Late-stage Breast Cancer Diagnosis Research Articles

Spatial association of racial/ethnic disparities between late-stage diagnosis and mortality for female breast cancer: where to intervene?

BackgroundOver the past twenty years, racial/ethnic disparities between late-stage diagnoses and mortality outcomes have widened due to disproportionate medical benefits that different racial/ethnic groups have received. Few studies to date have examined the spatial relationships of racial/ethnic disparities between breast cancer late-stage diagnosis and mortality as well as the impact of socioeconomic status (SES) on these two disparities at finer geographic scales.MethodsThree methods were implemented to assess the spatial relationship between racial/ethnic disparities of breast cancer late-stage diagnosis and morality. First, this study used rate difference measure to test for racial/ethnic disparities in both late-stage diagnosis and mortality of female breast cancer in Texas during 1995-2005. Second, we used linear and logistic regression models to determine if there was a correlation between these two racial/ethnic disparities at the census tract level. Third, a geographically-weighted regression analysis was performed to evaluate if this correlation occurred after weighting for local neighbors.ResultsThe spatial association of racial disparities was found to be significant between late-stage diagnosis and breast cancer mortality with odds ratios of 33.76 (CI: 23.96-47.57) for African Americans and 30.39 (CI: 22.09-41.82) for Hispanics. After adjusting for a SES cofounder, logistic regression models revealed a reduced, although still highly significant, odds ratio of 18.39 (CI: 12.79-26.44) for African-American women and 11.64 (CI: 8.29-16.34) for Hispanic women. Results of the logistic regression analysis indicated that census tracts with low and middle SES were more likely to show significant racial disparities of breast cancer late-stage diagnosis and mortality rates. However, values of local correlation coefficients suggested that the association of these two types of racial/ethnic disparities varied across geographic regions.ConclusionsThis study may have health-policy implications that can help early detection of breast cancer among disadvantaged minority groups through implementing effective intervention programs in targeted regions.

Geographic disparities in late-stage breast cancer diagnosis in California

Using cancer registry data for the population of California women aged 67+ with breast cancers, we estimated random intercept logistic models to examine how two socio-ecological predictors (residential isolation and poverty) were associated with probability of late-stage diagnosis for breast cancer. Using the multilevel modeling results, we calculated fully adjusted predicted probabilities associated with women in each Medical Service Study Area (MSSA) in California and classified the areas into two distinct groups: MSSAs with predicted rates below the 25th percentile (presumably the better outcome areas) and MSSAs with predicted rates above the 75th percentile (presumably the worse outcome areas) for two minority groups. Some areas had better outcomes for one group but worse outcomes for the other, suggesting that interventions to improve outcomes need different strategies for different groups in the same areas. Using information from geographic risk factors and multilevel modeling, this study informs interventions designed to reduce disparities in breast cancer outcomes.

Black residential segregation, disparities in spatial access to health care facilities, and late-stage breast cancer diagnosis in metropolitan Detroit

This study evaluates the role of black residential segregation and spatial access to health care in explaining the variation in late-stage diagnosis of breast cancer in metropolitan Detroit. Data pertaining to female breast cancer from 1998 to 2002 are obtained from the Michigan Cancer Surveillance Program. An isolation index is used to assess black segregation. The 2-step floating catchment area approach integrated with a Gaussian function is used to estimate the health care access. While socioeconomic factors at ZIP code level are controlled, ordinary least squares and spatial lag models are used to explore the association between the rates of late-stage diagnosis and segregation and health care access. Results suggest that living in areas with greater black segregation and poorer mammography access significantly increases the risk of late diagnosis of breast cancer. Disadvantaged populations including those with low socioeconomic status or sociocultural barriers tend to experience high rates of late diagnosis. Findings emphasize the need for heightened screening, surveillance, and intervention programs in these areas.

