for exercise, vigorous physical activity) and smoking history. The Anderson-Gill method was used as a time-varying analysis tool to continuously update exposures and covariates over time. Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals (CIs). Results: At baseline, 65.5% of women were never smokers and 44% reported <1 hr of vigorous physical activity per week. Women who reported any vigorous activity (≥1 hr/wk) had a lower, albeit not statistically significant, risk of lung cancer compared to women with no vigorous activity. In stratified analyses by smoking status, vigorous activity was inversely associated with lung cancer risk among never smokers (HR: 0.37; 95% CI: 0.15, 0.91), but was not associated with risk in former (HR: 1.39; 95% CI: (0.88, 2.21) or current smokers (HR: 1.06; 95% CI: 0.63, 1.77). Conclusion: Our findings suggest that intensity of physical activity may play a role in reducing lung cancer risk among Black women who had never smoked, but the number of lung cancer cases in that category was relatively small. No studies have examined the relationship between physical activity and lung cancer risk in black women and this relationship should be further explored to help reduce lung cancer disparities in the nation. Citation Format: Marsha Samson, Sarah Nomura, Chiranjeev Dash, Traci Bethea, Lynn Rosenberg, Lucile Adams-Campbell. Prospective cohort study of physical activity and lung cancer risk in the Black Women's Health Study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5252.

Abstract 5247: Aspirin use and estrogen receptor-negative breast cancer risk in African American women

Abstract Introduction: Use of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) has been hypothesized to be associated with reduced risk of breast cancer; however, results of epidemiological studies have been mixed. Further, few previous studies investigated these associations among African American women and no studies that included African Americans evaluated whether associations differ by estrogen receptor (ER) status. Methods: To assess the relation of aspirin use to risk of ER+ and ER- breast cancer in African American women, we conducted a prospective analysis within the Black Women's Health Study, an ongoing nationwide cohort of 59,000 black women that began in 1995. On baseline and biennial follow-up questionnaires, women reported regular aspirin use (defined as use at least three days per week) and years of use. Acetaminophen use was queried similarly. Among women with available information on aspirin use, 1701 invasive breast cancers occurred during follow-up through 2015, including 962 ER+ and 492 ER- tumors. All cancers were confirmed through pathology reports or state cancer registry data. We used age-stratified Cox proportional hazards regression models to estimate multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for associations of aspirin use with risk of ER+ and ER- breast cancer. All models adjusted for age at menarche, oral contraceptive use, parity, age at first birth, estrogen plus progestin use, body mass index, alcohol consumption, and use of other NSAIDs. Results: Compared to never use, current regular use of aspirin was associated with lower risk of breast cancer overall (HR 0.87; 95% CI 0.76, 1.00). The association was driven by a statistically significant inverse association for ER- breast cancer (HR 0.76; 95% CI 0.58, 0.99); for ER+ breast cancer, the corresponding HR was 0.92 (95% CI 0.77, 1.09). In contrast, we found no associations with acetaminophen use. Conclusions: Our observation of reduced risk of ER- breast cancer in relation to current regular use of aspirin is consistent with anti-inflammatory effects of aspirin, rather than hormone-dependent pathways. Aspirin may represent a potential opportunity for chemoprevention of ER- breast cancer; however, these findings require corroboration in additional studies. Citation Format: Kimberly A. Bertrand, Traci N. Bethea, Hanna Gerlovin, Patricia Coogan, Lucile L. Adams-Campbell, Lynn Rosenberg, Julie R. Palmer. Aspirin use and estrogen receptor-negative breast cancer risk in African American women [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5247.

Abstract C46: Fruit and vegetable intake and lung cancer incidence among Black women according to cigarette smoking status

