Late-stage Breast Cancer Diagnosis Research Articles

Is There a Relationship between County-Level Food Insecurity Rates and Breast Cancer Stage at Diagnosis?

The relationship between county food insecurity (FI) rate and breast cancer stage at diagnosis is not clear. Using 2010-2016 Surveillance Epidemiology and End Results (SEER) and Feeding America data we analyzed the association between county FI rate in quartiles (low, medium, high, very high) and breast cancer stage at diagnosis among adult females (≥18 years). We also analyzed the effect of insurance status and county poverty level on this relationship, and whether this relationship varies among non-elderly (<65 years) and elderly (≥ 65 years) individuals. Bivariate and multivariable multilevel logistic regression were used for analyses. Bivariate analysis showed increased likelihood of late-stage breast cancer with increasing county FI rate. This relationship persisted after adjusting for insurance status but was no longer significant after adjusting for county-level poverty rate. There was a statistically significant association between counties with very high food insecurity rates and late-stage breast cancer diagnosis (OR = 1.07; 95% CI = 1.00, 1.14) among the elderly population. Very high county food insecurity rate was associated with late-stage breast cancer among elderly women. Population-level interventions focused on counties with very high food insecurity rates could reduce disparities in stage at breast cancer diagnosis among elderly women.

180P Factors associated with late-stage diagnosis of breast cancer among Egyptian women

Tumor stage of breast cancer (BC) crucially determines its prognosis. Detecting BC at earlier stages comes with better prognosis, better response to treatment, and thereby higher survival rates, while diagnosis at late-stages (stage III & IV) has poor outcomes and responsible for the escalating mortality rates from the disease. Late-stage diagnosis of BC is a common problem in limited resources setting. The aim of the study was to understand the underlying factors associated with the late-stage diagnosis of BC in Egypt.

Geographic Disparities in Late-Stage Breast Cancer Diagnosis Rates and Their Persistence Over Time.

Background: Other than skin cancer, breast cancer is the most common cancer in the United States. Lower uptake of mammography screening is associated with higher rates of late-stage breast cancers. This study aims to show geographic patterns in the United States, where rates of late-stage breast cancer are high and persistent over time, and examines factors associated with these patterns. Materials and Methods: We examined all primary breast cancers diagnosed among all counties in 43 U.S. states with available data. We used spatial cluster analysis to identify hot spots (i.e., spatial clusters with above average late-stage diagnosis rates among counties). Demographic and socioeconomic characteristics were compared between persistent hot spots and those counties that were never hot spots. Results: Of the 2,599 counties examined in 43 states, 219 were identified as persistent hot spots. Counties with persistent hot spots (compared with counties that were never hot spots) were located in more deprived areas with worse housing characteristics, lower socioeconomic status, lower levels of health insurance, worse access to mammography, more isolated American Indian/Alaska Native, Black, or Hispanic neighborhoods, and larger income disparity. In addition, persistent hot spots were significantly more likely to be observed among poor, rural, African American, or Hispanic communities, but not among poor, rural, White communities. This analysis includes a broader range of socioeconomic conditions than those included in previous literature. Conclusion: We found geographic disparities in late-stage breast cancer diagnosis rates, with some communities experiencing persistent disparities over time. Our findings can guide public health efforts aimed at reducing disparities in stage of diagnosis for breast cancer.

Harvesting Health Knowledge: Breast Cancer Perceptions in the South Florida Latinx Farmworker Community.

South Florida agricultural regions, home to Latinx immigrant farmworkers, report higher rates of late-stage breast cancer diagnosis than national, state, and county-level averages. We conducted a community-based qualitative study on the needs, health knowledge gaps, barriers to breast cancer screening, and the role of community health workers (CHWs) in supporting the community's access to early detection services. We conducted three CHW focus groups (FGs) (n = 25) and in-depth interviews (n = 15), two FGs (n = 18) and in-depth interviews (n = 3) with farmworker community members, and informal interviews with cancer clinicians (n = 7). Using a grounded theory approach, five core themes regarding the community's barriers to accessing health care services emerged: (a) lack of information; (b) social and economic barriers; (c) cultural factors; (d) fears and mistrust; and (e) psychosocial concerns. Findings yield implications for community health practice, the potential impact of CHWs, and the production of breast cancer education to improve health equity along with the care continuum.

