Metropolitan Detroit Cancer Surveillance System Research Articles

Median Breslow thickness during, post and pre-COVID-19 lockdown and correlation with socioeconomic factors.

e21574 Background: Access to routine cancer care during COVID-19 pandemic was greatly affected. The impact of this on melanoma care is unknown. Breslow thickness (BT) was seen to decrease and then increase during and post-COVID-19 lockdown in Italy. Here, we aim to study the impact of COVID-19 lockdown on melanoma care in the United States. Methods: Patients diagnosed with cutaneous melanoma (CM) pre (September 15th 2019-March 14th 2020), during (March 15th-June 14th 2020), and post-lockdown (June 15th-December 14th 2020) were retrospectively studied using Metropolitan Detroit Cancer Surveillance System (MDCSS) database. Patients without an identifiable primary lesion, or with ocular, mucosal, or acral melanoma were excluded. Demographic and clinical characteristics were reviewed. The primary endpoint was median BT during and post vs pre-lockdown. Fisher's exact and Kruskal-Wallis tests were performed for categorical and continuous variables, respectively, to compare groups. Interaction in subgroup analyses was assessed using likelihood ratio tests. Linear regression analyses were performed with Box-Cox transformed BT. Cox proportional hazards regression analyses were performed for overall survival. Covariates for multivariable analysis were selected using LASSO-based penalized regression models. Results: 802 patients were included (pre N = 347, during N = 87, post N = 368). Patients diagnosed with CM post-lockdown were younger (age < 50 years pre = 14%, during = 13%, post = 23%). More patients diagnosed pre-lockdown carried government-issued insurance (pre = 48%, during = 39%, post = 38%). No difference (diff) in median BT was seen between periods (median = 0.6mm for pre, during, and pos). Married status was associated with a lower BT vs unmarried (diff = -0.19, 95% CI -0.36 to -0.014, p = 0.034) and higher census tract poverty level was associated with a higher BT (5%-10% diff = 0.17, 95% CI 0.004 to 0.33, p = 0.045; 10%-100% diff = 0.27, 95% CI 0.093 to 0.45, p = 0.003) vs 0-5% poverty on univariable analysis. Male gender was associated with a lower BT on multivariable analysis (diff = -0.12, 95% CI -0.20 to -0.04, p = 0.005) and lower risk of death on univariable analysis (HR = 0.50, 95% CI 0.31 to 0.82, p = 0.006). Conclusions: We found no difference in median BT during and post- vs pre-lockdown. We also identified at-risk populations (female, unmarried, and living in greater poverty areas) who could benefit from proactive melanoma care. Time to surgery from initial diagnosis during and post vs pre-lockdown would be of interest to study further.

Multiplicity of benign breast disease lesions and breast cancer risk in African American women.

The risk of developing subsequent breast cancer is higher in women diagnosed with benign breast disease (BBD) but these studies were primarily performed in non-Hispanic white populations. Still, these estimates have been used to inform breast cancer risk models that are being used clinically across all racial and ethnic groups. Given the high breast cancer mortality rates among African American (AA) women, it is critical to study BBD in this population, to ensure the risk models that include this information perform adequately. This study utilized data from AA women who underwent benign breast biopsies at a hospital served by the University Pathology Group in Detroit, Michigan, from 1998 to 2010. Patients were followed for subsequent breast cancers through the population-based Metropolitan Detroit Cancer Surveillance System (MDCSS). BBD lesion scores were assigned to represent the severity or extent of benign breast lesions, with higher scores indicating a greater number of distinct lesion types. Of 3,461 eligible AA women with BBD in the cohort, 6.88% (n=238) subsequently developed breast cancer. Examined individually, six of the eleven lesions (apocrine metaplasia, ductal hyperplasia, lobular hyperplasia, intraductal papilloma, sclerosing adenosis, columnar alterations and radial scars) were significantly associated with increased risk of breast cancer after adjustment for age and year of biopsy and were further considered in multiple lesion models. For every different type of benign breast lesion, subsequent risk of breast cancer increased by 25% (RR=1.25, 95% CI: 1.10, 1.42) after adjustment for age at biopsy and proliferative versus non-proliferative disease. In summary, this study affirms the increased breast cancer risk in AA women with BBD, particularly in those with multiple lesions. These findings have implications for the management of breast cancer risk in millions of women affected by BBD, a high risk group that could benefit from personalized surveillance and risk reduction strategies.