Abstract Objective: The objective of this project was to evaluate associations of fruit and vegetable intake, according to cigarette smoking history, with lung cancer incidence among U.S. Black women. Methods: The Black Women's Health Study is a prospective cohort study (analytic cohort=46,889) among Black women between the ages 21-69 at baseline (1995). Fruit and vegetable intake (collected in 1995 and 2001only) and smoking history were ascertained via questionnaires at baseline and during follow-up (every other year). Combined fruit and vegetable (<3, 3-5, ≥5 servings/day), total fruit (<1, 1-<2, ≥2 servings/day), citrus fruit (<1, 1-<2, ≥2 servings/day), total vegetable (<1, 1-<2, ≥2 servings/day), starchy vegetable (<1, 1-<2, ≥2 servings/day), non-starchy vegetable (<0.5, 0.5-<1, >1 servings/day), and cruciferous vegetable (<0.5, 0.5-<1, >1 servings/day) intakes were evaluated. Cigarette smoking measures that were evaluated include: 1) current smoking status (never, former, current <15 cigarettes/day, current ≥15 cigarettes/day); (2) age started smoking (never, <18, ≥18 years); (3) pack-years (never smoked, <10, 10-19, ≥20 pack-years); and (4) combined pack-years + age started smoking (never smoked, <18 years + <10 pack-years, <18 years + 10-19 pack-years, <18 years + ≥20 pack-years, ≥18 years + <10 pack-years, ≥18 years + 10-19 pack-years, ≥18 years + ≥20 pack-years). Cox proportional hazards regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for associations between fruit and vegetable intake and smoking and lung cancer incidence (N=306 cases through 2013) with exposures updated through follow-up. Associations between smoking history and lung cancer were additionally evaluated stratified by fruit and vegetable intake. Likelihood ratio X2 tests were utilized to assess interactions between smoking history and fruit and vegetable intake. Results: More than half the women reported no history of cigarette smoking (66.4%), while 18.4% were former smokers and 15.1% were current smokers (<15 cigarettes/day: 9.7%, ≥15 cigarettes/day: 5.4%). Reported fruit and vegetable intake was low, with 6.1% and 5.6% consuming at least 3 servings/day of fruit or vegetables, respectively. Smoking history was associated with increased lung cancer incidence. The adjusted HR of current cigarette smoking of ≥15 cigarettes/day compared to never smoking was 17.4 (95% CI: 11.5, 26.4). Combined fruit and vegetable intake was not significantly associated with lung cancer incidence in covariate-adjusted models (≥5 versus <3 servings/day HR:0.86, 95% CI: 0.54, 1.36). Similar, total intakes of fruit, citrus fruit, vegetable, starchy vegetable, non-starchy vegetable, and cruciferous vegetables were not associated with lung cancer incidence in adjusted models. Associations between smoking and lung cancer incidence did not differ by fruit and vegetable intake. Among women who reported “low” (<3 servings/day) fruits and vegetable intake the HR for women with ≥20 pack-years compared to never smokers was 12.3 (95% CI: 8.18, 18.5), while among women with “high” (≥3 servings/day) intake the HR was 15.2 (95% CI: 7.46, 30.8) (p-interaction=0.67). Conclusion: Low fruit and vegetable intake was widespread in this population of U.S. Black women, but results do not support an association between fruit and vegetable intake and lung cancer incidence, regardless of cigarette smoking history. Citation Format: Sarah JO Nomura, Chiranjeev Dash, Lynn Rosenberg, Julie Palmer, Lucile L. Adams-Campbell. Fruit and vegetable intake and lung cancer incidence among Black women according to cigarette smoking status [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C46.

Development of a Breast Cancer Risk Prediction Model for Women in Nigeria.

Background: Risk prediction models have been widely used to identify women at higher risk of breast cancer. We aimed to develop a model for absolute breast cancer risk prediction for Nigerian women.Methods: A total of 1,811 breast cancer cases and 2,225 controls from the Nigerian Breast Cancer Study (NBCS, 1998-2015) were included. Subjects were randomly divided into the training and validation sets. Incorporating local incidence rates, multivariable logistic regressions were used to develop the model.Results: The NBCS model included age, age at menarche, parity, duration of breastfeeding, family history of breast cancer, height, body mass index, benign breast diseases, and alcohol consumption. The model developed in the training set performed well in the validation set. The discriminating accuracy of the NBCS model [area under ROC curve (AUC) = 0.703, 95% confidence interval (CI), 0.687-0.719] was better than the Black Women's Health Study (BWHS) model (AUC = 0.605; 95% CI, 0.586-0.624), Gail model for white population (AUC = 0.551; 95% CI, 0.531-0.571), and Gail model for black population (AUC = 0.545; 95% CI, 0.525-0.565). Compared with the BWHS and two Gail models, the net reclassification improvement of the NBCS model were 8.26%, 13.45%, and 14.19%, respectively.Conclusions: We have developed a breast cancer risk prediction model specific to women in Nigeria, which provides a promising and indispensable tool to identify women in need of breast cancer early detection in Sub-Saharan Africa populations.Impact: Our model is the first breast cancer risk prediction model in Africa. It can be used to identify women at high risk for breast cancer screening. Cancer Epidemiol Biomarkers Prev; 27(6); 636-43. ©2018 AACR.