Neighborhood Racial/Ethnic Composition and Medical Discrimination’s Relation to Mammograms: A Philadelphia Case Study

Late-stage breast cancer diagnosis is common for women of color even though cancer screening rates in this group have increased over time. Perceived medical discrimination from health care providers is a key culprit of this inconsistency, discouraging women of color from seeking out timely preventative care. Non-white neighborhoods offer social support structures that mitigate discrimination. However, it is not clear whether this mitigation applies to the chance women of color get timely mammograms. This study addresses that question, applying Hierarchical Linear Modeling methods onto the Public Health Management Corporation’s 2006 and 2008 survey, as well as the 2005–2009 American Community Survey. Findings indicate that while neighborhood racial/ethnic composition does not directly reduce medical discrimination’s association to screening, factors closely connected to place, like health care access, do have a mitigating influence on this association. Also, neighborhood racial/ethnic composition and social support have a positive direct relation with screening.

Abstract PO-019: Delivering cancer prevention programs to Latinx and Korean immigrant communities in Los Angeles through community partnerships and a culturally adapted Cancer 101 Cancer Education and Training Program

Abstract Latinx and Korean immigrants (LKI) in the United States are less likely to incorporate cancer prevention practices (CPP), such as undergoing recommended cancer screening, as compared to white counterparts. Currently lacking are comprehensive, culturally tailored cancer prevention programs for LKI communities. One method of targeting these inequities and increasing CPP is the Cancer 101 Cancer Education and Training Program (CETP). CETP was developed in collaboration with American Indians and Alaska Natives (AI/AN) of Washington state as a cancer education resource to improve cancer knowledge, introduce preventative practices in a tribal setting, and increase survival rates for community members. Participants demonstrated a significant change in knowledge, attitudes and behaviors towards CPP. Given the need to improve CPP among LKI, and the success associated with the AI/AN CETP, the purpose of this study was to explore the impact on CPP through a culturally tailored CETP for LKI communities. We developed partnerships with the leadership of faith-based organizations (FBOs) and federally qualified health centers (FQHCs) serving predominantly LKI populations in neighborhoods with a high concentrations of late-stage cancer diagnoses. We referenced the Center for Disease Control’s (CDC) Community Guide for strategies of implementing tailored cancer programs. We administered our Spanish and Korean language Cancer and Healthcare in Los Angeles Survey (CHILAS) to FBO members to gather baseline awareness and perceptions of CPP. CHILAS data highlighted critical components that were used to modify the CETP. We translated the newly adapted CETP into Spanish and Korean and used it to conduct cancer prevention workshops and organize cancer screening events with our partnered FBOs and FQHCs. Our results include the development of partnerships with 15 FBOs where 12,000 predominantly LKI worshipped, in neighborhoods with a high incidence of late-stage breast cancer diagnoses. The results from 2,100 CHILAS and demographics were used to tailor the CETP for the communities of interest. Using the adapted CETP and strategies from the CDC’s Community Guide, 8,000 congregants received CPP information from the pulpit. Over 2 years, we delivered 63 cancer prevention workshops for 3,000 attendees, with 600 individuals participating in additional organized cancer screening programs and 35 volunteers and navigators trained. Furthermore, participants enrolled in community-based studies including the All of Us research project. Adaptation and application of the Cancer 101 CETP for LKI communities was an effective tool in disseminating cancer awareness and providing accessible cancer screening in high-need neighborhoods. Community partnerships shaped the Cancer 101 CETP to be a tangible and culturally sensitive resource for the communities of interest. We plan to sustain and expand this initiative through the creation of a comprehensive tool kit and training program for community leaders. Citation Format: Zul Surani, Bianca Luna, Dong Hee Kim, Ergueen Herrera, Loraine Escobedo, Robert Haile. Delivering cancer prevention programs to Latinx and Korean immigrant communities in Los Angeles through community partnerships and a culturally adapted Cancer 101 Cancer Education and Training Program [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-019.