Abstract 3456: The role of particulate matter exposure in racial differences in colorectal cancer mortality in metropolitan Detroit

Abstract Colorectal cancer (CRC) is the third most diagnosed cancer in the United States and the third leading cause of cancer-related deaths. Non-Hispanic Black (NHB) individuals have the highest rates of CRC incidence and mortality in the United States. These disparities are highly influenced by social determinants of health (SDOH). Neighborhood quality, a well-established SDOH, has been shown to influence cancer outcomes, oftentimes more heavily in minorities. Additionally, neighborhood quality is known to influence an individual’s risk of exposure to harmful environmental contaminants including ambient air pollution as a result of systemic racism such as segregation and historic redlining, leading to environmental injustices. Fine particulate matter (PM2.5) exposure has been shown to increase the risk of CRC mortality, however, its effects by race have not yet been examined. We sought to understand whether higher rates of exposure to PM2.5 played a role in racial differences in CRC survival in metropolitan Detroit. Patient data including census tract at diagnosis, demographics, and clinical features were obtained from the metropolitan Detroit cancer surveillance system registry. Ambient PM2.5 concentration data at the census tract were obtained from the Environmental Protection Agency (EPA) Remote Sensing Information Gateway (RSIG) and converted to annual averages to use in an interval-censored Cox proportional hazards regression model. We found that PM2.5 exposure partly attenuated the effect of race on overall mortality in all patients (NHB vs NHW: Hazard Ratio (HR) = 1.24, 95% Confidence Interval (CI) 1.20 - 1.27, p < 0.0001, NHB vs NHW after accounting for PM2.5: HR = 1.19, 95% CI = 1.16 - 1.23 p < 0.0001) and the effect was stronger among patients under 50 than over 50, though still significant in both models. Additionally, the effect of PM2.5 on mortality was much stronger among NHB patients than NHW patients (NHB HR = 1.30, 95% CI = 1.17 - 1.45, p < 0.0001; NHW HR = 1.06, 95% CI = 1.02 - 1.11 p = 0.008) and especially strong among NHB patients under 50 (HR = 2.51, 95% CI = 2.38 - 3.38, p < 0.0001) compared to any other group. We conclude that ambient air pollution, particularly PM2.5, disproportionately affects mortality risk in NHB CRC patients. These results highlight the importance of environmental justice research in biomedical research, and the need for a better understanding of environmental impact on tumor biology to prevent tumor progression and mortality among all patients. Citation Format: Natalie Gail Snider, Theresa Hastert, Gregory Dyson, Carina Gronlund, Elena M. Stoffel, Ed Peters, Laura Rozek, Ann Schwartz, Kristen Purrington. The role of particulate matter exposure in racial differences in colorectal cancer mortality in metropolitan Detroit [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 3456.

Abstract PR019: Evaluating the role of ambient air pollution in racial disparities of colorectal cancer incidence and survival in metropolitan Detroit

Abstract Colorectal cancer (CRC) is the third most diagnosed cancer in the United States and the third leading cause of cancer-related deaths. Moreover, Non-Hispanic Black (NHB) individuals have the highest rates of CRC incidence and mortality in the United States. We have become increasingly aware of the potential impact of social determinants of health (SDOH) on colorectal physiology and carcinogenesis. Other than individual and neighborhood level socioeconomic status (SES), neighborhood quality can also affect an individual’s risk of exposure to harmful environmental contaminants including ambient air pollution. Moreover, as NHB individuals are more likely to live in areas of lower area-level SES they experience these effects even further. We sought to understand whether higher exposure rates to fine particulate matter (PM2.5) played a role in racial differences in CRC incidence and survival in metropolitan Detroit. To do this, we obtained data from the Environmental Protection Agency (EPA) Environmental Justice Mapping and Screening Tool through the Georgetown University Environmental Impact Data Collective (EIDC) and patient data from the Metropolitan Detroit Cancer Surveillance System (MDCSS) registry. Incidence rates were calculated using population data from the American Community Survey. Associations between PM2.5 exposure and CRC incidence were estimated using Poisson modeling. Data were obtained for NHB (n=3778) and Non-Hispanic White (NHW) (n=9727) individuals diagnosed with invasive CRC between 2010 and 2019 in Wayne, Oakland, and Macomb counties, including their geocoded census tract at diagnosis as well as demographic and clinical features. Vital status was reported as months from the date of diagnosis to either death or last contact. PM2.5 metrics were converted to the national percentile of PM2.5 in the air utilizing the Bayesian space-time downscaling fusion model for derived estimates of air quality at the census tract level. Survival was assessed using Cox Proportional Hazards modeling. We found that an increase in the PM2.5 percentile increased the risk for CRC overall for NHB and NHW patients (Relative Risk [RR] = 1.80, 95% Confidence Interval [CI] = 1.55 - 2.08, p-value <0.0001). This association was even stronger among NHB patients (RR = 7.94, 95% CI = 5.45 - 11.52, p-value < 0.0001), but was not statistically significant among NHW patients (RR = 1.12, 95% CI = 0.95 – 1.32, p-value = 0.16). PM2.5 exposure was not associated with survival overall or stratified by race. We conclude that ambient air pollution, particularly PM2.5, increases the risk of CRC cancer and disproportionately affects NHB patients but may not play a role in mortality risk. These results highlight the importance of environmental justice research in biomedical research and the need for a better understanding of the etiology of CRC within and among differing genetic ancestries and races by evaluating the genetic and epigenetic differences in patient tumor samples. Citation Format: Natalie G. Snider, Theresa Hastert, Ed Peters, Elena M. Stoffel, Laura Rozek, Ann Schwartz, Kristen Purrington. Evaluating the role of ambient air pollution in racial disparities of colorectal cancer incidence and survival in metropolitan Detroit [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 PR019.