Inflammatory signatures distinguish metabolic health in African American women with obesity.

Obesity-driven Type 2 diabetes (T2D) is a systemic inflammatory condition associated with cardiovascular disease. However, plasma cytokines and tissue inflammation that discriminate T2D risk in African American women with obese phenotypes are not well understood. We analyzed 64 circulating cytokines and chemokines in plasma of 120 African American women enrolled in the Black Women’s Health Study. We used regression analysis to identify cytokines and chemokines associated with obesity, co-morbid T2D and hypertension, and compared results to obese women without these co-morbidities, as well as to lean women without the co-morbidities. We then used hierarchical clustering to generate inflammation signatures by combining the effects of identified cytokines and chemokines and summarized the signatures using an inflammation score. The analyses revealed six distinct signatures of sixteen cytokines/chemokines (P = 0.05) that differed significantly by prevalence of T2D (P = 0.004), obesity (P = 0.0231) and overall inflammation score (P < E-12). Signatures were validated in two independent cohorts of African American women with obesity: thirty nine subjects with no metabolic complications or with T2D and hypertension; and thirteen breast reduction surgical patients. The signatures in the validation cohorts closely resembled the distributions in the discovery cohort. We find that blood-based cytokine profiles usefully associate inflammation with T2D risks in vulnerable subjects, and should be combined with metabolism and obesity counselling for personalized risk assessment.

Exogenous Hormone Use and Endometrial Cancer in U.S. Black Women.

Background: Although endometrial cancer risk differs among white and black women, few data on its associations with exogenous hormone use in the latter group are available. Studies have reported lower endometrial cancer risk among users of oral contraceptives (OCs), but higher risk among users of estrogen-only female menopausal hormones (FMHs). Evidence for the risk among estrogen plus progestin FMHs users is equivocal.Methods: We followed 47,555 Black Women's Health Study participants with an intact uterus from 1995 through 2013. Data on exogenous hormone use, covariates, and endometrial cancer were obtained biennially. Self-reported incident cases of endometrial cancer were confirmed by medical records or cancer registries whenever possible. We estimated incidence rate ratios (IRRs) and 95% confidence intervals (CIs) using Cox proportional hazards regression.Results: We observed 300 endometrial cancer cases during 689,546 person-years of follow-up. Compared with never use, ≥10 years' duration of OC use was associated with lower risk (multivariable IRR = 0.45, 95% CI, 0.27-0.74), but risk was higher among current users of estrogen-only (IRR = 3.78, 95% CI, 1.69-8.43) and estrogen plus progestin FMH (IRR = 1.55, 95% CI, 0.78-3.11). Risk was not increased among former users of estrogen-only (IRR = 0.87, 95% CI, 0.44-1.72) or estrogen plus progestin FMH (IRR = 0.63, 95% CI, 0.36-1.09).Conclusions: Current use of estrogen-only and estrogen plus progestin FMH was associated with increased risk of endometrial cancer. Risk appeared lower among former users of estrogen plus progestin FMH. Long-term OC use was associated with reduced risk.Impact: Our results are generally consistent with those among white women. Cancer Epidemiol Biomarkers Prev; 27(5); 558-65. ©2018 AACR.

Highlights of This Issue

Metformin is widely used in the management of type 2 diabetes mellitus. Epidemiologic studies have reported strong inverse associations between metformin use and risk of several cancers, including colorectal (CRC). Concern that time-related biases, such as immortal time bias, were influencing reported associations led Bradley and colleagues to re-examine metformin and CRC risk using methods to minimize these biases. Specifically, the authors accounted for time-varying exposure to metformin and other diabetes medications and adjusted for diabetes duration. Despite applying more rigorous methods, the authors observed an inverse association between long-term metformin use and CRC risk that appeared to be restricted to men.Hepatocellular carcinoma (HCC) incidence is rising in regions where established HCC risk factors are not predominant. The rise is likely due to factors such as obesity and unhealthy lifestyle exposures. This study, by Assi and colleagues, presents an analytical framework to explore exposure-specific metabolic signatures and assess their mediating role in the association between various lifestyle behaviors and HCC risk using detailed metabolomic and lifestyle data from a large prospective cohort. Metabolic profiles of obesity, smoking, and alcohol intake mediated HCC carcinogenesis. These findings contribute to further understanding of HCC etiology, thus strengthening public health advice for cancer prevention by modifying unhealthy lifestyle behaviors.Using novel questionnaire, biomarker, and vital records data, this study by Boen and colleagues examines how diverse measures of social support relate to mortality risk among individuals with cancer as well as the mediating role of inflammation as a biological mechanism. Findings revealed that cancer patients reporting less social support satisfaction had higher mortality risk than those reporting greater satisfaction, partly due to the elevated risk of inflammation associated with low satisfaction. The study offers new insights for intervention efforts aimed at promoting meaningful social connections as a means for improving cancer survival.Endometrial cancer incidence has been increasing among black women. Despite established roles of estrogens and progestins in endometrial cancer etiology, few studies have investigated the influence of exogenous hormone use among black women. Similar to prior findings, the Black Women's Health Study found that oral contraceptive use was associated with reduced endometrial cancer risk; estrogen-only menopausal hormone use was associated with increased risk. Also consistent with previous studies, the protective effects of oral contraceptive use were weaker among obese women. The results of this study by Sponholzt and colleagues suggest that the high obesity prevalence among black women may contribute to their increasing endometrial cancer incidence by mitigating the beneficial effects of oral contraceptive use.