Late-Stage Diagnosis and Associated Factors Among Breast Cancer Patients in South and Southwest Ethiopia: A Multicenter Study

Breast cancer is a leading cause of cancer death in women in low- and middle-income countries, largely because of late-stage diagnosis. Yet studies are very limited in the Ethiopian context. Therefore, we determined the occurrence of late-stage disease and associated factors in selected public hospitals in south and southwest Ethiopia. A 5-year retrospective cross-sectional study was conducted on breast cancer patient medical records from January 2013 to December 2017 in 6 hospitals. Multivariable logistic regression was performed to identify factors associated with late-stage disease (stage III and IV). Adjusted odds ratios (AOR) with 95% confidence intervals were used. P< .05 was considered statistically significant. Overall, 426 breast cancer patients were identified, and 72.5% were diagnosed with late-stage disease. The mean ± standard deviation patient age was 42.8 ± 13.4 years. Factors associated with late diagnosis were patient delay in seeking care (AOR= 2.50; 95% confidence interval [CI], 1.51-4.16); health system delays (AOR= 1.62; 95% CI, 1.02-2.59); female sex (AOR= 3.46; 95% CI, 1.50-7.98); rural residence (AOR= 2.37; 95% CI, 1.45-3.86); chief complaint of breast lump (AOR= 3.01; 95% CI, 1.49-6.07); and history of comorbidities (AOR= 1.72; 95% CI, 1.02-2.91). The majority of patients were diagnosed with late-stage diagnosis of breast cancer. Patient delays in seeking care, health system delays, being female, rural residence, and patient comorbidities were associated factors. These findings provide evidence that efforts to increase public and health provider awareness to promote early breast cancer diagnosis, particularly in rural areas, are needed in south and southwest Ethiopia.

Factors associated with late-stage diagnosis of breast cancer among women in Addis Ababa, Ethiopia.

Stage at diagnosis is a key determinant of breast cancer prognosis. In this study, we characterize stage at diagnosis and determine factors associated with advanced stage at diagnosis among women diagnosed with invasive breast cancer in Addis Ababa, capital city of Ethiopia. Stage information was collected from medical records of 441 women with invasive breast cancer seen in seven major health facilities in Addis Ababa, from January 2017 to June 2018; these seven facilities capture 90% of all incident breast cancer cases in the city. We used multivariable Poisson regression model with robust variance to determine factors associated with advanced stage at diagnosis. The predominant tumor histology was ductal carcinoma (83.7%). More than half of the tumors' grade was moderately or poorly differentiated. The median tumor size at presentation was 4cm. Sixty-four percent of the patients were diagnosed at advanced stage of the disease (44% stage III and 20% stage IV), with 36% of the patients diagnosed at early-stage (5% stage I and 31% stage II). The prevalence of advanced stage disease was significantly higher among women who used traditional medicine before diagnostic confirmation (adjusted prevalence ratio [aPR] = 1.31; p = 0.001), had patient delay of > 3 months (aPR = 1.16; p = 0.042) and diagnosis delay of > 2months (aPR = 1.24; p = 0.004). But it was lower among women who had history of breast self-examination (aPR = 0.77; p = 0.021). Advanced stage at diagnosis of breast cancer among women in Addis Ababa is strongly associated with use of traditional medicine and with prolonged time interval between symptom recognition and disease confirmation. Community- and health systems-level interventions are needed to enhance knowledge about breast cancer and facilitate timely diagnoses.

Impact of Phone-Call and Access-Enhancing Intervention on Mammography Uptake among Primary Care Patients at an Urban Safety-Net Hospital: A Randomized Controlled Study

Our urban safety-net hospital (SNH) has very low screening mammogram rates within its primary care clinics. Despite Commission on Cancer (CoC) accreditation, we see ~ 3 × more late-stage breast cancer diagnoses than other CoC sites across the country, and recently showed this to be strongly associated with lack of screening (Ahmadiyeh et al. in J Health Care Poor Underserved, in press, 2020). Here we study whether a two-step intervention (phone calls and assistance scheduling mammograms) increases uptake over usual care. Randomized controlled study of 890 women aged 50-65years who were due for biennial screening mammograms and who were established within one of five primary care clinics at an urban SNH. Each patient in the intervention group was called with overdue status (up to three times, voicemail left if needed) and offered assistance scheduling mammogram appointment. Mammography uptake at 3 and 6months was analyzed. Intervention significantly increased uptake compared with usual care at both timepoints (18% versus 6% at 3months; χ2 = 27.597, p < 0.0001; 23% versus 12% at 6months; χ2 = 18.0, p < 0.0001), with scheduling component driving effectiveness. Of those who were successfully contacted, uptake was significantly greater among those who scheduled appointments versus those who did not (47% versus 9%, χ2 = 95, p < 0.0001), and uptake was no different between contacted but not scheduled patients and usual care controls. Phone call with access-enhancing intervention (facilitating mammogram appointments) increased screening mammogram uptake among primary care patients in an urban safety-net setting and may be applicable to other urban SNHs around the country.

