Disparities In Breast Cancer Outcomes Research Articles

Racial Disparities and Strategies for Improving Equity in Diagnostic Follow-Up for Abnormal Screening Mammograms.

Black and White women undergo screening mammography at similar rates, but racial disparities in breast cancer outcomes persist. To assess potential contributors, we investigated delays in follow-up after abnormal imaging by race/ethnicity. Women who underwent screening mammography at our urban academic center from January 2015 to February 2018 and received a Breast Imaging Reporting and Data System 0 assessment were included. Kaplan-Meier estimates described distributions of time between diagnostic events from (1) screening to diagnostic imaging and (2) diagnostic imaging to biopsy. Multivariable logistic regression models estimated the associations between race/ethnicity and receipt of follow-up within 15 and 30 days. Two thousand five hundred and fifty-four women were included (48.6% non-Hispanic [NH] Black, 38.2% NH White, 13.1% other/unknown). Median time between screening and diagnostic imaging varied by race/ethnicity (White: 7 days [IQR, 2-14]; Black: 12 days [IQR, 7-23]; other/unknown: 9 days [IQR, 5-21]). There were similar disparities in days between diagnostic imaging and biopsy (White: 12 [IQR, 7-24]; Black: 21 [IQR, 13-37]; other/unknown: 16 [IQR, 9-30]) and between screening and biopsy (White: 20 [IQR, 11-41]; Black: 35 [IQR, 22-63]; other/unknown: 27.5 [IQR, 17-42]). After adjustment, odds of diagnostic imaging follow-up within 15 days of screening were lower for Black versus White women (odds ratio, 0.59 [95% CI, 0.44 to 0.80]; P < .001). In this diverse cohort, disparities in timely diagnostic follow-up after abnormal breast screening were observed, with Black women waiting 1.75 times as long as White women to obtain a tissue diagnosis. National guidelines for time to diagnostic follow-up may facilitate more timely breast cancer care and potentially affect outcomes.

Abstract PO4-09-09: Deep Immunoprofiling Demonstrates Racial Differences in the Peripheral Immune System in Women at Risk for Breast Cancer

Abstract Background: Disparities in breast cancer outcomes between Non-Hispanic Black (NHB) and Non-Hispanic White (NHW) women have been attributed to NHB women presenting with more aggressive subtypes and later stage disease, differences in treatment receipt and adherence, access to care and tumor biology. However, previous work has shown that these known factors do not fully account for the observed disparities in outcomes. Systemic immune fitness is a factor not previously studied that may play a role in dictating disease progression and therapeutic responses. Numerous factors, including age and race, impact immune system function and understanding these changes is critical to address disparities in breast cancer outcomes. Here, we developed a pipeline for deep immunoprofiling of peripheral blood mononuclear cells (PBMC) at single cell resolution by full-spectrum flow cytometry. Using this pipeline, we sought to investigate whether there are differences in immune fitness between NHB and NHW women at high risk for developing breast cancer. Methods: PBMC were collected and processed from age-matched NHB and NHW women (n=20/cohort) identified as being at high risk for developing breast cancer through our institution’s B-PREP (Breast Cancer Personalized Risk Assessment Education and Prevention) clinic. Two custom antibody panels and protocols for comprehensive immunoprofiling of T and B cell subsets (T/B Panel), as well as monocytic, NK, and dendritic cell subsets (M/N/D Panel), along with functional and exhaustion markers were designed, optimized, and implemented. Traditional gating strategies were used to quantify proportions of canonical cell populations, and unbiased high dimensionality reduction analysis was performed using the OMIQ analysis platform to assess phenotypes and functional status of various immune cell subsets. Results: Significant differences between cohorts in abundance as well as phenotype of various cell populations were observed. Specifically, CD4+ follicular helper T cells, TEMRA CD8, and CD45RA Terminal Effector CD8+ cells were enriched in NHB women while PD-1+/CD3+ cells and PD-1+/CD8+ cells were enriched in the NHW women (Table). Additionally, several immunosuppressive and systemic inflammatory immune cell types were enriched in NHB women (Table). Conclusions: Deep immunoprofiling using single-cell spectral flow cytometry revealed differences in peripheral immune cells between NHB and NHW women at high risk for breast cancer. The significant enrichment of immunosuppressive monocytes and several activated NK cell populations in PBMC samples from NHB women relative to those from NHW women indicate an altered immune environment that may influence breast cancer development. Additional analysis, including a larger sample size and patients with invasive cancer, are ongoing to further understand if differences in immune fitness between NHB and NHW women are associated with disparities in breast cancer outcomes. Table: PBMC populations (% of CD45+) that are significantly enriched in NHB relative to NHW patients Citation Format: Esther Ogayo, Milos Spasic, Tasnim Rahman, Olga Kantor, Tari King, Peter van Galen, Sandra McAllister, Elizabeth Mittendorf. Deep Immunoprofiling Demonstrates Racial Differences in the Peripheral Immune System in Women at Risk for Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-09-09.