The role of area-level socioeconomic disadvantage in racial disparities in cancer incidence in metropolitan Detroit.

Neighborhood deprivation is associated with both race and cancer incidence, but there is a need to better understand the effect of structural inequities on racial cancer disparities. The goal of this analysis was to evaluate the relationship between a comprehensive measure of neighborhood-level social disadvantage and cancer incidence within the racially diverse population of metropolitan Detroit. We estimated breast, colorectal, lung, and prostate cancer incidence rates using Metropolitan Detroit Cancer Surveillance System and US decennial census data. Neighborhood socioeconomic disadvantage was measured by the Area Deprivation Index (ADI) using Census Bureau's American Community Survey data at the Public Use Microdata Areas (PUMA) level. Associations between ADI at time of diagnosis and cancer incidence were estimated using Poisson mixed-effects models adjusting for age and sex. Attenuation of race-incidence associations by ADI was quantified using the "mediation" package in R. ADI was inversely associated with incidence of breast cancer for both non-Hispanic White (NHW) and non-Hispanic Black (NHB) women (NHW: per-quartile RR = 0.92, 95% CI 0.88-0.96; NHB: per-quartile RR = 0.94, 95% CI 0.91-0.98) and with prostate cancer incidence only for NHW men (per-quartile RR = 0.94, 95% CI 0.90-0.97). ADI was positively associated with incidence of lung cancer for NHWs and NHBs (NHW: per-quartile RR = 1.12, 95% CI 1.04-1.21; NHB: per-quartile RR = 1.37, 95% CI 1.25-1.51) and incidence of colorectal cancer (CRC) only among NHBs (per-quartile RR = 1.11, 95% CI 1.02-1.21). ADI significantly attenuated the relationship between race and hormone receptor positive, HER2-negative breast cancer (proportion attenuated = 8.5%, 95% CI 4.1-16.6%) and CRC cancer (proportion attenuated = 7.3%, 95% CI 3.7 to 12.8%), and there was a significant interaction between race and ADI for lung (interaction RR = 1.22, p < 0.0001) and prostate cancer (interaction RR = 1.09, p = 0.00092). Area-level socioeconomic disadvantage is associated with risk of common cancers in a racially diverse population and plays a role in racial differences in cancer incidence.

Quality of life in endometrial cancer survivors by grade of disease.

Endometrial cancer (EC) is the most common gynecologic malignancy in developed countries, with overall incidence increasing, particularly high-grade disease. There is sparse information regarding quality of life (QOL) in EC survivors with a focus on grade of disease. A total of 259 women with EC diagnosed between 2016 and 2020 were identified via the Metropolitan Detroit Cancer Surveillance System and consented to enroll in the Detroit Research on Cancer Survivors cohort study (if African American, n = 138) or completed the baseline interview (if non-Hispanic white, n = 121). Each respondent provided information about their health history, educational attainment, health behaviors, and demographics. The Functional Assessment of Cancer Therapy-General (FACT-G) and Endometrial-specific (FACT-En) were used to assess QOL. Women diagnosed with high-grade (n = 112) and low-grade (n = 147) EC participated in this study. EC survivors with high-grade disease reported significantly lower QOL compared to survivors with low-grade disease (85 vs. 91, respectively, p value = 0.025) as assessed by the FACT-G. This difference was driven by lower physical and functional subscales among women with high-grade disease compared to those with low-grade disease (p value = 0.016 and p = 0.028, respectively). Interestingly, EC-specific QOL measures, as assessed by the FACT-En, did not differ by grade. Grade of disease impacts QOL in EC survivors, as well as socioeconomic, psychological, and physical factors. Most of these factors are amenable to interventions and should be assessed in patients after an EC diagnosis.

Area-level Socioeconomic Disadvantage and Cancer Survival in Metropolitan Detroit.

Racial segregation is linked to poorer neighborhood quality and adverse health conditions among minorities, including worse cancer outcomes. We evaluated relationships between race, neighborhood social disadvantage, and cancer survival. We calculated overall and cancer-specific survival for 11,367 non-Hispanic Black (NHB) and 29,481 non-Hispanic White (NHW) individuals with breast, colorectal, lung, or prostate cancer using data from the Metropolitan Detroit Cancer Surveillance System. The area deprivation index (ADI) was used to measure social disadvantage at the census block group level, where higher ADI is associated with poorer neighborhood factors. Associations between ADI and survival were estimated using Cox proportional hazards mixed-effects models accounting for geographic grouping and adjusting for demographic and clinical factors. Increasing ADI quintile was associated with increased overall mortality for all four cancer sites in multivariable-adjusted models. Stratified by race, these associations remained among breast (NHW: HR = 1.16, P < 0.0001; NHB: HR = 1.20, P < 0.0001), colorectal (NHW: HR = 1.11, P < 0.0001; NHB: HR = 1.09, P = 0.00378), prostate (NHW: HR = 1.18, P < 0.0001; NHB: HR = 1.18, P < 0.0001), and lung cancers (NHW: HR = 1.06, P < 0.0001; NHB: HR = 1.07, P = 0.00177). Cancer-specific mortality estimates were similar to overall mortality. Adjustment for ADI substantially attenuated the effects of race on mortality for breast [overall proportion attenuated (OPA) = 47%, P < 0.0001; cancer-specific proportion attenuated (CSPA) = 37%, P < 0.0001] prostate cancer (OPA = 51%, P < 0.0001; CSPA = 56%, P < 0.0001), and colorectal cancer (OPA = 69%, P = 0.032; CSPA = 36%, P = 0.018). Area-level socioeconomic disadvantage is related to cancer mortality in a racially diverse population, impacting racial differences in cancer mortality. Understanding the role of neighborhood quality in cancer survivorship could improve community-based intervention practices.