Abstract C105: Late-stage diagnosis of breast cancer and associated factors at rural hospitals in Ethiopia: A mixed-method study

Abstract Background: A key factor for beneficial breast cancer (BC) outcome is detection at early stage; however, late-stage diagnosis of BC is a common problem in Africa. In Ethiopia the causes for late-stage presentation are not well studied, particularly in rural settings. Thus, the main aim of this study was to assess the magnitude of late-stage diagnosis of BC and its associated factors at six selected public hospitals in south and southwestern Ethiopia, where 80.6% of the population inhabits rural areas. Methods: A hospital-based retrospective cross-sectional study was conducted from January 2013 to December 2017. A total of 426 BC patients' records were reviewed. Qualitative data were collected by in-depth interview from purposely selected health care providers and patients. Multiple logistic regression was used to identify factors associated with late-stage diagnosis of BC. P-value &amp;lt;0.05 was used to determine level of significance. Result: Of the 426 BC patients, 72.5% presented with late-stage disease (stage III and IV). The median age was 42.8 years (+/- 13.4 years). 93.4% of the cases were female. 73% (331/426) patients had longer than 3 months' delay to treatment. 89.9 % of the patients presented with a palpable mass and 42.3% presented with an active wound. Among all, 34.3% were referred to the regional centers by private and public health facilities, thus indicating a previous point of contact with a heath care provider. Almost one third (33.8 percent) were diagnosed with Grade III disease. Independent risk factors for late stage of presentation and diagnosis were the patient's own delay to care (AOR=1.87, 95% CI; 1.04, 3.38); living in a rural area (AOR=2.97, 95%CI; 1.66, 5.34); and delays within the health care system to refer (AOR=2.03, 95%CI; 1.09, 3.78). Females were at more risk than males (AOR=3.75 95%CI; 1.33, 10.54). Patients with breast masses (AOR=4.09, 95%CI; 1.66, 10.11), wounds (AOR=0.41, 95%CI 0.24, 0.72), and Grade III tumor (AOR=2.45, 95%CI; 1.27, 4.73) were also associated to late stage at presentation. The In-depth interview revealed that lack of awareness and knowledge to BC, use of traditional therapy, considering symptoms as “not serious,” and long waiting times to receive care at referred health facilities were the main reasons for late-stage presentation and diagnosis. Conclusion: The study found that patient delay, rural residence, breast lump and wound, tumor grade, sex and a referral history were factors related to the high proportion of late stage at diagnosis. Hence, there is a need to increase patients' awareness to prevent delays in diagnosis and to strengthen the capacity of early detection, diagnosis and referrals within the health care system. Citation Format: Aragaw Tesfaw, Sefonias Getachew, Lesley Taylor, Eva Johanna Kantelhardt, Adamu Addissie. Late-stage diagnosis of breast cancer and associated factors at rural hospitals in Ethiopia: A mixed-method study [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C105.

Abstract B127: Hispanic-White residential segregation and stage at diagnosis among female residents of Texas