Abstract PO1-09-05: Reversing Rural Disparity Through Increased Access to Breast Care Using Model of Academic-Community Collaboration

Abstract Background: Rural disparity in Breast Cancer (BC) often relates to poor geographic access. We are small county in rural North Carolina with historically poor outcomes, including more advanced stages of BC at presentation, higher mastectomy rates, and higher BC-specific mortality rates than elsewhere. Beginning in 2002 we increased access to care by construction of a 19-bed Critical Access Hospital. With a higher median age population (10 years older), and cancer as the number one cause of death (30% of all deaths), we began to increase access to services with focus on cancer. Two decades later, we still do not provide all aspects of care locally, but through a model of collaboration we have increased access to all aspects of cancer care. Breast Cancer is the most common, and this report details the reversal in disparity seen rurally based on our model of collaboration with both a regional community cancer program and academic cancer program. Methods: We partnered with academic and community cancer centers in nearby counties to increase access to imaging, cancer specialists, radiation therapy and chemotherapy services, and support services for breast care. When we could not provide these services locally, we helped navigate patients to these other facilities to improve access. We invited dedicated breast surgeon from community cancer program to attend clinic weekly in our area. We created virtual breast-specific tumor boards to discuss 100% of cases prospectively, with improved access to pathologists, geneticists, fellowship-trained imaging specialists, breast surgeons and other multi-disciplinary care members (reconstructive surgery, PT/OT, integrative medicine, GYN). We became cancer accredited with both COC and NAPBC. We compare metrics pre/post-improvements. Results: Baseline: 1. Mortality rates: (2002-2006) 5-year BC mortality rates in our region averaged 32.3/100,000 population which was in the top quartile for the state, 30% higher than the state average. 2. Stages at presentation: 47% of BC stages were early (stages 0/1) in our service region compared to 62% elsewhere (NCDB data). Stage IV represented 6% in our region versus 4% elsewhere. 2500 mammograms/year at hospital at baseline. 3. Surgery/Radiation Therapy: Mastectomy rates averaged &amp;gt;50% in region, with correspondingly lower breast conserving rates than elsewhere due to lack of access to breast surgeons and radiation therapy services locally. Closest RT facility 80 miles. 4. Distances to high quality breast care averaged 150 miles. Closest Academic/Community Cancer Program 2-hour drive (one way). Post Collaboration: 1. Mortality rates: (2015-2019), 5-year BC mortality rates in our region averaged 16.3/100,000 population which is in the lowest quartile, 20% lower than the state average. 2. Stages at presentation: 74% of BC stages are early (stages 0/I) in our region versus 68% elsewhere. Stage IV now below parity with 3% locally versus 4% nationally. More than 5100 mammograms/year done currently at local hospital. 3. Surgery/Radiation Therapy: Mastectomy rates average 21%, with partial mastectomy rates of 79% in our area versus 70% elsewhere (NAPBC data) with RT services available locally. 4. Distances to quality breast care average 20 miles, and we are nationally accredited program in breast care as a critical access hospital. Analytic case load is now triple baseline numbers. Conclusion: We reversed the trend in rural disparity in breast cancer outcomes through model of collaboration. We increased screening rates locally, doubling the number of screening/diagnostic exams, increased the percentage of early stage at diagnosis, halved our mastectomy rates, and reduced BC-specific mortality 50% relative to baseline (and now 20% lower than state). We are now at parity with most BC-specific quality metrics reflecting a huge shift in rural disparity, which could only be achieved rurally through collaboration. Reversing Rural Disparity Through Increased Access to Breast Care Using Model of Academic-Community Collaboration This table depicts the changes in our region over time, which have brought us to parity with Breast Care nationally. Citation Format: Charles Shelton, Antonio Ruiz. Reversing Rural Disparity Through Increased Access to Breast Care Using Model of Academic-Community Collaboration [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-09-05.

Racial disparities in disease-specific mortality and surgical management of patients with ductal carcinoma in situ with microinvasion.

Given persistent racial disparities in breast cancer outcomes, this study explores racial differences in disease-specific mortality and surgical management among patients with microinvasive ductal carcinoma in situ (DCIS-MI). The Surveillance, Epidemiology, and End Results Program was queried for patients aged 18+ years with DCIS-MI between January 1, 2010 and December 31, 2018. The study cohort was divided into non-Hispanic Black (NHB) and non-Hispanic White (NHW) patients. Disease-specific mortality was evaluated using Cox proportional hazards models. A total of 3400 patients were identified, of which 569 (16.7%) were NHB and 2831 (83.3%) were NHW. Compared with NHW patients, NHB patients had more positive lymph nodes (7.6% vs. 3.9% p < 0.001). In addition, NHB women were more likely to undergo axillary lymph node dissection (6.0% vs. 3.8%, p = 0.044) and receive chemotherapy (11.8% vs. 7.2%, p < 0.001). There were no racial differences in breast surgery type (p = 0.168), reconstructive surgery (p = 0.362), or radiation therapy (p = 0.342). Overall, NHB patients had worse disease-specific mortality (adjusted hazard ratio 2.13, 95% confidence interval [CI]: 1.10-4.14) with mortality risks diverging from NHW women after 3 years (6 years rate ratio [RR] 2.12, 95% CI: 1.13-4.34; 9 years RR 2.32, 95% CI: 1.24-4.35). NHB women with DCIS-MI present with higher nodal disease burden and experience worse disease-specific mortality than NHW women.

Socioecologic Factors and Racial Differences in Breast Cancer Multigene Prognostic Scores in US Women