Abstract A019: Evaluating racial disparities in cancer survivorship via the role of area-level socioeconomic disadvantage in metropolitan Detroit

Abstract The role of socioeconomic status and race on cancer survivorship has been identified, however, the role of neighborhood disadvantage and race in cancer survivorship has not been well studied. This analysis aimed to evaluate the relationship between a comprehensive measure of neighborhood-level social disadvantage and cancer survivorship in the racially diverse population of metropolitan Detroit. We calculated overall and cancer-specific survival for 11,367 Non-Hispanic Black (NHB) and 29,481 Non-Hispanic White (NHW) individuals with breast, colorectal, lung, and prostate cancer using data from the Metropolitan Detroit Cancer Surveillance System. Neighborhood socioeconomic disadvantage was measured by the Area Deprivation Index (ADI) at the census block group level using data from the Census Bureau’s American Community Survey. Associations between ADI and survival were estimated using Cox proportional hazards mixed-effects models accounting for geographic grouping and adjusting for demographic, clinical, and treatment factors. Among all participants, an increase in ADI quartile was associated with increased overall mortality for all four cancer sites in multivariable models adjusting for race, age at diagnosis, stage, treatment, and Gleason score (prostate only). When stratifying by race, these associations remained among breast (NHW: Hazard Ratio (HR)=1.10, 95% Confidence Interval (CI) 1.05-1.15, p&amp;lt;0.0001; NHB: HR=1.14, 95% CI 1.05-1.23, p&amp;lt;0.0001), prostate (NHW: HR=1.14, 95% CI 1.09-1.20, p&amp;lt;0.0001; NHB: HR=1.08, 95% CI 1.01-1.16, p&amp;lt;0.0001), and lung cancer (NHW: HR=1.05, 95% CI 1.03-1.08, p&amp;lt;0.0001; NHB: HR=1.05, 95% CI 0.99-1.11, p=0.069), while the ADI-mortality association for colorectal cancer cases appears to be restricted only to NHWs (NHW: HR=1.09, 95% CI 1.05-1.14, p&amp;lt;0.0001; NHB: HR=1.05, 95% CI 0.98-1.12, p=0.15). Associations of cancer-specific mortality were like those of overall mortality, with a few exceptions including Hormone Receptor (HmR)+/HER2-specific mortality which was only significant in NHW women (HR=1.09, 95% CI 0.99-1.20, p=0.077), while HmR+/HER2+-specific mortality was consistent for NHW (HR=1.23, 95% CI 1.01-1.49, p=0.037) and NHB women (HR=1.21, 95% CI 0.84-1.75, p=0.31). Adjustment for ADI substantially attenuated the effects of race on overall mortality for all cancer types, except lung cancer, and significantly attenuated the effect of race on overall mortality for overall breast (proportion attenuated=54%, 95% CI 33-92%, p&amp;lt;0.0001), HmR+/HER2- breast (proportion attenuated=45%, 95% CI 19-113%, p&amp;lt;0.0001), and prostate cancer (proportion attenuated=54%, 95% CI 33-96%, p&amp;lt;0.0001); and attenuated the effects of race on cancer-specific survival only for overall breast (proportion attenuated=40%, 95% CI 16% to 87%, p&amp;lt;0.0001) and marginally for HmR+/HER2- breast cancer (proportion attenuated=24%, 95% CI -4% to 78%, p=0.094). Area-level socioeconomic disadvantage is related to the risk of cancer mortality in a racially diverse population and impacts the role of racial differences in cancer mortality. Citation Format: Natalie G. Snider, Theresa Hastert, Mrudula Nair, Madhav KC, Julie Ruterbusch, Ann Schwartz, Ed Peters, Elena Stoffel, Laura Rozek, Kristen Purrington. Evaluating racial disparities in cancer survivorship via the role of area-level socioeconomic disadvantage in metropolitan Detroit [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 A019.

Interaction of race and socioeconomic status as risk modulators of treatment delay and cancer-specific mortality in uterine cancer.