Religious and Spiritual Coping and Risk of Incident Hypertension in the Black Women's Health Study.

The few studies of the relationship between religion and/or spirituality (R/S) and hypertension are conflicting. We hypothesized that R/S may reduce the risk of hypertension by buffering adverse physiological effects of stress. We prospectively assessed the association of R/S with hypertension within the Black Women's Health Study (BWHS), a cohort study initiated in 1995 that follows participants through biennial questionnaires. The 2005 questionnaire included four R/S questions: (i) extent to which one's R/S is involved in coping with stressful situations, (ii) self-identification as a religious/spiritual person, (iii) frequency of attending religious services, and (iv) frequency of prayer. Incidence rate ratios (IRRs) and 95% confidence intervals were calculated for each R/S variable in relation to incident hypertension using Cox proportional hazards regression models, controlling for demographics, known hypertension risk factors, psychosocial factors, and other R/S variables. During 2005-2013, 5,194 incident cases of hypertension were identified. High involvement of R/S in coping with stressful events compared with no involvement was associated with reduced risk of hypertension (IRR: 0.87; 95% CI: 0.75, 1.00). The association was strongest among women reporting greater levels of perceived stress (IRR: 0.77; 95% CI: 0.61, 0.98; p interaction = .01). More frequent prayer was associated with increased risk of hypertension (IRR: 1.12; 95% CI: 0.99, 1.27). No association was observed for the other R/S measures. R/S coping was associated with decreased risk of hypertension in African American women, especially among those reporting higher levels of stress. Further research is needed to understand the mechanistic pathways through which R/S coping may affect health.

Experiences of Racism and Breastfeeding Initiation and Duration Among First-Time Mothers of the Black Women's Health Study.

Breastfeeding rates are lower for black women in the USA compared with other groups. Breastfeeding and lactation are sensitive time points in the life course, centering breastfeeding as a health equity issue. In the USA, experiences of racism have been linked to poor health outcomes but racism relative to breastfeeding has not been extensively investigated. This study aims to investigate the association between experiences of racism, neighborhood segregation, and nativity with breastfeeding initiation and duration. This is a prospective secondary analysis of the Black Women's Health Study, based on data collected from 1995 through 2005. Daily and institutional (job, housing, police) racism, nativity, and neighborhood segregation in relation to breastfeeding were examined. Odds ratios and 95% confidence intervals were calculated using binomial logistic regression for the initiation outcomes (N = 2705) and multinomial logistic regression for the duration outcomes (N = 2172). Racism in the job setting was associated with lower odds of breastfeeding duration at 3-5months. Racism with the police was associated with higher odds of breastfeeding initiation and duration at 3-5 and 6months. Being born in the USA or having a parent born in the USA predicted lower odds of breastfeeding initiation and duration. Living in a segregated neighborhood (primarily black residents) as a child was associated with decreased breastfeeding initiation and duration relative to growing up in a predominantly white neighborhood. Experiences of institutionalized racism influenced breastfeeding initiation and duration. Structural-level interventions are critical to close the gap of racial inequity in breastfeeding rates in the USA.

Association of Degree of European Genetic Ancestry With Serum Vitamin D Levels in African Americans.