Disproportionately aggressive tumor biology among non-Hispanic Black women with early-stage, estrogen receptor (ER)-positive breast cancer contributes to racial disparities in breast cancer mortality. It is unclear whether socioecologic factors underlie racial differences in breast tumor biology. To examine individual-level (insurance status) and contextual (area-level socioeconomic position and rural or urban residence) factors as possible mediators of racial and ethnic differences in the prevalence of ER-positive breast tumors with aggressive biology, as indicated by a high-risk gene expression profile. This retrospective cohort study included women 18 years or older diagnosed with stage I to II, ER-positive breast cancer between January 1, 2007, and December 31, 2015. All data analyses were conducted between December 2022 and April 2023. The primary outcome was the likelihood of a high-risk recurrence score (RS) (≥26) on the Oncotype DX 21-gene breast tumor prognostic genomic biomarker. Among 69 139 women (mean [SD] age, 57.7 [10.5] years; 6310 Hispanic [9.1%], 274 non-Hispanic American Indian and Alaskan Native [0.4%], 6017 non-Hispanic Asian and Pacific Islander [8.7%], 5380 non-Hispanic Black [7.8%], and 51 158 non-Hispanic White [74.0%]) included in our analysis, non-Hispanic Black (odds ratio [OR], 1.33; 95% CI, 1.23-1.43) and non-Hispanic American Indian and Alaska Native women (OR, 1.38; 95% CI, 1.01-1.86) had greater likelihood of a high-risk RS compared with non-Hispanic White women. There were no significant differences among other racial and ethnic groups. Compared with non-Hispanic White patients, there were greater odds of a high-risk RS for non-Hispanic Black women residing in urban areas (OR, 1.35; 95% CI, 1.24-1.46), but not among rural residents (OR, 1.05; 95% CI, 0.77-1.41). Mediation analysis demonstrated that lack of insurance, county-level disadvantage, and urban vs rural residence partially explained the greater odds of a high-risk RS among non-Hispanic Black women (proportion mediated, 17%; P < .001). The findings of this cohort study suggest that the consequences of structural racism extend beyond inequities in health care to drive disparities in breast cancer outcome. Additional research is needed with more comprehensive social and environmental measures to better understand the influence of social determinants on aggressive ER-positive tumor biology among racial and ethnic minoritized women from disadvantaged and historically marginalized communities.

Abstract 2139: Identifying molecular mechanisms in triple negative breast cancer disparities: Unveiling the role of Hedgehog signaling in non-Hispanic Black women

Abstract Triple negative breast cancer (TNBC) represents an aggressive and therapeutically challenging breast cancer subtype with higher incidence and mortality rates in non-Hispanic Black (NHB) women. This disparity persists even after adjusting for socioeconomic factors, tumor biology, and quality of care. The study aims to unravel specific molecular mechanisms underlying this disparity, with a focus on Hedgehog signaling pathways in premenopausal NHB women. Understanding these mechanisms is vital for developing targeted therapies and personalized medicine approaches to address these health disparities. Our research utilized a unique cohort of NHB and non-Hispanic White (NHW) women who underwent breast reduction surgery at the Mayo Clinic and donated breast tissue samples for our study. We isolated RNA from whole tissue sections from a cohort of 12 NHB and 40 NHW women who were parous and premenopausal at time of surgery. We performed gene expression profiling using NanoString BC360 and IO360 assays. This allowed us to identify a distinct gene expression signature characteristic of basal-like/TNBC and indicative of heightened activity in the Hedgehog signaling pathway. We also employed advanced cell culture techniques to generate tissue organoids and subculture human mammary epithelial cells (HMECs) that preserve the intrinsic characteristics of the original tissue samples. We found that significantly differential expression of IL20RA and SOX10, principal factors in the gene expression signature, were preserved in both the derived organoids and the HMECs. These results suggest a potential intrinsic difference in the activation of the Hedgehog pathway in the breast epithelial cells of NHB women. This activation may contribute to increased proliferation and transformation of basal stem cells within the breast, possibly fueling the development and progression of TNBC. The implication of activated Hedgehog signaling in NHB women opens new avenues for understanding TNBC disparities. IL20RA and SOX10 represent potential biomarkers for TNBC risk that may serve as a stratification tool for NHB women. The results of this study have the potential to improve assessment and management of TNBC risk among NHB women, thereby contributing significantly to reducing health disparities in breast cancer outcomes. Citation Format: Jennifer Vanessa Cabezas, Savanna Touré, Matthew Wilson, Melody L. Stallings Mann, Laura M. Pacheco-Spann, Joshua W. Ogony, Mark E. Sherman, Derek C. Radisky. Identifying molecular mechanisms in triple negative breast cancer disparities: Unveiling the role of Hedgehog signaling in non-Hispanic Black women [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2139.

Abstract 707: Calorie restriction to augment radiation response in models of Black women with breast cancer

Abstract Introduction: Black women have higher mortality from breast cancer (BrCa) than other populations. While several factors contribute to this disparity, insulin-like growth factor 1 receptor (IGF-1R), is notably overexpressed in tumors originating in Black women compared to White women, which is associated with tumor progression and resistance to radiation therapy (RT). Caloric restriction (CR) is noted to reduce the expression of members of the IGF-1R pathway. We hypothesize that CR increases the efficacy of RT, in Black women, by downregulating the IGF-1R pathway to decrease tumor growth. Methods: To understand the feasibility of implementing CR in Black women with BrCa, patients received a CR diet during adjuvant breast RT on an IRB approved investigator-initiated clinical trial and pre- and post- measures were evaluated. BrCa cell lines originating from Black (MD-MBA-468 and MD-MBA-157) or White patients (MDA-MB-231 and MDA-MB-436) were exposed to RT in the presence and absence of CR medium, IGF-1 to upregulate the pathway, and PPP, an IGF-1R inhibitor to evaluate the role of dietary interventions and IGF-1R pathway modulation in altering the RT response. Finally, human BrCa tissue was collected and ex vivo explants were used to evaluate the role of diet to augment the RT response. Results: In the pilot clinical trial, 32 patients were enrolled, 50% of whom were Black (16B/16W). Black patients had more adverse baseline physiologic parameters and corresponding higher insulin and systemic inflammation as measured by ESR, IFNγ, Il-1β, and TNFα at baseline. Adherence to CR was 87.3% for the Black patients who had an average weight loss of 7.33 lbs, and decreased insulin and cholesterol levels after CR+RT. In intro, in Black originating cells, cell viability experiments showed that CR+RT decreased cell viability by 53% &amp; 46% while RT alone reduced viability by 32 &amp; 41%. In White originating cells, CR+RT decreased cell viability by 52% and 53% while RT alone reduced viability by 42% and 26%. IGF-1R inhibition with PPP caused a more significant decrease in viability when given with RT than CR+RT did. The opposite effect was noted when IGF-1 was added to the cell lines and that increase was prevented by treatment with IGF-1+RT+CR. This was confirmed in vivo. Explants revealed CR helped decrease proliferation and increase apoptosis for all cancer patients. Conclusion: Taken together, these data demonstrate that Black patients can adhere to dietary interventions during RT therapy for breast cancer which may help achieve better tumor control via downregulation of the IGF-1R pathway which is often notably upregulated in this population. This benefit is widely applicable with equivalent efficacy between patients of both races and all breast cancer subtypes. Future studies should investigate the role of downregulating IGF-1R via dietary interventions to narrow disparities in breast cancer outcomes in our black patient population. Citation Format: Noelle B. Francois, Anuradha A. Shastri, Siani Harding, Tiziana DeAngelis, Adeseye Adekeye, Nicole Simone. Calorie restriction to augment radiation response in models of Black women with breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 707.