5595 Background: The majority of studies of uterine cancer combine high and low-grade histologies and do not sample a diverse cohort of patients. In many studies race is treated as biologic construct, when it may be better thought of as a proxy for socioeconomic inequity and deprivation. Socioeconomic (SE) deprivation may play a significant role in the disease trajectory of women with uterine cancer. Methods: Data were drawn from the Metropolitan Detroit Cancer Surveillance System which covers a tri-county area of approximately 4 million people. We included non-Hispanic Black (NHB) and White (NHW) women diagnosed with uterine cancer between 2010 and 2018. Poorly differentiated and undifferentiated endometrioid, serous, clear cell, mixed, carcinosarcoma and mucinous histologies were considered high grade. Patients diagnosed by death certificate, or with unknown stage or histology were excluded. Socioeconomic status was assessed using the Yost Score, an area-level composite measure of socioeconomic deprivation derived from census-tract data at cancer diagnosis. Lower Yost quintile indicates higher deprivation. Competing risk analysis was used to determine risk of uterine cancer specific mortality (reported as subdistribution hazard ratio [SHR]) and to assess statistical interaction between race and Yost score. Results: A total of 4,840 patients were identified. Race conferred significant increased risk of cancer-specific mortality (SHR 2.11, p &lt; 0.0001). Race and Yost score interacted to increase risk of cancer-specific mortality in NHB women in the lowest Yost quintile (SHR 2.23, p &lt; 0.0001) compared to NHW and NHB women in the highest quintiles. The interaction between race and Yost score persisted only among women with low grade cancers (SHR 1.7, p = 0.04). Time from diagnosis to surgery increased as Yost score decreased. Women in the lowest Yost quintile had lower likelihood of receiving surgery within 6 weeks of diagnosis (OR 0.74, p = 0.001). This effect persisted among women with low grade cancer (NHB OR 0.75, p = 0.014; lowest Yost quintile OR 0.68, p &lt; 0.0001). An association between race, Yost score and delays in time to surgery was not seen among women with high grade cancers. Conclusions: Race and Yost score, an area-based measure of socioeconomic deprivation, are associated with increased cancer-specific mortality risk among women with low grade cancer. NHB race and high socioeconomic deprivation are associated with delayed primary surgery. The interaction between race and socioeconomic deprivation may underlie known disparities in uterine cancer survival, particularly in low grade disease where there is the greatest opportunity for timely curative surgery.

Abstract PO-087: Diagnosis in young adulthood as a risk factor for unmet social needs among African American cancer survivors

Abstract Background: Increasing attention is being paid to understanding and addressing the financial consequences of cancer and cancer treatment; however, in addition to the direct and indirect costs of cancer care, survivors with few financial resources also face social needs such as food insecurity and housing instability. On average, young adults have fewer financial resources than older adults, placing them at risk for adverse financial outcomes due to cancer, including unmet social needs. The purpose of this study is to estimate associations between young adult age at diagnosis and prevalence of social needs among African American cancer survivors. Methods: We utilized data from 3,241 participants in the Detroit Research on Cancer Survivors (ROCS) cohort. African American adults were invited to participate if they were between the ages of 20-79 at diagnosis with breast, colorectal, lung, or prostate cancer since January 1, 2013; or diagnosed with endometrial cancer (ages 20-79) or any other cancer (ages 20-49) since January 1, 2016. Cases were identified through the Metropolitan Detroit Cancer Surveillance System, a population-based cancer registry. Participants self-reported several forms of unmet social needs, including food insecurity, recent utility shut-offs, housing instability, inability to get medical care due to lack of transportation, and whether they generally felt safe in their neighborhood. Modified Poisson models estimated prevalence ratios (PR) and 95% confidence intervals (CI) for social needs by age at diagnosis (20-39 vs. 65+) and tests for trend by 4-level age (20-39, 40-54, 55-64, 65+), controlling for demographic, socioeconomic, and cancer-related factors. Results: Overall, 32% of ROCS participants reported experiencing social needs, and prevalence was inversely associated with age at diagnosis such that 48% of survivors diagnosed as young adults reported any social needs compared with 22% of those diagnosed as older adults (PRadjusted: 2.3, 95% CI: 1.8-2.9; ptrend&amp;lt;0.001). Associations between young adult age at diagnosis and social needs were particularly high for utility shutoffs (PRadjusted: 4.7, 95% CI: 2.8-7.8) and food insecurity (PRadjusted: 3.4, 95% CI: 2.3-4.9) compared with those diagnosed as older adults. Young adults also reported substantially higher prevalence of not feeling safe in their neighborhood (PRadjusted: 2.8, 95% CI: 1.7, 4.6), housing instability (PRadjusted: 2.7, 95% CI: 1.7-4.5), and going without medical care due to lack of transportation (PRadjusted: 2.0, 95% CI: 1.2-3.3). There was an inverse association with age and all social needs examined (all ptrend&amp;lt;0.001). Conclusions: Each unmet social need considered was at least twice as common among African American cancer survivors diagnosed as young adults compared with those diagnosed when they were 65 or older. Young adults often have fewer financial resources compared older adults and should be prioritized in the development of interventions aimed at improving financial outcomes among cancer survivors. Citation Format: Theresa A. Hastert, Julie J Ruterbusch, Jean A. McDougall, Jamaica R.M. Robinson, Shaila M. Strayhorn, Andrew Abdallah, Gowri Chandrashekar, Ann G. Schwartz. Diagnosis in young adulthood as a risk factor for unmet social needs among African American cancer survivors [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-087.