Combining Areal and Point Data in Geostatistical Interpolation: Applications to Soil Science and Medical Geography

A common issue in spatial interpolation is the combination of data measured over different spatial supports. For example, information available for mapping disease risk typically includes point data (e.g. patients' and controls' residence) and aggregated data (e.g. socio-demographic and economic attributes recorded at the census track level). Similarly, soil measurements at discrete locations in the field are often supplemented with choropleth maps (e.g. soil or geological maps) that model the spatial distribution of soil attributes as the juxtaposition of polygons (areas) with constant values. This paper presents a general formulation of kriging that allows the combination of both point and areal data through the use of area-to-area, area-to-point, and point-to-point covariances in the kriging system. The procedure is illustrated using two data sets: (1) geological map and heavy metal concentrations recorded in the topsoil of the Swiss Jura, and (2) incidence rates of late-stage breast cancer diagnosis per census tract and location of patient residences for three counties in Michigan. In the second case, the kriging system includes an error variance term derived according to the binomial distribution to account for varying degree of reliability of incidence rates depending on the total number of cases recorded in those tracts. Except under the binomial kriging framework, area-and-point (AAP) kriging ensures the coherence of the prediction so that the average of interpolated values within each mapping unit is equal to the original areal datum. The relationships between binomial kriging, Poisson kriging, and indicator kriging are discussed under different scenarios for the population size and spatial support. Sensitivity analysis demonstrates the smaller smoothing and greater prediction accuracy of the new procedure over ordinary and traditional residual kriging based on the assumption that the local mean is constant within each mapping unit.

Neighborhood Changes in Concentrated Immigration and Late Stage Breast Cancer Diagnosis

Immigrant women are at greater risk for late stage breast cancer diagnosis. The rapid increase in the US foreign-born population and new immigration patterns lead us to investigate the association between changes in immigrant population and the likelihood of distant metastasis stage at diagnosis of breast cancer among women in Cook County, Illinois. Analyses employed Illinois State Cancer Registry data for 42,714 breast cancer cases diagnosed between 1994 and 2003 in conjunction with 1990 and 2000 Census tract data. We find that concentration of and increases in immigrant populations within neighborhoods contributed to the risk of late stage breast cancer diagnosis. These findings suggest that, although some health indicators for immigrant populations have improved in recent years, important health disparities in breast cancer diagnosis still remain at the neighborhood level. They further suggest that cancer screening and follow-up resources should be directed to areas experiencing rapid increases in immigrant populations.

Visualizing and testing the impact of place on late-stage breast cancer incidence: A non-parametric geostatistical approach

This paper describes the combination of three-way contingency tables and geostatistics to visualize the non-linear impact of two putative covariates on individual-level health outcomes and test the significance of this impact, accounting for the pattern of spatial correlation and correcting for multiple testing. The methodology is used to explore the influence of distance to mammography clinics and census-tract poverty level on the rate of late-stage breast cancer diagnosis in three Michigan counties. Incidence rates are significantly lower than the area-wide mean (18.04%) mainly in affluent neighbourhoods [0–5% poverty], while higher incidences are mainly controlled by distance to clinics. The new simulation-based multiple testing correction is very flexible and less conservative than the traditional false discovery rate approach that results in a majority of tests becoming non-significant. Classes with significantly higher frequency of late-stage diagnosis often translate into geographic clusters that are not detected by the spatial scan statistic.