Race, Gene Expression Signatures, and Clinical Outcomes of Patients With High-Risk Early Breast Cancer

There has been little consideration of genomic risk of recurrence by breast cancer subtype despite evidence of racial disparities in breast cancer outcomes. To evaluate associations between clinical trial end points, namely pathologic complete response (pCR) and distant recurrence-free survival (DRFS), and race and examine whether gene expression signatures are associated with outcomes by race. This retrospective cohort study used data from the Investigation of Serial Studies to Predict Your Therapeutic Response With Imaging and Molecular Analysis 2 (I-SPY 2) multicenter clinical trial of neoadjuvant chemotherapy with novel agents and combinations for patients with previously untreated stage II/III breast cancer. Analyses were conducted of associations between race and short- and long-term outcomes, overall and by receptor subtypes, and their association with 28 expression biomarkers. The trial enrolled 990 female patients between March 30, 2010, and November 5, 2016, with a primary tumor size of 2.5 cm or greater and clinical or molecular high risk based on MammaPrint or hormone receptor (HR)-negative/ERBB2 (formerly HER2 or HER2/neu)-positive subtyping across 9 arms. This data analysis was performed between June 10, 2021, and October 20, 2022. Race, tumor receptor subtypes, and genomic biomarker expression of early breast cancer. The primary outcomes were pCR and DRFS assessed by race, overall, and by tumor subtype using logistic regression and Cox proportional hazards regression models. The interaction between 28 expression biomarkers and race, considering pCR and DRFS overall and within subtypes, was also evaluated. The analytic sample included 974 participants (excluding 16 self-reporting as American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, or multiple races due to small sample sizes), including 68 Asian (7%), 120 Black (12%), and 786 White (81%) patients. Median (range) age at diagnosis was 47 (25-71) years for Asian, 49 (25-77) for Black, and 49 (23-73) years for White patients. The pCR rates were 32% (n = 22) for Asian, 30% for Black (n = 36), and 32% for White (n = 255) patients (P = .87). Black patients with HR-positive/ERBB2-negative tumors not achieving pCR had significantly worse DRFS than their White counterparts (hazard ratio, 2.28; 95% CI, 1.24-4.21; P = .01), with 5-year DRFS rates of 55% (n = 32) and 77% (n = 247), respectively. Black patients with HR-positive/ERBB2-negative tumors, compared with White patients, had higher expression of an interferon signature (mean [SD], 0.39 [0.87] and -0.10 [0.99]; P = .007) and, compared with Asian patients, had a higher mitotic score (mean [SD], 0.07 [1.08] and -0.69 [1.06]; P = .01) and lower estrogen receptor/progesterone receptor signature (mean [SD], 0.31 [0.90] and 1.08 [0.95]; P = .008). A transforming growth factor β signature had a significant association with race relative to pCR and DRFS, with a higher signature associated with lower pCR and worse DRFS outcomes among Black patients only. The findings show that women with early high-risk breast cancer who achieve pCR have similarly good outcomes regardless of race, but Black women with HR-positive/ERBB2-negative tumors without pCR may have worse DRFS than White women, highlighting the need to develop and test novel biomarker-informed therapies in diverse populations.

Abstract A014: Connecting with Black patients through targeted, breast cancer messaging in the clinic setting

Abstract Background: While overall breast cancer incidence among Black women is lower than among white women, Black women are, on average, about 40 percent more likely to die of the disease as compared to white women. And the incidence rates are higher among Black women under age 40 (where incidence is the number of new cases that develop in a specific time period). Black women experience higher rates of death from breast cancer due to a combination of factors, including barriers to early diagnosis, the aggressive nature of certain breast cancers that are more prevalent in Black women (Triple Negative Breast Cancer and Inflammatory Breast Cancer, for example), and a lack of quality care. One of the key findings from Komen’s report ‘Closing the Gap: A Roadmap to Save the Lives of Black Women in America’ (2021) indicated a need for better education and resources for patients to support health decisions. Specifically, qualitative data from focus groups across 10 cities with significant disparities in breast cancer outcomes showed information was needed about breast cancer screening guidelines and family health history in the community to identify high-risk families. Hypothesis: To determine if targeted, patient-faced educational messages in point-of-care settings would connect with Black patients and educate them on breast cancer resources provided by Susan G. Komen. Our efforts focused particularly in cities with the greatest breast cancer disparities (Atlanta, GA; Chicago, IL; Dallas, TX; Houston, TX; Los Angeles, CA; Memphis, TN; Philadelphia, PA; St. Louis, MO; Tidewater, VA; Washington, DC) . Methods: In 11 focus cities, select educational messaging over a six-month period appeared through static digital content in patient exam rooms featuring Black imagery and patient-empowering breast cancer resources content. The 20-second reels appeared every 15-20 minutes in 471 primary care and OB/GYN offices/2,336 exam rooms. Patients in these offices responded (n=315) through an online survey to share demographic information including gender and ethnicity and to identify how aware they were of Black women’s risk of breast cancer mortality, that resource programs exist to support breast health including those offered by Susan G. Komen and that Komen has a program aimed at addressing this disparity within the Black community. Results: By sharing educational messaging directly to patients in the clinic, significant awareness was achieved. Those who responded to the survey included 38% Black women. The targeted messaging campaign reached the intended audience and connected Black patients with additional resources to take action on their breast health. In particular, increased awareness of specific interventions was achieved. In future efforts to empower Black women and improve outcomes, direct, culturally tailored education presented in the clinic setting may be a useful tool and lead to better utilization of key resource programs and overall improved health education. Citation Format: Nikki Hopewell, Brady Kazar, Michelle Strong, Krissa Smith. Connecting with Black patients through targeted, breast cancer messaging in the clinic setting [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A014.