Germline mutations in DNA damage repair genes and HOXB13 among African American men diagnosed with early-onset prostate cancer.

10505 Background: Inherited defects in DNA damage repair (DDR) genes (e.g. ATM, BRCA1/2) and the tumor suppresser gene HOXB13 are rare in the general population, but have been observed at a higher rate among men with early-onset and advanced prostate cancer. However, most studies include few, if any, African American men, highlighting the need to understand the contribution of mutations in these genes in this high-risk population. Methods: A population-based cohort of 757 African American men diagnosed with prostate cancer at age 62 years or younger were identified and enrolled through the Metropolitan Detroit Cancer Surveillance System (MDCSS), one of NCI’s founding members of the SEER program. Participants completed a short survey to collect information on family history, medical history (including cancer-related treatment), surveillance, and health behaviors. Each participant submitted a saliva or blood sample for genetic analyses and consent for tumor tissue if available. All clinical data were collected through linkage with the MDCSS registry. Full exome sequencing was performed and herein, we report the mutation patterns observed in a panel of DNA repair genes and HOXB13. All variants were ranked according to frequency (MAF &lt; 1%); REVEL, SIFT and PolyPhen scores for pathogenic potential; evidence from existing literature; and prevalence in the cohort. Results: Among the 744 African American prostate cancer cases with adequate DNA for sequencing and thus included in this analysis, the mean age at diagnosis was 55.6 years, 29% reported a family history of prostate cancer in a first degree family member, and 40% were initially diagnosed with intermediate- to high-risk disease (stage T3/T4 and/or Gleason 4+3 and higher at diagnosis). We identified 20 variants that were either known or predicted to be pathogenic in 11 candidate genes ( ATM, ATR, BRCA1/2, BRIP1, CHEK2, FANCA, HOXB13, MSH2, PALB2, and PMS2). These particular variants were more common among men diagnosed before age 55 and in men with high grade cancer in this cohort. Conclusions: Our results suggest that mutations in DDR genes and HOXB13 may be important cancer risk factors for African American men diagnosed with early-onset and intermediate- to high-risk disease. Further study is necessary to describe the spectrum and prevalence of genetic mutations in this population including the characterization of variants of unknown significance.

The impact of the COVID-19 pandemic on African American cancer survivors living in metropolitan Detroit.

12129 Background: COVID-19 has had profound direct and indirect effects on population health to date and long-term effects are anticipated. Vulnerabilities to the most serious consequences of infection include older age, obesity, African American race and the presence of comorbid conditions. African American cancer survivors represent a particularly high-risk group, therefore understanding the impact of the virus and our strategies to prevent its spread on this patient population is important. Methods: The Detroit Research on Cancer Survivors (ROCS) cohort is a unique effort to understand the determinants of poor outcomes in African American cancer survivors. Eligible participants were diagnosed with breast, prostate, colorectal, or lung cancer on or after 1/1/2013, or with endometrial or any other cancer before age 50 on or after 01/01/2016 and were identified through the Metropolitan Detroit Cancer Surveillance System cancer registry. To date, we have enrolled 4173 survivors. Full participation includes completion of a baseline survey, and collection of biospecimens, medical records and tumor tissue, if available. Participants are also followed annually for outcomes and changes in history. A supplemental survey focused on the impact of COVID-19 was offered to enrolled participants beginning in the spring of 2020. The results presented here include data from 890 survivors who also completed the ROCS COVID survey. Results: Nearly all ( &gt; 99%) survivors reported some change in their daily activities in an effort to reduce the risk of infection. At the time of survey, just over 1/3 of participants reported being tested for the virus and among those, 12% reported positive results. More than 40% of survivors reported some disruption in their access to medical care. A substantial ( &gt; 40%) proportion of survivors reported feeling anxious, depressed and/or isolated during the COVID-19 pandemic. Approximately 40% of patients reported changes in health behaviors as a direct result of the pandemic that are known to negatively affect survivorship outcomes (physical inactivity, smoking, alcohol use). Notably, 30% of survivors reported declines in physical activity and these declines were significantly associated with increased anxiety (p = 0.008), depression (p = 0.005) and poorer health-related quality of life (p &lt; 0.001). Conclusions: The influence of the COVID-19 pandemic on African American cancer survivors has been substantial, affecting both their physical and mental health and access to needed medical care. Coupled with changes in health behaviors as a direct result of the pandemic, these factors will likely affect outcomes in this high-risk patient population making further study and interventions necessary to mitigate the long-term impact of the pandemic on cancer outcomes.