Abstract Background: Breast cancer is the second leading cause of cancer-related deaths among females in the United States. Individual and neighborhood-level characteristics have been associated with breast cancer-related disparities. There is a paucity of literature about Hispanic-White residential segregation and stage at diagnosis of breast cancer, and whether residential segregation explains or moderates disparities in stage at diagnosis among Hispanics. Objectives: To explore whether Hispanic-White residential segregation is associated with late-stage breast cancer, and how it explains or moderates disparities in stage at diagnosis of breast cancer associated with Hispanic ethnicity. To explore whether health insurance coverage and census tract (CT) poverty level explains or moderates disparities associated with residential segregation. Methods: This is a retrospective data analysis using the Texas Cancer Registry. The analyses were restricted to non-Hispanic White and Hispanic females ages 18 and older diagnosed with breast cancer from 2007-2014, and who had only one primary tumor. The dependent variable was stage at diagnosis (early, late). The independent variables of interest were Hispanic-White residential segregation, race/ethnicity, type of insurance coverage and CT poverty level. Multilevel logistic regression models with individuals nested within CT were used for analyses. The final sample size was 80,149 individuals nested within 5,023 CT. Results: Hispanics were more likely to be diagnosed with late-stage breast cancer (OR=1.14; 95% CI=1.10-1.19). Increasing Hispanic-White residential segregation was associated with increased likelihood of late-stage diagnosis (OR=1.46; 95% CI=1.04-2.05). Type of health insurance explained some of the association between residential segregation and late-stage diagnosis. Residential segregation did not explain or moderate the association between Hispanic ethnicity and breast cancer stage at diagnosis. Predicted probability estimates showed that individuals who were uninsured or insured through Medicaid had similar probabilities of late-stage diagnosis. These disparities were worse for uninsured or Medicaid-insured Hispanic residents of highly segregated CTs. Conclusion: Hispanic-White residential segregation was associated with increased likelihood of late-stage breast cancer diagnosis. Interventions to increase early-stage breast cancer diagnosis are needed among residents of CTs with high residential segregation, especially among Medicaid insured and uninsured women. Interventions aimed at raising awareness of the association between Hispanic residential segregation and breast cancer stage at diagnosis among healthcare providers should be explored. Citation Format: Chinedum Ojinnaka. Hispanic-White residential segregation and stage at diagnosis among female residents of Texas [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B127.

Abstract P2-02-02: Lack of screening mammography and black race are associated with late-stage breast cancer diagnosis in safety-net setting

Abstract Importance: In our urban safety-net hospital (SNH) setting, we see approximately three times more late-stage (stage III and IV) breast cancer at diagnosis than the rest of the country. Breast cancers diagnosed at later stages have lower survival than those diagnosed at earlier stages. The aim of this study is to determine the factors associated with late-stage breast cancer diagnosis in our SNH setting. Method: This is a retrospective study of all breast cancer cases diagnosed or treated at the primary SNH in the Kansas City, MO metro area between January 2011-July 2018 (n=615). All female breast cancer patients diagnosed with early-stage (stage 0 or I, n=314) or late-stage (stage III or IV, n=98) disease were included. Those diagnosed at stage II (n=176), recurrent breast cancer (n=20) or with conflicting or unknown stage (n=27) were excluded. Variables analyzed: clinical TNM stage at diagnosis, age, race, insurance type, zip code, tumor subtype, whether patient presented with symptoms, whether a screening mammogram was obtained in the two years prior to diagnosis, and whether the patient was referred from outside our institution, or internally. Median household income and distance to treating facility were imputed from patient-level zipcode data. Multiple logistic regression was performed to determine the variables that contributed the most to the late-stage at diagnosis. Results: Three variables were significantly associated with late-stage diagnosis in the multiple regression: not having had a screening mammogram within two years (p&amp;lt;0.0001, OR 0.132, CI= 0.063, 0.277), being black (p= 0.0051, OR 2.549, CI = 1.325, 4.904), and having HER2 positive disease (p=0.0213, OR=2.695, CI= 1.159, 6.265). A race by tumor marker interaction was examined, and was not found to be significant. Conclusions: In our safety-net hospital setting, not having a screening mammogram in the two years prior to a breast cancer diagnosis was the most significant factor associated with late-stage at diagnosis, followed by being black. Screening mammography ought to be actively promoted in safety-net hospital settings with excess late-stage diagnosis. Black women may need different risk-based screening guidelines. Citation Format: Marissa A Mendez, An-Lin Cheng, Nasim Ahmadiyeh. Lack of screening mammography and black race are associated with late-stage breast cancer diagnosis in safety-net setting [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-02-02.

Factors Associated with Late-Stage Breast Cancer Diagnosis in an Urban Safety-net Hospital.