Mammography Capacity: Impact on Screening Rates and Breast Cancer Stage at Diagnosis

Mammography capacity in the U.S. reportedly is adequate, but has not been examined in nonmetropolitan areas. This study examined the relationships between in-county mammography facilities and rates of mammography screening and late-stage diagnosis of breast cancers. The association between a mammography facility in the county of residence (2002-2004) and the odds of screening within 2 years were examined (in 2007) among Texas women aged >40 years who responded to the 2004 Behavioral Risk Factor Surveillance System survey, using multivariate logistic regression to control for age, race, ethnicity, education, income, self-reported health, insurance, and usual source of care. Similarly, the association between an in-county mammography facility and the odds of diagnosis with locally advanced or disseminated disease was examined among Texas women aged >40 years who developed breast cancer in 2004. Half of the 254 counties in Texas had no mammography facility. After controlling for confounding factors, an in-county facility was associated with significantly higher odds of screening (OR=3.27; p=0.03) and lower odds of late-stage breast cancer at diagnosis (OR=0.36; 95% CI=0.26-0.51; p<0.001). The risks of late-stage diagnosis were higher for African-American women (OR=1.52; 95% CI=1.22-1.89; p<0.001) and Hispanic women (OR=1.23; 95% CI=0.99-1.53; p=0.06) than for white women. Although mammography capacity in the U.S. may be adequate on average, the unequal distribution of facilities results in large rural areas without facilities. Screening rates in these areas are suboptimal and are associated with late-stage diagnosis of breast cancer.

Frequency of late-stage breast cancer diagnoses despite high mammography screening rates in an HMO

1526 Background: Kaiser Permanente Southern California (KPSC) led the nation in screening women for breast cancer (BCa) with a mammography rate of nearly 90% in 2007 according to 2008 Healthcare Effectiveness Data and Information Set (HEDIS) measures. Despite successes in improving screening rates in this health plan that serves 3+ million diverse members, the percentage of women diagnosed with late stage BCa (stage III, IV) remained stable, varying from 12.9% (N∼323) in 2003 to 10.8% (N∼270) in 2007. To identify patient and health care factors associated with late stage diagnosis and the impact of its enhanced screening implementation guidelines, KPSC undertook this study. Methods: This cross-sectional study included a cohort of 10,580 BCa patients from 2003–2007. We compared women diagnosed with late stage disease versus those with early stage disease (stages I, II). P values (2-sided) were based on the chi-square distribution. Adjusted odds ratios and 95% confidence intervals were estimated using unconditional logistic regression. Results: Factors that were positively associated with late stage diagnosis in the univariate analyses included age, lack of recent mammography screening, worse tumor features, 80+ years of age, minority race, lower geocoded household income, increased healthcare visits, and use of Pap testing (P &lt; 0.01 for all variables). Factors significantly associated with late stage diagnosis in the multivariate model included only lack of recent mammography screening (OR = 1.35, 95% CI: 1.14–1.58) and worse tumor features including high grade (grade 3, OR = 2.58, 95% CI: 1.96–3.40), positive lymph nodes (OR = 53.49, 95% CI: 39.90–71.72), and HER-2+ tumors (OR = 1.40, 95% CI: 1.13–1.72). Conclusions: Targeting older women, those with lower utilization, and women who did not have a recent mammogram may help further lower the prevalence of late stage diagnoses. However, given the extent of the health plan's previous efforts to enhance BCa screening rates, a ceiling effect may limit additional benefit. Additional efforts to decrease the rate of advanced tumor stage at diagnosis may include improving interpretation of mammograms or earlier detection of aggressive tumors by enhanced BRCA genetic testing. No significant financial relationships to disclose.

Late-Stage Breast Cancer Diagnosis and Health Care Access in Illinois*

The variations of breast cancer mortality rates from place to place reflect both underlying differences in breast cancer prevalence and differences in diagnosis and treatment that affect the risk of death. This article examines the role of access to health care in explaining the variation of late-stage diagnosis of breast cancer. We use cancer registry data for the state of Illinois by zip code to investigate spatial variation in late diagnosis. Geographic information systems and spatial analysis methods are used to create detailed measures of spatial access to health care such as convenience of visiting primary care physicians and travel time from the nearest mammography facility. The effects of spatial access, in combination with the influences of socioeconomic factors, on late-stage breast cancer diagnosis are assessed using statistical methods. The results suggest that for breast cancer, poor geographical access to primary health care significantly increases the risk of late diagnosis for persons living outside the city of Chicago. Disadvantaged population groups including those with low income and racial and ethnic minorities tend to experience high rates of late diagnosis. In Illinois, poor spatial access to primary health care is more strongly associated with late diagnosis than is spatial access to mammography. This suggests the importance of primary care physicians as gatekeepers in early breast cancer detection.