Comorbidities at time of diagnosis as a predictor of more or less aggressive treatment modalities in early-invasive breast cancer.

e12591 Background: Comorbidities and advanced age have been shown to play important roles in breast cancer treatment and outcomes. Reduced doses of chemotherapy, worse treatment-related side-effects, poor performance status in patients with significant comorbidities, and the biological interplay between other diseases and cancer may also play roles. We evaluated the relationship between age and pre-existing comorbidities and receipt of local and systemic therapy in a cohort of African American (AA) women with early invasive breast cancer. Methods: The study population included 1,169 AJCC stage I-III invasive breast cancer survivors from the Detroit Research on Cancer Survivors (ROCS) study, a large cohort of AA cancer survivors. Comorbidities (both individual diseases and a combined count that was categorized as low/medium/high comorbidity burden), age at diagnosis, and other demographic variables were obtained from self-reported standardized questionnaires. Cancer-related variables including treatment were obtained from the Metropolitan Detroit Cancer Surveillance System registry. Recommended treatment was subdivided into localized (surgery ± radiation; N = 1,156), hormonal (N = 848) and chemotherapy (N = 680). Logistic regression estimated the associations between age and pre-existing comorbid conditions and the receipt of recommended treatments. Adjusted models included variables that were selected a priori and were significant predictors in univariate analysis. Results: Most women received recommended localized treatment (82.6%), hormone treatment (73.7%), and chemotherapy (79.9%). There were no differences in receipt of localized treatment based on age or comorbidity burden in adjusted analyses. However, arthritis and depression were significantly associated with not receiving recommended localized treatment (Odds ratio (OR): 0.66, 95% CI: 0.47, 0.93 and OR: 0.53, 95% CI: 0.36, 0.78, respectively). Women with a history of obesity (BMI ≥30) were more likely to receive recommended hormone therapy (OR: 1.64, 95% CI: 1.19, 2.26), while women with congestive heart failure were less likely (OR: 0.46, 95% CI: 0.23, 0.90). Receipt of recommended chemotherapy was less likely for those with increasing age (Ptrend&lt; 0.01) and increasing comorbidity burden (Ptrend= 0.02). Those with a history of arthritis (OR: 0.66, 95% CI: 0.44, 0.99) and hypercholesterolemia (OR: 0.62, 95% CI: 0.41, 0.95) were also less likely to receive recommended chemotherapy. Conclusions: Advanced age and presence of pre-existing co-morbid medical conditions appears to influence the receipt of chemotherapy, while individual conditions were associated with receipt of local treatment or hormone therapy in a cohort of AA survivors, suggesting the importance of providing comprehensive medical care for all women with early invasive breast cancer.

Abstract PO-207: Cancer diagnosis in young adulthood as a risk factor for financial hardship among African American cancer survivors

Abstract Background: Financial hardship is common among cancer survivors, particularly those with fewer financial resources at the time of diagnosis. Previous work suggests that working age adults (usually &amp;lt;65 at diagnosis) have worse financial outcomes than older adults (ages 65+); however, little is known about the financial outcomes of young adult (ages 20-39) relative to middle aged and older cancer survivors, despite their often-limited financial resources. The purpose of this study is to estimate associations between young adult age at diagnosis and material, behavioral, and psychological financial hardship among African American cancer survivors. Methods: We utilized data from 3,348 participants in the Detroit Research on Cancer Survivors (ROCS) cohort. African American adults were invited to participate if they were between the ages of 20-79 at diagnosis with breast, colorectal, lung, or prostate cancer since January 1, 2013; or diagnosed with endometrial cancer (ages 20-79) or any other cancer diagnosed at age 20-49 since January 1, 2016 and identified through the Metropolitan Detroit Cancer Surveillance System. Participants self-reported several forms of material and behavioral financial hardship (MFH and BFH, respectively). Psychological financial hardship was measured using the COST score. Modified Poisson models estimated prevalence ratios (PR), and 95% confidence intervals (CI) for financial hardship outcomes and age at diagnosis (20-39, 40-54, 55-64, 65+) controlling for demographic, socioeconomic, and cancer-related factors. Results: Overall, 44% of ROCS participants reported MFH, and prevalence was inversely associated with age at diagnosis such that 72% of young adults (ages 20-39) reported MFH compared with 31% of adults ages 65+ (PRadjusted: 1.97, 95% CI: 1.62-2.39; ptrend&amp;lt;0.001). Results were similar for individual forms of MFH, including decreased income, using assets to pay for care, current cancer debt, and borrowing from friends or family to pay for cancer care (all PRs &amp;gt;2.0 with 95% CIs excluding 1.0). BFH was reported by 24% of survivors and was also more common among young adults than those 65+ (29% vs. 21%; PRadjusted: 1.66, 95% CI: 1.14-2.43; ptrend=0.015); however, younger age was not associated with prevalence of specific forms of BFH. COST scores (calculated so that lower scores reflect greater financial distress) were also inversely related to age. Mean COST score was 24.3 overall and ranged from 19.3 (95% CI: 17.4, 21.1) among young adults to 26.8 (95% CI: 26.2, 27.4) among adults 65+ at diagnosis (ptrend&amp;lt;0.001). Conclusions: MFH is much more common, and psychological financial hardship is much more severe, in African American cancer survivors diagnosed between the ages of 20-39 compared with those diagnosed as older adults. Young age at diagnosis should be considered a risk factor for cancer-related financial hardship and addressed in work designed to reduce the adverse financial impacts of cancer. Citation Format: Theresa A. Hastert, Julie J. Ruterbusch, Mrudula Nair, Angie S. Wenzlaff, Jennifer L. Beebe-Dimmer, Stephanie S. Pandolfi, Ann G. Schwartz. Cancer diagnosis in young adulthood as a risk factor for financial hardship among African American cancer survivors [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-207.