Abstract IA035: Narrowing disparities in breast cancer: A multi-level perspective

Abstract Seminar Abstract: Despite improvements in breast cancer detection and treatment, racial disparities in breast cancer outcomes persist. In the United States, particularly the southeastern region, Black women are more likely to experience breast cancer-related mortality than any other race or ethnic group—regardless of subtype, age, or socioeconomic status. The drivers of disparities are likely multifactoral and include interacting factors (e.g., tumor, treatment, patient, and neighborhood characteristics) that contribute to race differences in breast cancer-specific mortality. Emerging data suggest that the excess breast cancer mortality experienced by Black women is linked to broader systems of oppression that impact everything from access and quality of care to tumor aggressiveness and treatment response—the imprints of which may be detectable in tumor biology. Comprehensive, multi-level approaches to addressing disparities will aid the identification of causal and contributing factors, moving us beyond merely documenting differences to creating action-oriented models aimed at achieving equitable cancer care within the social contexts of the communities affected. Citation Format: Lauren E. McCullough. Narrowing disparities in breast cancer: A multi-level perspective [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr IA035.

Abstract B062: Prevalence of pathogenic BRCA1/2 variants among Latinas in the All of Us Cohort

Abstract Latinas in the United States are disproportionately affected by breast cancer, but little is known about genetic risk factors for breast cancer in this population. Genetic variants in BReast CAncer genes 1 and 2 (BRCA1/2) are known to be associated with heritable cancer risk, yet the prevalence of BRCA1/2 pathogenic variants in the Latina population is not well characterized. This study aims to examine the prevalence of pathogenic BRCA1/2 variants among Latinas in the NIH All of Us research program, which includes a large number of individuals representative of the diversity of the United States population. Using data from the All of Us research program, we will analyze the prevalence of these variants among Latinas, in addition to all other racial and ethnic groups. To date, the All of Us cohort contains 245,400 genomes, and of those 41,940 (17%) are from self-identified Hispanic/Latino/or Spanish participants. We will compare the prevalence of pathogenic, or likely pathogenic, variants across self-reported race/ethnicity and continental genetic ancestry categories. Our study will leverage the diversity of All of Us and enable us to compare our data with those from more Eurocentric databases. With these data, we can potentially 1) identify novel variants that could predispose to increased cancer risk; and 2) clarify the previous designations of variants characterized to have undetermined/unknown significance due to the limitations of using a single Eurocentric reference genome. Identifying the actual prevalence of pathogenic BRCA1/2 variants among Latinas is important for improving breast cancer prevention, detection, and treatment in this population. The findings of this study have the potential to inform genetic counseling and testing recommendations for Latina patients at high risk of developing breast cancer, as well as others. This will also enable healthcare providers to better understand the unique genetic factors contributing to breast cancer risk among this population. Ultimately, this knowledge can improve the care of Latina patients and contribute to the broader effort to advance health equity and reduce disparities in breast cancer outcomes among Latinas. Citation Format: Cathy Samayoa, Erick Olivares, Catherine Gavile, Adriana Visbal. Prevalence of pathogenic BRCA1/2 variants among Latinas in the All of Us Cohort [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B062.

Abstract C134: Efficacy of mobile mammography and state-funded cancer services in reducing disparities in follow-up adherence: A retrospective analysis

Abstract Objective: Mobile mammography programs, such as the one at Stony Brook Cancer Center (SBCC), play an important role in providing breast cancer screening services to underserved communities. Follow-up to abnormal mammogram screenings is critical for early cancer detection, but patients often encounter barriers that prevent timely diagnostic procedures. We aim to evaluate the role of New York State’s Cancer Services Program (CSP) in facilitating follow-up care among underserved patients who participated in SBCC’s mobile mammography initiative. Methods: We conducted a retrospective analysis of 817 mobile mammography patients who required additional testing following an abnormal mammogram over a five-year period. Of these, 68% were beneficiaries of the CSP, while 32% were insured. Results: Our findings revealed that among CSP beneficiaries, only 3.5% were lost to follow-up, compared to a significant 16.5% of insured patients who did not adhere to recommended follow-up care. This suggests that the CSP’s supportive role is critical in ensuring follow-up care among underserved communities. Conclusions: The CSP’s substantial impact on follow-up care adherence highlights the program's effectiveness in reducing healthcare disparities. However, more work is needed to enhance follow-up care adherence among insured patients. Solutions may include identifying and addressing barriers to care and implementing targeted interventions to improve patient outcomes. Implications for Policy or Practice: Mobile mammography programs, such as SBCC’s initiative, demonstrate a potential strategy for reducing health disparities in breast cancer screening and detection. Securing access to follow-up care is crucial for improving patient outcomes. Addressing barriers to care, strengthening patient education, and enhancing outreach efforts can increase participation in screening initiatives, thus advancing health equity and reducing disparities in breast cancer outcomes. Citation Format: Patrick J. Dineen, Mollie M. Williams. Efficacy of mobile mammography and state-funded cancer services in reducing disparities in follow-up adherence: A retrospective analysis [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C134.