Late diagnosis of breast cancer is associated with lower survival. This study determines the factors associated with late-stage breast cancer diagnosis in an urban safety-net hospital (SNH) with excess late-stage disease. Single-institution retrospective study of all early-stage vs. late-stage breast cancer cases diagnosed or treated at the primary SNH in the Kansas City, Missouri area between January 2011-July 2018. Multiple logistic regression was performed to determine the variables that contributed most to late stage at diagnosis. The most significant factor associated with late-stage diagnosis was lack of screening mammogram within two years of diagnosis (p&lt;.0001, OR 7.5, CI = 3.6, 15.3). Patients referred from within the SNH compared with those presenting from community health centers were significantly less likely to present with late-stage disease (p=.04, OR 0.50, CI = 0.25, 0.98). Screening mammography ought to be actively promoted in SNH settings with excess late-stage diagnosis.

Metabolic fingerprinting in breast cancer stages through 1H NMR spectroscopy-based metabolomic analysis of plasma

Breast cancer (BC) is one of the most common malignancies among women worldwide, which is indeed associated with metabolic reprogramming. However, BC is a very complex and heterogeneous disease, which can relate with the changes in metabolic profiles during BC progression. Hence, investigating the metabolic alterations during BC stage progression may reveal the deregulated pathways and useful metabolic signatures of BC. To demonstrate the metabolic insights, we opted 1H NMR spectroscopy based metabolomics of blood plasma of early and late stage BC (N = 72) with age and gender matched healthy subjects (N = 50). Further, the metabolic profiles were analyzed to delineate the potential signatures of BC by performing multivariate and nonparametric statistical analysis in early and late stages of BC in comparison with healthy subjects. Sixteen metabolites levels were differentially changed (p < 0.05) in the early and late stages of BC from healthy subjects. Among them, the levels of hydroxybutyrate, lysine, glutamate, glucose, N-acetyl glycoprotein, Lactate were highly distinguished in BC stages and showed a good biomarker potential using receiver-operating curves based diagnostic models. Furthermore, the significant modulation and good diagnostic performances of glutamate, N-acetyl glycoprotein and Lactate in LBC as compared to EBC give their significance in the BC progression. In general, our observations demonstrate that these panels of metabolites may act as vital component of the metabolism of early to late stage BC progression. Our results also open new avenue towards early and late stage BC diagnosis and intervention implying metabolomics approaches.

Uptake of Gynecological Cancer Screening and Performance of Breast Self-Examination Among 50-Year-Old Migrant and Non-migrant Women in Germany: Results of a Cross-Sectional Study (InEMa).

Our aim was to provide data regarding uptake of gynecological early detection measures and performance of breast self-examinations among migrant women in Germany. Cross-sectional self-reported data were collected using paper-and-pencil questionnaires. Descriptive analyses, Chi square-tests, and logistic regression were applied. Results were adjusted for educational level. Of 5387 women, 89.9% were autochthonous, 4.1% German resettlers, 2.8% Turkish, 3.1% other migrants. Participation rates regarding cancer screening differed significantly, with the lowest proportion in Turkish migrants (65.0%), resettlers (67.8%), other migrants (68.2%) and autochthonous population (78.2%). No differences in performance of breast self-examinations were detected. When adjusted for education, results indicated only slight changes in the odds to participate in screening irregularly or not at all. Results support existing evidence by showing lower participation rates in cancer screening among migrant women, but there were no differences regarding breast self-examinations. Migrant women form a potential high-risk group for late-stage diagnosis of cervical or breast cancer.

Abstract PR08: Tumor masking or tumor aggressiveness? A structural equations modeling approach to estimate the impact of breast density on breast cancer stage, overall and by race