Circulating levels of vitamin D are generally lower in African Americans than in US whites, and 1 prior analysis carried out in a small number of African Americans suggested that, within this population, vitamin D levels may be related to the degree of genetic admixture. We assessed the association between percentage of European ancestry and serum vitamin D level (assessed in 2013-2015) among 2,183 African-American women from the Black Women's Health Study whose DNA had been genotyped for ancestry-informative markers. ADMIXMAP software was used to estimate the percentage of European ancestry versus African ancestry in each individual. In linear regression analyses with adjustment for genotype batch, age, body mass index, supplemental vitamin D use, ultraviolet B radiation flux in the participant's state of residence, and season of blood draw, each 10% increase in European ancestry was associated with a 0.67-ng/mL increase in serum vitamin D concentration (95% confidence interval: 0.17, 1.17). The association was statistically significant only among women who were not taking vitamin D supplements (for each 10% increase in European ancestry, β = 0.86, 95% confidence interval: 0.14, 1.57). Among African Americans, use of vitamin D supplements may help to reduce vitamin D deficiency associated with genetic ancestry.

Abstract A18: Association of anthropometric factors with risk of colorectal neoplasia in the Black Women's Health Study

Abstract Evidence for the association of anthropometric factors with colorectal neoplasms is limited for African Americans. Association of 6 anthropometric measures with the risk of both colorectal adenomas and colorectal cancer (CRC) in the ongoing Black Women's Health Study cohort was examined. Using a nested case-control design for the adenoma analyses, 954 cases of colorectal adenoma were compared with 3,816 controls without a colorectal polyp, matched on age and follow-up time. For the CRC analyses, 413 incident CRC cases were identified over a 16-year follow up (802,783 person-years). Cases of adenoma and CRC were verified by medical record review. We used multivariable logistic regression analyses (for adenoma) and Cox proportional hazards analyses (for CRC) that included anthropometric exposures and selected confounders. Among postmenopausal women, risk of adenoma increased by 10% (95% CI: 1.00, 1.22), 11% (95% CI: 1.01, 1.29), and 9% (1.00, 1.19) with 1 standard deviation increase in body mass index, waist circumference, and weight change since age 18 , respectively. Anthropometric factors were not associated with adenoma risk among premenopausal women. None of the anthropometric factors were associated with CRC risk among either pre- or postmenopausal women. Future research should attempt to replicate the modest association of obesity with colon adenoma risk but not CRC risk among postmenopausal African American women. Citation Format: Chiranjeev Dash, Lynn Rosenberg, Jeffrey Yu, Sarah Nomura, Julie Palmer, Lucile L. Adams-Campbell. Association of anthropometric factors with risk of colorectal neoplasia in the Black Women's Health Study [abstract]. In: Proceedings of the AACR International Conference: New Frontiers in Cancer Research; 2017 Jan 18-22; Cape Town, South Africa. Philadelphia (PA): AACR; Cancer Res 2017;77(22 Suppl):Abstract nr A18.

Type II Diabetes and Incidence of Estrogen Receptor Negative Breast Cancer in African American Women.

White women with type II diabetes (T2D) have an estimated 20% increased risk of developing breast cancer. Little is known about associations by breast cancer subtype or among African American (AA) women, who are disproportionately affected by T2D and estrogen receptor negative (ER-) breast cancer. We assessed the relation of T2D to incidence of ER- and ER+ breast cancer in data from the Black Women's Health Study, a prospective cohort of AA women enrolled in 1995 and followed biennially. During 847,934 person-years of follow-up, there were 1,851 incident invasive breast cancers, including 914 ER+ and 468 ER- cases. Multivariable Cox proportional hazards models were used to compute HRs for breast cancer incidence associated with T2D relative to no T2D, controlling for body mass index (BMI) and other potential confounders. The HR for T2D relative to no T2D was 1.18 [95% confidence interval (CI) 1.00-1.40] for overall breast cancer incidence, with the increase accounted for by ER- cancer: HRs were 1.02 (95% CI, 0.80-1.31) for ER+ and 1.43 (95% CI, 1.03-2.00) for ER- cancer. The HR for T2D and ER- breast cancer was highest among nonobese women (1.92; 95% CI, 1.22-3.04). The findings suggest that AA women with T2D are at increased risk of developing ER- breast cancer and that poor metabolic health may be more important than obesity for this subtype. Given the high prevalence of T2D in AA women, the observed association could, in part, explain racial disparities in incidence of ER- breast cancer. Cancer Res; 77(22); 6462-9. ©2017 AACR.

Pubertal growth and adult height in relation to breast cancer risk in African American women.