Turning the Page on Breast Cancer in Ohio: Lessons learned from implementing a multilevel intervention to reduce breast cancer mortality among Black women.

Turning the Page on Breast Cancer (TPBC) uses a multilevel approach to reduce breast cancer (BC) mortality among Black women. TPBC intervenes by (1) improving health care facilities' ability to conduct effective BC screening, follow-up, and treatment; (2) involving community-based organizations; and (3) providing education and personal risk information through a culturally relevant website. Ohio has among the worst BC mortality rates in the United States for Black women. TPBC is in its third year of providing targeted interventions in 12 Ohio counties with particularly high BC rates among Black women. TPBC enrolls health care facilities, collects organizational and patient data, and conducts key informant interviews to inform the provision of appropriate evidence-based interventions. TPBC engages Black communities through community-based organizations and social media advertising. The TPBC website offers BC information, connects Black women to community BC resources, and provides access to a risk-assessment tool. TPBC has provided tailored information packets, evidence-based interventions, and systematic support for improving the tracking and follow-up of breast health care among patients in 10 clinical partnerships. The project has provided education at community events monthly since mid-2021. The TPBC website (http://endbreastcancerohio.org) is promoted through social media (primarily Facebook) and community events to reach Black women aged 25-70 years. To date, 4108 unique users have visited the website, of whom 15.9% completed the risk assessment. Novel strategies are needed to address persistent disparities in BC outcomes among Black women. TPBC demonstrates the potential effectiveness of multiple methods of community-based, clinic-based, and web-based engagement. Turning the Page on Breast Cancer (TPBC) aims to reduce breast cancer mortality among Black women in Ohio by conducting multilevel, community-engaged interventions in 12 counties. Women are provided risk information and education at virtual and in-person community events and through a community-friendly website that was launched in November 2020. Almost 4000 women have visited the website, which offers community-targeted information, urges screening for individuals at elevated risk, and offers access to patient navigation services; 655 users have used a breast cancer risk-assessment tool on the site. Community-based organizations conduct educational efforts. TPBC partners with health care facilities, which are taught to improve their ability to conduct effective breast cancer screening, follow-up, and treatment. So far, TPBC has provided educational information, evidence-based intervention lists, tailored information packets, and ongoing quarterly support to partners in 10 counties. Evaluation will focus on aggregated data for screening and genetic testing referral at the clinic level.

Racial and Ethnic Differences in Long-Term Adverse Radiation Therapy Effects Among Breast Cancer Survivors

Breast and skin changes are underrecognized side effects of radiation therapy for breast cancer, which may have long-term implications for quality of life (QOL). Racial and ethnic disparities in breast cancer outcomes, including long-term QOL differences after breast radiation therapy, are poorly understood. We conducted a cross-sectional survey study of patients from the Texas Cancer Registry who received diagnoses of stage 0-II breast cancer from 2009 to 2014 and treated with lumpectomy and radiation therapy; 2770 patients were sampled and 631 responded (23%). The BREAST-Q Adverse Effects of Radiation overall score and subindices measured the effect of radiation therapy on breast tissue. Multivariable logistic regression evaluated associations of demographic and treatment characteristics with outcomes. The median age was 57 years (IQR, 48-65), median time from diagnosis to survey response 9 years (IQR, 7-10), and the cohort included 62 Asian American or Pacific Islander (9.8%), 11 American Indian or Alaskan Native (AIAN) (1.7%), 161 Black (25.5%), 144 Hispanic (22.8%), and 253 White (40.1%) patients. Mean BREAST-Q Adverse Effects of Radiation score was worse for AIAN patients (-22.2; 95% CI, -39.9 to -4.6; P=.01), Black patients (-10.8; 95% CI, -16.1 to -5.5; P < .001), and Hispanic patients (-7.8; 95% CI, -13.0 to -2.5; P=.004) compared with White patients, age <50 compared with ≥65 (effect size -8.6; 95% CI, -14.0 to -3.2; P=.002), less than a college education (-5.8; 95% CI, -10.0 to -1.6; P=.01), bra cup size of D/E versus A/B (-5.3; 95% CI, -9.9 to -0.65; P=.03), and current smokers (-11.3; 95% CI, -18.3 to -4.2; P=.002). AIAN, Black, and Hispanic patients reported worse changes in skin pigmentation, telangiectasias, dryness, soreness, and/or irritation compared with White patients. AIAN, Black, and Hispanic patients reported substantially worse long-term breast and skin QOL outcomes after radiation therapy. Additional work is needed to understand these differences and how to alleviate them.

Prevalence and patterns of breast white adipose tissue inflammation among American Black women and indigenous Nigerian women with early-stage breast cancer.