Late-Stage Breast Cancer Diagnosis and Health Care Access in Illinois∗

Late-Stage Breast Cancer Diagnosis and Health Care Access in Illinois∗

Mammography stages of change in middle-aged women with schizophrenia: An exploratory analysis

BackgroundHealth care providers and educators who seek to create health promotion programs and individualized comprehensive care plans for women with schizophrenia are hindered by the lack of data to guide their efforts.PurposeThis study tested the hypothesis that women with schizophrenia adhere to mammography screening guidelines at the same rate as other same-age women. The study also investigated the validity of the Health Belief (HB) and Stages of Change (SOC) models for breast cancer screening among women with schizophrenia.MethodsSocio-demographic and clinical variables, as well as knowledge, attitudes, and barriers were assessed as a function of stage of change related to breast cancer screening in 46 women with schizophrenia.ResultsWomen with schizophrenia were statistically less likely to be adherent to the screening recommendations than those without schizophrenia. Some support was found for the validity of the HB and SOC models for breast cancer screening in women with schizophrenia. Women in the Precontemplation stage had significantly higher negative attitude scores compared to Contemplation and Action/Maintenance stages (59.7, 45.7, and 43.2, respectively), and there was a trend for more barriers in the Precontemplation group (4.6, 2.6, 2.7 respectively).ConclusionGiven the small sample size, further research on the rates of breast cancer screening in women with schizophrenia is warranted. Nonetheless, these data suggest that providers who care for women with schizophrenia may need to make take additional measures to ensure that this population receives appropriate screening so as to not put them at greater risk for a late-stage diagnosis of breast cancer. Furthermore, these pilot data suggest that HB and SOC theory-based interventions may be valid for increasing mammography rates in women with schizophrenia.

Benefit of screening mammography in reducing the rate of late-stage breast cancer diagnoses (United States)

We studied the benefit of modern mammography screening in community settings, evaluating age-related differences in rates of late-stage breast cancer detection. Our multicenter population-based case-control study included 931 black and white women with incident breast cancer (American Joint Commission on Cancer Stage IIB or higher) diagnosed 1994-1998 and 4,016 randomly sampled controls never diagnosed with breast cancer. Adjusted odds ratios (ORs) estimated the relative rate of late-stage diagnosis in screened and non-screened women. Women aged 50-64 at diagnosis with at least one screening mammogram in the previous 2 years were significantly less likely to have late-stage diagnosis (OR = 0.41, 95% CI 0.33-0.52). Results for women aged 40-49 were consistent with a screening benefit, although the confidence interval marginally overlapped the null (OR = 0.81, 95% CI 0.64-1.02). Mammography screening was associated with lower rates of late-stage breast cancer among both premenopausal (OR = 0.64, 95% CI 0.50-0.81) and postmenopausal (OR = 0.44, 95% CI 0.35-0.56) women. With modern mammography in the community, rates of late-stage breast cancer diagnoses are lower in screened compared to non-screened women ages 40 and older, but age-related differences persist.

Spatial equity in facilities providing low- or no-fee screening mammography in Chicago neighborhoods.