Adult height has been positively associated with breast cancer risk. The timing of pubertal growth-as measured by age at menarche and age at attained height-may also influence risk. We evaluated associations of adult height, age at attained height, and age at menarche with incidence of invasive breast cancer in 55,687 African American women in the prospective Black Women's Health Study. Over 20 years, 1,826 invasive breast cancers [1,015 estrogen receptor (ER) positive; 542 ER negative] accrued. We used multivariable Cox proportional hazards regression to estimate hazards ratios (HRs) and 95% confidence intervals (CIs) for associations with breast cancer overall and by ER status, mutually adjusted for the three factors of interest. Adult height was associated with increased risk of ER+ breast cancer (HR for ≥70 inches vs ≤63 inches: 1.44; 95% CI: 1.09, 1.89) but not ER- (corresponding HR: 1.16; 95% CI: 0.78, 1.71) (p heterogeneity = 0.34). HRs for attained height before age 13 versus age >17 were 1.30 (95% CI: 0.96, 1.76) for ER+ and 1.25 (95% CI: 0.80, 1.96) for ER- breast cancer. Results for age at menarche (≤11 vs ≥14 years) were similar for ER+ and ER- breast cancer (HR for breast cancer overall: 1.30; 95% CI: 1.12, 1.50). We confirmed height as a strong risk factor for ER+ breast cancer in African American women and identified early age at attained height as a risk factor for both ER+ and ER- breast cancer, albeit without statistical significance of the latter associations. While adult height and timing of pubertal growth are inter-related, our findings suggest that they may be independent risk factors for breast cancer.

Perceived racism and incident diabetes in the Black Women's Health Study.

Our aim was to assess the association of perceived racism with type 2 diabetes, and the possible mediating influence of diet and BMI. The Black Women's Health Study, a follow-up of 59,000 African-American women, began in 1995. Over 16years 5344 incident cases of diabetes occurred during 576,577 person-years. Cox proportional hazards models were used to estimated HRs and 95% CIs for categories of 'everyday racism' (interpersonal racism in daily life) and 'lifetime racism' (reporting ever treated unfairly due to race with respect to police, housing or work) and incident type 2 diabetes. Models were adjusted for age, questionnaire cycle, marital status, socioeconomic status, education, family history of diabetes, physical activity, alcohol use and smoking status, with and without inclusion of terms for dietary patterns and adult BMI. Compared with women in the lowest quartile of exposure, women in the highest quartile of exposure to everyday racism had a 31% increased risk of diabetes (HR 1.31; 95% CI 1.20, 1.42) and women with the highest exposure to lifetime racism had a 16% increased risk (HR 1.16; 95% CI 1.05, 1.27). Mediation analysis estimated that BMI accounted for half of the association between either the everyday or lifetime racism measure and incident diabetes. Perceived everyday and lifetime racism were associated with increased risk of type 2 diabetes in this cohort of African-American women and appear to be at least partly mediated by BMI.

A Clinical Validation of Self-Reported Periodontitis Among Participants in the Black Women's Health Study.

There is a paucity of data on the validity of self-report of periodontal disease in African Americans. The Black Women's Health Study (BWHS), a United States national cohort study of 59,000 black women followed via mailed questionnaires since 1995, offered the opportunity to clinically validate self-reported periodontitis among a sample of participants. Oral health questionnaires were sent to study participants residing in Massachusetts. Respondents living in the Boston metro area were invited for clinical examination. Self-reports were compared with clinical data obtained from the 77 women (mean age: 59 years) who were examined. The authors examined the predictive ability of individual and combined questionnaire items with respect to clinical periodontal disease severity. Validation parameters were calculated for each question, and receiver operating characteristic statistics were generated to compare questionnaire items. Periodontitis prevalence in the validation sample was 24% for severe periodontitis and 61% for moderate disease. Performance of individual questionnaire items with respect to predicting periodontitis was better for severe compared with moderate disease. Combinations of questionnaire items improved the predictive ability with respect to severe disease beyond that of individual questionnaire items. Prevalence of severe periodontitis was similar to other age-comparable populations, without regard for race or sex, whereas prevalence of total periodontitis (moderate and severe) among women of similar age and/or race was much higher. Predictive ability of questionnaire items assessed in the BWHS was similar to that in other studies.

Cumulative Lactation and Onset of Hypertension in African-American Women.