Abstract Background: Non-Latina (nL) black women are diagnosed at later stages and with more aggressive forms of breast cancer than their nL white counterparts, including higher-grade tumors and those that lack estrogen and progesterone receptors (ER/PR negative). High breast density (HBD) is a strong risk factor for a late-stage breast cancer diagnosis among women undergoing mammography screening, yet nL black women are slightly less likely to have dense breasts according to the standard clinical classification method. We previously found that after adjusting for differences in obesity using body mass index (BMI), nL black women were substantially more likely to have dense breasts compared to nL white women. Dense breast tissue can mask tumors and cause them to go undetected at screening, only to arise later as a lump, discovered symptomatically when they later stage. It is also conceivable that dense breast tissue could predispose women to develop more aggressive breast cancers that grow more rapidly, are more likely to arise between screens as “true interval” cancers, and therefore might be detected with more frequent screening. We used path analysis (or structural equations modeling, SEM) to estimate the separate contributions of tumor masking and tumor aggressiveness in mediating HBD's associations with later stage, overall and by race. Methods: We used data on 4691 women from the Metropolitan Chicago Breast Cancer Registry, aged 40-79, and diagnosed at stages 1 (early), 2,3 or 4 (later), between 2001 and 2013. Breast density was obtained from the screening mammogram preceding diagnosis. Mode of detection was defined dichotomously as symptomatic versus screen detected. Path analysis (conducted in Mplus) was used to estimate the age, race, and BMI adjusted, direct and indirect effects of HBD on stage at diagnosis. Because estimates can vary depending on model assumptions, we ran simultaneous linear regression models and also ran simultaneous ordered probit regression models. In both sets of models we estimated the relative contributions of tumor masking and tumor aggressiveness in transmitting the association of HBD with stage at diagnosis. Results: A one-unit increase in BD was associated with a 9-percentage-point increased prevalence of later stage (stage 2,3,4, vs. 1) at diagnosis. Roughly one third of the HBD, later-stage association could be explained by tumor masking, and virtually none of the association could be explained by tumor aggressiveness. Similar results were obtained for linear and ordered probit models. Results were broadly similar for nL black and nL white women. Conclusion: Ours is the first analysis we are aware of to formally confirm via mediation analyses that tumor masking is the primary process through which women with dense breasts are disproportionately diagnosed at later stages. To reduce opportunities for tumor masking, women with dense breasts are often referred for supplemental/advanced imaging with breast MRI, ultrasound, or (increasingly) tomosynthesis. We think it is likely that the current criteria for referring women for advanced imaging based on breast density may contribute to racial disparities because (1) they do not account for the greater prevalence of more aggressive breast cancer in nL black patients, and (2) they do not account for the disproportionate prevalence of obesity among nL black women, which may obscure the usefulness of the usual clinical classification method of BMI in making referrals for supplemental imaging. Citation Format: Katherine Y. Tossas-Milligan, Garth H. Rauscher, Richard Campbell, Victoria Seewaldt. Tumor masking or tumor aggressiveness? A structural equations modeling approach to estimate the impact of breast density on breast cancer stage, overall and by race [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 PR08.

Rural-Urban Disparities in Access to Breast Cancer Screening: A Spatial Clustering Analysis.

The purpose of this study was to examine rural-urban differences in access to breast cancer screening in a predominantly rural Midwestern state in the United States. The study is a retrospective analysis of pooled cross-sectional data for the years 2008 to 2012. We conducted hot spot analyses of the rate of late-stage diagnosis of breast cancer at the census tract level in Nebraska for cases diagnosed between 2008 and 2012, using cancer registry data. We also conducted hot spot analyses of access to mammography facilities (distance to the nearest center) using data on mammography facilities from the US Food and Drug Administration and rates of screening using the National Private Insurance Claims data for year 2013. The spatial clustering analyses found that urban areas in Nebraska had lower distances to mammography centers, higher screening rates and lower rates of late-stage diagnosis of breast cancer. Rural areas had higher distance to the mammography centers and higher rates of late-stage at diagnosis for breast cancer. The evidence from this study points to geographic disparities in access to screening for breast cancer. Mitigating the access issues that rural women face would require interventions specifically targeted to rural populations.

Return on Investment Analysis of Breast Cancer Screening and Downstaging in Egypt: Implications for Developing Countries

The aim of this study was to perform a return-on-investment (ROI) analysis of a breast cancer screening program in Egypt by comparing net profit in treatment costs saved to program cost investment. The breast cancer downstaging program targeted women living in an Egyptian slum, where residents have low access to health care. Program costs were estimated by using data from interviews with program administrative staff. Screening and treatment costs were estimated by using Ministry of Health medical reimbursement data. Estimates for expected rates of downstaging were modeled on the basis of data from a previous study. ROI, or relative cost savings, was calculated by comparing treatment cost savings to costs for the screening program. A baseline ROI for facility-based screening was calculated, followed by ROIs for different scenarios. Average per-person treatment cost for screened and unscreened patients was estimated to be $28,632 and $58,170, respectively, with a cumulative lifetime risk of 6.36%. Total screening program cost per person was $112.10. The study estimated an expected decrease in late-stage breast cancer diagnosis by 13.7% as a result of the screening program, saving $4,049 in treatment costs per individual diagnosed. The analysis resulted in a positive ROI of 133% for facility-based screening. Breast cancer represents an increasing burden on health care in Egypt and other developing countries. This study concludes that a community-based downstaging program resulted in a positive ROI, or overall cost-savings. The findings inform that policymakers in low-income and middle-income countries may consider implementing community-based downstaging programs for breast cancer.