e12560 Background: Racial disparities in breast cancer outcomes pose a major public health challenge. Complex interactions between social determinants of health and tumor biology, mediated by obesity and adiposity, may play an important role in these disparities. White adipose tissue inflammation (WATi) of the breast, which is histologically defined by the presence of crown-like structures (CLS-B), occurs in the setting of excess adiposity and promotes tumor growth via elevated levels of aromatase, proinflammatory growth factors, and metabolic dysregulation. Here we examined relationships between race, body mass index (BMI), and WATi in two cohorts of patients with early-stage breast cancer: 1) American Black women and 2) indigenous Nigerian women. Methods: Non-tumor breast WAT specimens were collected from patients undergoing mastectomy for treatment or prevention of breast cancer at Memorial Sloan Kettering Cancer Center (MSK) in the US and Obafemi Awolowo University Teaching Hospital (OAUTH) in Nigeria. WATi was defined by the presence of CLS-B as detected by CD68 immunostaining. All tissue analyses were performed at MSK. Associations among BMI and WATi were tested within each cohort using Kendall’s tau rank correlation and compared between cohorts using Pearson's Chi-squared test. Results: A total of 224 American women were enrolled at MSK between 2011-2018, of whom 39 self-reported Black race. At OAUTH, 97 Nigerian women were enrolled between 2018-2022. Invasive carcinoma was present in 32 American Blacks and 97 Nigerians. Of those with invasive carcinoma, the prevalence of WATi among American Black women was 72% vs. 37% in the Nigerian cohort ( p&lt;0.001). In the US cohort, there was no significant difference between the prevalence of WATi among Black vs. non-Black patients (72% vs. 62%; p=0.3). 44% of American Blacks were obese and 34% overweight compared with 27% and 39% of Nigerians, respectively (p=0.07). The prevalence of WATi varied by BMI category within each cohort, as shown. Overweight/obesity was associated with WATi in the Nigerian (p=0.009) and American cohorts (p&lt;0.001); a trend was observed in the American Black subgroup (p=0.13). Conclusions: Breast WATi and obesity were more prevalent among American Black women with breast cancer compared with Nigerian women. These findings highlight the need for further investigation of environment, lifestyle patterns, and body composition differences between indigenous and diaspora populations. [Table: see text]

Abstract P4-03-28: Patient Reported Symptom Burden Amongst Immigrant and Canadian Long-Term Resident Women Undergoing Breast Cancer Surgery

Abstract Background: Disparities in breast cancer outcomes are well documented, with a burgeoning body of literature shedding light on the influence of multiple factors. Much of the literature comes from the US, with the current situation in Canada less well understood. Canada’s universal health care system may mitigate some, but unlikely all differences. First generation immigrants compromise 21.9% of the Canadian population. Differences in breast cancer screening rates and stage at diagnosis have been demonstrated between immigrant and non-immigrant Canadian women. However, breast cancer outcomes in the Canadian immigrant population have not been well studied. Patient reported outcomes are one such set of outcomes and crucial in understanding the patient experience. The purpose of this study is to compare symptom burden and trajectories between immigrant and Canadian long-term resident women with breast cancer undergoing breast cancer surgery in Ontario. Methods: A population-level retrospective cohort-study using linked Ontario administrative databases was constructed. Women &amp;gt;18 years of age with newly diagnosed breast cancer between 2010-2016 undergoing surgery at a regional cancer center were included. Baseline variables including immigration status, age, stage, comorbidity and income quintile were collected. The proportion of patients reporting moderate/severe Edmonton Symptom Assessment System Scale (ESAS) scores for each of 9 individual symptom categories over time was collected. Multivariable logistic regression models using generalized estimating equations with exchangeable correlation structure to account for repeated measures were constructed to assess the probability of a moderate/severe score for each of the individual ESAS symptom categories. Results: The cohort included 14,056 women, of which 12,250 (87.2%) were categorized as long-term Canadian residents and 1,806 (12.8%) as immigrants. Immigrant women had a younger mean age of diagnosis (53 vs. 61 years), were more likely to reside in a lowest income quintile neighbourhood (22.2% vs 15.4%), were less likely to be on a primary care physician roster within the last 2 years (83.7% vs. 90.4%) and were less often diagnosed with Stage I/II disease (80.9% vs. 84.6%) (all p&amp;lt; 0.0001). The proportion of women reporting moderate/severe scores was significantly higher amongst immigrant women for 7/9 symptom categories (anxiety, depression, drowsiness, nausea, pain, shortness of breath and well-being) with the largest difference observed for depression (13.1% vs 10.8%, p&amp;lt; 0.0001) and pain (14.8% vs. 12.0%, p&amp;lt; 0.0001). Comparing symptom trajectories, differences between groups were most pronounced within the first 12 months, though for depression and pain, statistically significant differences also existed at 36 months. On multivariable regression analysis, immigration status was persistently associated with higher proportion of moderate/severe score for pain only (OR 1.12, 95% CI 1.02-1.23). Immigration status was associated with a protective effect for anxiety (OR 0.86, 95% CI 0.78-0.94), drowsiness (OR 0.81, 95% CI 0.73-0.89) and tiredness (OR 0.86, 95% CI 0.79-0.94). Conclusions: To our knowledge, this is the first study comparing symptom burden amongst immigrant and non-immigrant Canadian women with breast cancer at a population-level. Immigrant women undergoing breast cancer surgery were found to have a higher burden of symptoms across most categories, and for depression and pain this difference was found to persist even at 3-years. However, the higher burden of symptoms in many categories seemed to be explained by factors such as younger age and more advanced disease. Adjusting for other factors, immigrant women with breast cancer reported more pain, indicating a need for better symptom management in this population. Citation Format: Elena Parvez, Megan M. Chu, David Kirkwood, Aristithes Doumouras, Jessica Bogach. Patient Reported Symptom Burden Amongst Immigrant and Canadian Long-Term Resident Women Undergoing Breast Cancer Surgery. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-03-28.

Abstract ED9-3: Effects of age on the tumor microenvironment

Abstract Dr. McAllister’s translational research group studies breast cancer as a systemic disease with an emphasis on the role of immune fitness in disease control and response to therapy. In this education session, Dr. McAllister will introduce the concept of “immunological age”. She will discuss her team’s ongoing efforts to understand how age sets the stage for triple-negative breast cancer (TNBC) progression and response to immune checkpoint blockade therapy. Her team was the first to report that bone marrow derived immune cells from 8–10-week-old young mice promote more aggressive TNBC growth when transferred to 12–15-month-old aged mice (Marsh, et al., Cancer Research, 2016). They subsequently identified cellular and molecular mechanisms that promote aggressive disease, as typically observed in younger individuals. Likewise, her group was the first to report that immune checkpoint blockade therapy is less effective in older mice with TNBC and discovered a treatment strategy that improved outcomes in pre-clinical TNBC models (Sceneay, et al., Cancer Discovery, 2019). The same tumor cellular and molecular pathways that stratified by age in their pre-clinical models also defined age-stratified differences between younger (under 40) and older (over 65) TNBC patients in the METABRIC dataset. She will present her team’s new work on functional aspects of immunological age in TNBC and the ongoing efforts of the Older Women with Breast Cancer Research and Treatment Team at the Dana-Farber/Brigham Cancer Center. Ultimately, she and her team wish to eliminate age- and race-based disparities in breast cancer outcomes. Citation Format: Sandra McAllister. Effects of age on the tumor microenvironment [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr ED9-3.