Recent research suggests living in an economically disadvantaged neighborhood is associated with decreased likelihood of undergoing mammography and increased risk of late-stage breast cancer diagnosis. Long distances and travel times to facilities offering low- or no-fee mammography may be important barriers to adherence to mammography screening recommendations for women living in economically disadvantaged urban neighborhoods, in which African-Americans are disproportionately represented. The purpose of this study was to examine whether the spatial distribution of facilities providing low- or no-fee screening mammography in Chicago, Illinois, is equitable on the basis of neighborhood socioeconomic and racial characteristics. We found that distance and travel times via automobile and public transportation to facilities generally decrease as neighborhood poverty increases. However, we also found that the strength of the association between neighborhood poverty level and two of the spatial accessibility measures-distance and public transportation travel time-is less strong in African-American neighborhoods. Among neighborhoods with the greatest need for facilities (i.e., neighborhoods with the highest proportions of residents in poverty), African-American neighborhoods have longer travel distances and public transportation travel times than neighborhoods with proportionately fewer African-American residents. Thus, it appears that the spatial accessibility of low- and no-fee mammography services is inequitable in Chicago. In view of persistent social disparities in health such as breast cancer outcomes, these findings suggest it is important for researchers to examine the spatial distribution of health resources by both the socioeconomic and racial characteristics of urban neighborhoods.

Medicare and the Health of Women with Breast Cancer

Abstract This paper investigates the effect of health insurance on health and the use of health services by exploiting a change in insurance status that occurs for most Americans at age 65; that is, eligibility for the U.S. Medicare program. A regression discontinuity design is employed to identify discontinuities at age 65 in the relationship between age and access to care and health status, especially for groups more likely to be uninsured prior to age 65, such as those with less than a high school education or blacks and Hispanics. The paper focuses on the use of health services and health outcome related to breast cancer, a common cause of death among women, and one for which good access to early detection services is thought to significantly improve survival. Results show that the use of health services including mammography increases discontinuously at age 65, especially for women without a high school degree and for black and Hispanic women. A modest decrease in the probability of late-stage breast cancer diagnosis at age 65 is also found for white and Hispanic women.

The importance of place of residence in predicting late-stage diagnosis of breast or cervical cancer

We tested whether inner-city women were at significantly increased risk of late-stage cancer diagnosis because they resided in extremely poor and socially isolated neighborhoods or in neighborhoods meeting the federal definition of a medically underserved area (MUA). Cancer registry data on women in three American cities were matched to Census data. Using logistic regression we found that residence in economically and socially distressed or medically underserved neighborhoods tended to increase the likelihood of late-stage cancer diagnoses. Further, we found that not all areas that are economically and socially distressed receive the federal MUA designation. Consequently, we argue that economically and socially distressed neighborhoods should be automatically designated as MUA.

Feeling healthy: so why should Mexican-descent women screen for breast cancer?

Mexican-descent women are at particular risk of late-stage breast cancer diagnosis by being the least likely of the major U.S. Hispanic subgroups to undergo breast cancer screening. This grounded theory study investigated how cultural health beliefs regarding the causes and nature of breast cancer influence women's decision to participate in screening. Thirty-four women (age 49 to 81) were interviewed in five focus groups using theoretical sampling across levels of acculturation and socioeconomic status. Analysis of the most prevalent cultural health beliefs led to a discovery that the core problem Mexican-descent women face is that they perceive there is no reason to participate in breast cancer screening when they are "feeling healthy." In addition, women who subjectively and cognitively feel healthy and otherwise have no evidence of illness according to their cultural health beliefs are unlikely to risk feeling ill rather than healthy by seeking to discover breast cancer through screening.

Socio-demographic factors, health behavior and late-stage diagnosis of breast cancer in Germany: A population-based study

Late-stage diagnosis of breast cancer is associated with poor survival. Identification of individuals at high risk of late-stage diagnosis could be an effective step to reduce breast cancer mortality. We examined the association of socio-demographic factors and health behavior with breast cancer stage in a population-based sample of 380 female breast cancer patients in Saarland, Germany. Overall, 182 women (47.9%) were diagnosed with late-stage (regional or distant) breast cancer. After control for potential confounding by multivariate logistic regression, an increased risk of late-stage diagnosis was observed for older age (OR = 1.8; 95% CI 1.0–3.2), foreign nationality (OR = 3.9; 95% CI 0.7–20.8), living in large households (OR = 1.7; 95% CI 1.0–2.9), non-participation in general health check-up (OR = 1.5; 95% CI 0.9–2.4) and low interest in health care (OR = 1.6; 95% CI 1.0–2.7). The proportion of late-stage cancer was clearly decreased when tumors were detected by screening (OR = 0.4; 95% CI 0.2–0.8). Certain socio-demographic factors and characteristics of health behavior seem to represent independent risk indicators of late-stage diagnosis.