Late-Stage Diagnosis of Breast Cancer in Brazil: Analysis of Data from Hospital-Based Cancer Registries (2000-2012).

To analyze the time trend and the factors regarding the diagnosis of late-stage breast cancer in Brazil from 2000 to 2012. We conducted a retrospective cohort study using data from hospital-based cancer registries. Joinpoint regression was used to analyze the time trends of stage at diagnosis. The risk of late-stage presentation was estimated using multinomial logistic regression. A total of 170,757 cases were analyzed. The median time from diagnosis to treatment was of 43 days (range: 0-182 days). The percentage of cases with late-stage diagnosis decreased from 2000 to 2002, with an annual percent change (APC) of -6.6% (95% confidence interval [95%CI]: -7.6--5.5%); it increased from 2002 until 2009, with an APC of 1.1% (95% CI: 0.9-1.3%), and remained stable up to 2012. Women with college education (compared with illiterate women) had less chance of having a late-stage diagnosis (odds ratio [OR]: 0.32; 95%CI: 0.29-0.35). The odds were greater among brown women (OR: 1.30; 95%CI: 1.21-1.41) and black women (OR: 1.63; 95%CI: 1.47-1.82), compared with white women. The odds were also higher for women treated in facilities located and in the Northern region of Brazil (OR: 1.23; 95%CI: 1.04-1.45) and in the Midwest (OR: 1.61; 95%CI: 1.34-1.94), compared with those treated in the southern region of the country. Age, histological type, and marital status were some of the other factors that were positively related to staging at the diagnosis. Access to diagnosis of breast cancer is uneven in Brazil, and women with lower socioeconomic status present a greater probability of having an advanced stage at diagnosis.

Socioeconomic Factors, Health Behavior, and Late-Stage Diagnosis of Breast Cancer: Considering the Impact of Delay in Diagnosis

Stage of cancer at diagnosis is one of the most important factors in patient prognosis. By controlling for diagnostic delay, this study aimed to identify factors associated with late-stage breast cancer (BC). From November 2014 to January 2017, required information on 497 patients who were newly diagnosed with BC was obtained from patients' medical records. Logistic regression was used to measure the association between cancer stage and study variables. Only 18.3% of patients were diagnosed at stage I. The rest were diagnosed at stage II (45.5%) or higher (36.2%). Among those with≤ 3 months' diagnostic delay, age (odds ratio [OR]= 0.96; 95% confidence interval [CI], 0.93-0.99), place of residence (OR urban/rural= 1.72; 95% CI, 1.42-1.93), income (OR high/low= 0.27; 95% CI, 0.10-0.72), performing breast self-examination (OR yes/no= 0.51; 95% CI, 0.0.26 -0.98), smoking (OR yes/no= 2.23; 95% CI, 1.37-3.62), history of chest X-ray (OR yes/no= 1.40; 95% CI, 1.16-1.98), presence of chronic diseases (OR yes/no= 1.73; 95% CI, 1.36-5.48), and, for those with a delay of > 3 months, marriage age (OR= 0.83; 95% CI, 0.73-0.94), income (OR high/low= 0.07; 95% CI, 0.008-0.63), family history of BC (OR= 3.82; 95% CI, 1.05-5.05), daily exercise (OR< 10/10-20= 0.10; 95% CI, 0.01-0.67), and presence of chronic diseases (OR yes/no= 1.77; 95% CI, 1.73-5.07), were associated with late-stage of cancer. Shortening the diagnostic delay can help patients receive medical treatment at an earlier disease stage, resulting in better prognosis. Smokers, younger women, and those with chronic conditions or a family history of BC should take extra caution, as they may have worse prognosis if diagnosed with cancer.