Hypertension affects nearly 1 of 3 women and contributes to cardiovascular disease, the leading cause of death in the United States. Breastfeeding leads to metabolic changes that could reduce risks of hypertension. Hypertension disproportionately affects black women, but rates of breastfeeding among black women lag behind those in the general population. In the Black Women's Health Study (n = 59,001), we conducted a nested case-control analysis using unconditional logistic regression to estimate the association between breastfeeding and incident hypertension at ages 40-65 years using data collected from 1995 to 2011. Controls were frequency-matched 2:1 to 12,513 hypertensive women by age and questionnaire cycle. Overall, there was little evidence of association between ever breastfeeding and incident hypertension (odds ratio = 0.97, 95% confidence interval: 0.92, 1.02). However, age modified the relationship (P = 0.02): Breastfeeding was associated with reduced risk of hypertension at ages 40-49 years (odds ratio = 0.92, 95% confidence interval: 0.85, 0.99) but not at older ages. In addition, risk of hypertension at ages 40-49 years decreased with increasing duration of breastfeeding (P for trend = 0.08). Our results suggest that long-duration breastfeeding may reduce the risk of incident hypertension in middle age. Addressing breastfeeding as a potential preventative health behavior is particularly compelling because it is required for only a discrete period of time.

Reproductive factors and incidence of endometrial cancer in U.S. black women

Previous studies have shown that reproductive history is a strong determinant of endometrial cancer risk among white women. Less is known about how reproductive history affects endometrial cancer risk among black women, whose incidence and mortality differ from white women. We investigated the associations of age at menarche, parity, timing of births, and menopausal age with endometrial cancer in the Black Women's Health Study, a prospective cohort study. Every 2years from 1995 to 2013, 47,555 participants with intact uteri at baseline in 1995 completed questionnaires on reproductive and medical history, and lifestyle factors. Self-reported cases of endometrial cancer were confirmed by medical record, cancer registry, or death certificate when available. Cox proportional hazards regression was used to estimate multivariable incidence rate ratios (IRR) and 95% confidence intervals (CI). During 689,501 person-years of follow-up, we identified 300 incident cases of endometrial cancer. The strongest associations with endometrial cancer were found for early age at menarche (<11 vs. 12-13 years: IRR 1.82, 95% CI 1.31, 2.52), and later age at first birth (≥30 vs. <20 years: IRR 0.26, 95% CI 0.13, 0.50). Parous women were less likely than nulliparous women to develop endometrial cancer (IRR 0.77, 95% CI 0.57, 1.05), but there was little evidence of a dose-response relationship for number of births. Associations between reproductive factors and endometrial cancer among black women were generally consistent with those in studies of white women.

Attendance at Religious Services, Prayer, Religious Coping, and Religious/Spiritual Identity as Predictors of All-Cause Mortality in the Black Women's Health Study.

Previous longitudinal studies have consistently shown an association between attendance at religious services and lower all-cause mortality, but the literature on associations between other measures of religion and spirituality (R/S) and mortality is limited. We followed 36,613 respondents from the Black Women's Health Study from 2005 through December 31, 2013 to assess the associations between R/S and incident all-cause mortality using proportional hazards models. After control for numerous demographic and health covariates, together with other R/S variables, attending religious services several times per week was associated with a substantially lower mortality rate ratio (mortality rate ratio = 0.64, 95% confidence interval: 0.51, 0.80) relative to never attending services. Engaging in prayer several times per day was not associated with mortality after control for demographic and health covariates, but the association trended towards a higher mortality rate ratio when control was made for other R/S variables (for >2 times/day vs. weekly or less, mortality rate ratio = 1.28, 95% confidence interval: 0.99, 1.67; P-trend<0.01). Religious coping and self-identification as a very religious/spiritual person were associated with lower mortality when adjustment was made only for age, but the association was attenuated when control was made for demographic and health covariates and was almost entirely eliminated when control was made for other R/S variables. The results indicate that service attendance was the strongest R/S predictor of mortality in this cohort.