Access and Late-Stage Diagnosis of Breast Cancer in the Military Health System

The results reported in this paper are from a larger study examining the relationship between access and stage at diagnosis of breast cancer in African-American and white women. This paper focuses on the results describing the extent to which potential and realized access predict stage at diagnosis within an equal economic access health care system. Data in this descriptive-comparative study were collected through secondary analysis using the tumor registry records of 62 African-American and 573 white women diagnosed with breast cancer in the military health system between January 1, 1988, and December 31, 1997. Logistic regression analysis revealed that late-stage breast cancer was more likely to be diagnosed in African-American women from low socioeconomic strata with incidental breast self-examination-discovered cancers. The most significant predictors of late-stage diagnosis were means of discovery and the length of time between discovery and diagnosis.

The effects of major depression and phobia on stage at diagnosis of breast cancer.

To examine the longitudinal effects of major depression and phobia on stage at diagnosis of subsequent breast cancer. Data from the New Haven Epidemiologic Catchment Area (ECA) study were linked to the Connecticut Tumor Registry (CTR). The sample comprised of seventy-two women with a first primary breast cancer diagnosed sometime after their baseline ECA study interview. In the ECA study, lifetime psychiatric history was assessed using the Diagnostic Interview Schedule based on DSM-III criteria. Stage at diagnosis of breast cancer was taken from CTR records and dichotomized into early stage (in situ and localized tumors) versus late stage (regional and distant tumors). A positive history of major depression was associated with an increased likelihood of late-stage diagnosis of breast cancer (odds ratio [OR] = 9.81, p = 0.039), whereas a positive history of phobic disorders was associated with a decreased likelihood of late-stage diagnosis (OR = 0.01, p = 0.021), controlling for sociodemographic characteristics of the sample. These analyses revealed a longitudinal association between reported lifetime psychiatric history and stage at diagnosis of subsequent breast cancer. Phobia may motivate women to adhere to breast cancer screening recommendations and to report suspicious symptoms to a physician without delay. Major depression, on the other hand, was identified as an important predictor of late-stage diagnosis; proper recognition and management of depression in the primary care setting may have important implications for breast cancer detection and survival.

Late-stage diagnosis of breast cancer in women of lower socioeconomic status: public health implications.

To assess the success of breast cancer control activities in Connecticut, we examined data from the Connecticut Tumor Registry, determining differences in breast cancer stage at time of diagnosis over time and in selected subgroups. From 1982 to 1985, the percentage of women with cancer confined to the breast increased from 54.0 percent to 61.3 percent. During 1984 and 1985, lower socioeconomic status (SES) women with breast cancer were less likely than higher SES women to be diagnosed with early-stage disease (56.9 percent vs 62.7 percent). SES was estimated by census tract of residence. In the same years, the overall incidence of breast cancer was greater in higher SES women. Projections based on these incidence data found that lower SES women, as compared to higher SES women, had a higher rate of expected breast cancer deaths (24.6 vs 19.7 per 100,000), and a greater percentage of those deaths considered preventable by early detection (22 percent vs 11 percent). The rate of preventable deaths in lower SES women was 2.5 times as great as that for higher SES women (5.3 vs 2.1 per 100,000). Tumor registries can serve as useful surveillance systems to aid cancer control programs. Breast cancer early-detection programs should give special attention to lower SES women.