Neighborhood and racial influences on triple negative breast cancer: evidence from Northeast Ohio.

Triple negative breast cancer (TNBC) is an aggressive subtype of breast cancer (BC) with higher recurrence rates and poorer prognoses and most prevalent among non-Hispanic Black women. Studies of multiple health conditions and care processes suggest that neighborhood socioeconomic position is a key driver of health disparities. We examined roles of patients' neighborhood-level characteristics and race on prevalence, stage at diagnosis, and mortality among patients diagnosed with BC at a large safety-net healthcare system in Northeast Ohio. We used tumor registry to identify BC cases from 2007 to 2020 and electronic health records and American Community Survey for individual- and area-level factors. We performed multivariable regression analyses to estimate associations between neighborhood-level characteristics, measured by the Area Deprivation Index (ADI), race and comparative TNBC prevalence, stage at diagnosis, and total mortality. TNBC was more common among non-Hispanic Black (53.7%) vs. non-Hispanic white patients (46.4%). Race and ADI were individually significant predictors of TNBC prevalence, stage at diagnosis, and total mortality. Race remained significantly associated with TNBC subtype, adjusting for covariates. Accounting for TNBC status, a more disadvantaged neighborhood was significantly associated with a worse stage at diagnosis and higher death rates. Our findings suggest that both neighborhood socioeconomic position and race are strongly associated with TNBC vs. other BC subtypes. The burden of TNBC appears to be highest among Black women in the most socioeconomically disadvantaged neighborhoods. Our study suggests a complex interplay of social conditions and biological disease characteristics contributing to racial disparities in BC outcomes.

Selected Articles from This Issue

Highlights| February 06 2023 Selected Articles from This Issue Author & Article Information Online ISSN: 1538-7755 Print ISSN: 1055-9965 ©2023 American Association for Cancer Research2023American Association for Cancer Research Cancer Epidemiol Biomarkers Prev (2023) 32 (2): 155. https://doi.org/10.1158/1055-9965.EPI-32-2-HI Related Content A commentary has been published: Dietary Factors and Early-Onset Colorectal Cancer in the United States—an Ecologic Analysis A commentary has been published: Longitudinal Changes in Immune Activation Serum Biomarkers Prior to Diagnosis and Risk of B-cell NHL Subtypes A commentary has been published: Race Differences in Patient-Reported Symptoms during Chemotherapy among Women with Early-Stage Hormone Receptor–Positive Breast Cancer View more A commentary has been published: Geographic Patterns in U.S. Lung Cancer Mortality and Cigarette Smoking View less Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Article Versions Icon Versions Version of Record February 6 2023 Citation Selected Articles from This Issue. Cancer Epidemiol Biomarkers Prev 1 February 2023; 32 (2): 155. https://doi.org/10.1158/1055-9965.EPI-32-2-HI Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest Search Advanced Search Symptom burden differences may contribute to racial disparities in breast cancer outcomes. In this retrospective cohort study of 1,273 women with early-stage hormone receptor-positive breast cancer from a large cancer center, Black women more frequently experienced worsening physical and psychological symptoms during chemotherapy compared to White women. Hu and colleagues found that differences in baseline sociodemographic and clinical characteristics contributed to the increasing symptom burden among Black patients. However, most of the differences in the physical symptom changes were not explained by these characteristics, which suggests inadequate symptom management among Black women. More research is needed to ensure equitable symptom management among all patients. Lung cancer remains the leading cause of cancer death in the United States. Shreves and colleagues investigated spatial patterns in smoking prevalence and lung cancer mortality rates by sex. They report the first observation of a significant cluster of counties where the relationship between smoking prevalence... You do not currently have access to this content.

Abstract IA038: Race and immune microenvironments in context of individual- and community-level covariates

Abstract Black women and women with African Ancestry have higher frequency of aggressive breast cancer subtypes, namely triple-negative breast cancer (TNBC) or Basal-like breast cancer, and often have tumors that show immunogenic features. Under a cells-to-society conceptual model of racialized breast cancer outcomes, differences in tumor biology and microenvironment interact with individual- and community-level variables so that differences in tumor biology reflect ancestry in combination with social determinants of health. Using data and biospecimens from the Carolina Breast Cancer Study, we evaluated immune expression by gene expression analysis and by immunofluorescence and other spatial techniques. Our results show that Black women more frequently have immunogenic tumors with a robust adaptive immune response, in accordance with higher frequency of Basal-like breast cancers. Adaptive immune response was also associated with specific breast cancer genetic features, such as p53 status, and was associated with differential recurrence outcomes. Immunogenic tumors of Basal-like subtype were also associated with individual-level socioeconomic factors (education, income, prediagnostic health care utilization) and community-level socioeconomic factors (census tract-level poverty and disadvantage). These data suggest that while some biologically-targeted therapies may help narrow disparities in breast cancer outcomes among those diagnosed with breast cancer, individual- and community-level variables are also important and may help to identify intervention strategies for prevention of aggressive subtypes. Citation Format: Melissa A. Troester. Race and immune microenvironments in context of individual- and community-level covariates [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr IA038.