Abstract A47: Cancer genetics research in Alabama: Recruitment mechanisms to reach the underserved

Abstract Over 60% of the Alabama population is medically underserved, including the entire population of many Alabama counties. These counties are generally rural and have transportation barriers, thus a lack of access to healthcare results in poor cancer outcomes. These healthcare gaps, in addition to lower education levels and mistrust towards researcher/healthcare providers, highlight the challenges but also the need to make a difference in this underserved and understudied population. In general, recruitment for human genetic research studies presents major challenges, and, despite federal mandates to include women and minorities in federally funded research, African Americans (AAs) remain underrepresented in cancer genetic research. Recruitment of participants requires extensive efforts and strategic planning in order to overcome the difficulties, such as distrust towards medical research and logistical challenges of recruiting under-served and under-represented individuals. These considerations led to the establishment of two IRB-approved protocols, hospital recruitment (#14-232) and community-based recruitment (CBR; #15-111) to recruit cancer individuals/families from Alabama and identify genetic risk factors. Hospital recruitment was established through a partnership with East Alabama Medical Center (EAMC), and CBR targets medically underserved individuals through a mechanism aimed to educate and build trust in the community. Through connections fostered by community-partners, CBR team members travel to rural communities all over Alabama to be introduced to, educate, and recruit patients/survivors and their family members. All CBR team members are phlebotomy trained. Recruitment particularly focuses on cancer associated with Hereditary Breast and Ovarian Cancer (HBOC) Syndrome since there are two disparities within the AA population that may be genetically linked. Firstly, AA women are generally diagnosed with a more aggressive and less treatable breast cancer (BC) sub-type and have a higher incidence rate of BC under the age of 40 compared to Caucasians. Secondly, AA males are generally diagnosed with prostate cancer (PC) at a younger age and with larger tumors compared to Caucasians. Considering that (1) an early age of onset is a hallmark of hereditary cancer, (2) hereditary BC is associated with an increased risk of ovarian cancer (OvC) and PC, and (3) the Black Women's Health Study has demonstrated there is a strong familial component of AA BC, inherited and potentially overlapping genetic risk factors may explain these disparities. Thus, the study enrollment criteria include individuals (1) diagnosed with BC, OvC, or PC under the age of 45 and/or (2) diagnosed with BC, OvC, or PC with have a cancer family history. Ultimately, in an effort to recruit informative families for genetic study, both cancer-affected and unaffected family members of study participants can join the study. To date, 133 DNA samples from 74 cancer families are stored in the Merner DNA Bank; 33 and 41 probands have been recruited through EAMC and CBR, respectively. CBR has been the most effective mechanism of AA BC recruitment (20/36) compared to hospital recruitment (5/32). Probands are screened for known and candidate susceptibility genes using the BRAP (BReast And Prostate) gene-screening panel. This aims to provide insight towards the true contribution of mutations in known susceptibility genes, and identify non-mutation individuals/families for novel HBOC susceptibility gene discovery efforts. Additionally, this study offers each participant the option to receive her/his confidential research-based gene screening results and aims to translate those results to the clinic by providing free UAB telegenetic counseling to underserved individuals through the use of telemedicine carts at equipped Alabama County Health Departments. Citation Format: Nancy Merner, Madison Chandler, Amber Davis, Ebony Jackson, Erin Bilgili, Cameron Turner, Kasey Shepp, Stephanie Spina, Brandon Johnson. Cancer genetics research in Alabama: Recruitment mechanisms to reach the underserved. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A47.

Differential Patterns of Risk Factors for Early-Onset Breast Cancer by ER Status in African American Women.

Given the disproportionately high incidence of early-onset breast cancer and aggressive subtypes, such as estrogen receptor (ER)-negative tumors, in African American (AA) women, elucidation of risk factors for early onset of specific subtypes of breast cancer is needed. We evaluated associations of reproductive, anthropometric, and other factors with incidence of invasive breast cancer by age at onset (<45, ≥45) in 57,708 AA women in the prospective Black Women's Health Study. From 1995 to 2013, we identified 529 invasive breast cancers among women <45 years of age (151 ER-, 219 ER+) and 1,534 among women ≥45 years (385 ER-, 804 ER+). We used multivariable Cox proportional hazards regression to estimate hazard ratios (HRs) for associations by age and ER status. Higher parity, older age at first birth, never having breastfed, and abdominal adiposity were associated with increased risk of early-onset ER- breast cancer: HRs were 1.71 for ≥3 births versus one birth; 2.29 for first birth after age 25 versus <20 years; 0.61 for ever having breastfed versus never; and 1.64 for highest versus lowest tertile of waist-to-hip ratio. These factors were not associated with ER- cancer in older women or with ER+ cancer regardless of age. Differences in risk factors by ER subtype were observed for breast cancer diagnosed before the age of 45 years. Etiological heterogeneity by tumor subtype in early-onset breast cancer, in combination with a higher prevalence of the risk factors in AA women, may explain, in part, racial disparities in breast cancer incidence. Cancer Epidemiol Biomarkers Prev; 26(2); 270-7. ©2016 AACR.