Abstract PR20: Work outcomes, financial distress, and health-related quality of life among African American cancer survivors

Abstract Background: Many employed cancer survivors have difficulty maintaining employment during and after cancer treatment, potentially contributing to financial hardship related to cancer and lower health-related quality of life (HRQOL). The objective of this study is to estimate associations between work changes and decreased work participation and financial distress and HRQOL among employed African American cancer survivors. Methods: We utilized data from 910 employed participants in the Detroit Research on Cancer Survivors (ROCS) cohort. African American survivors diagnosed with primary invasive female breast, colorectal, lung, or prostate cancer since January 1, 2013 and identified through the Metropolitan Detroit Cancer Surveillance System were eligible to participate. Participants self-reported employment status; decreases in employment participation (going from full time to part time employment or from being employed to unemployed or on disability after diagnosis); taking paid and unpaid leave; making changes to their hours, schedules, or duties related to cancer; financial distress using the COST measure; and HRQOL using the FACT-G. Linear regression models controlled for demographic, socioeconomic, and cancer-related factors. Results: Mean FACT-G score was 83.1 and mean COST score was 24.6. In adjusted models, FACT-G scores were 13.8 (95% CI: 10.7, 17.2) points lower among survivors who decreased work participation, 5.7 (95% CI: 3.0, 8.4) points lower among those who changed their hours, duties, status, or schedules, 4.6 (95% CI: 1.9, 7.2) points lower among those who took unpaid time off, and 3.4 (95% CI: 0.4, 6.4) points lower among survivors who took extended paid time off. Similarly, COST scores were 9.4 (95% CI: 7.5, 11.2) points lower (reflecting higher financial distress) among survivors who decreased work participation, 5.5 (95% CI: 4.0, 7.0) points lower among those making work changes, 6.5 (95% CI: 5.0, 7.9) points lower among those taking unpaid leave, and 1.8 (95% CI: 0.1, 3.5) points lower among those taking extended paid time off. Work changes were not associated with changes in FACT-G scores between ROCS enrollment and first year follow-up. Work changes and paid and unpaid leave were not associated with differences in COST scores between ROCS enrollment and first year follow-up; however, among survivors who decreased work participation between diagnosis and ROCS enrollment COST scores increased by 3.2 (95% CI: 1.4, 5.0) points between ROCS enrollment and first year follow-up. Conclusions: Employment changes after cancer, particularly decreased work participation and changing hours, duties, employment status, and schedules were associated with lower HRQOL among cancer survivors, but not with differences in HRQOL over time. Survivors who experienced employment changes due to cancer also reported higher financial distress, although this distress lessened over time among survivors who decreased work participation. Citation Format: Theresa A. Hastert, Jaclyn M. Kyko, Julie J. Ruterbusch, Angie S. Wenzlaff, Mrudula Nair, Jennifer L. Beebe-Dimmer, Stephanie S. Pandolfi, Ann G. Schwartz. Work outcomes, financial distress, and health-related quality of life among African American cancer survivors [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 PR20.

Abstract A118: Work changes and predictors of decreased work participation among African American cancer survivors

Abstract Background: Cancer-related financial hardship is common and is associated with lower health-related quality of life, particularly among African American cancer survivors. Employment outcomes during and after cancer treatment may represent modifiable risk factors to reduce financial hardship and improve wellbeing among cancer survivors, but employment outcomes among African American survivors are not well understood. Methods: We utilized data from the Detroit Research on Cancer Survivors (ROCS) cohort. African American adults ages 20-79 were eligible to join the cohort if they were diagnosed with a first primary breast, colorectal, lung, or prostate cancer since January 1, 2013, as identified through the Metropolitan Detroit Cancer Surveillance System cancer registry. The present analyses include 445 survivors who reported being employed before their cancer diagnosis. We estimated prevalence of work-related outcomes, including changes to hours, duties, and schedules; and extended time off. We further estimated the prevalence and identified predictors of decreased work participation (going from being employed at diagnosis to not employed or from full time to part time employment) between diagnosis and ROCS baseline survey (median: 13 months) using modified Poisson regression. Adjusted models controlled for age, household income, and cancer site. Results: One-third (33%) of survivors reported taking at least one month off of work, including 19% who used paid sick time, 8% who used paid vacation, and 21% who took at least one month of unpaid time off. Changes to work schedules (46%), hours worked (40%), or work duties (25%) were also common. Nearly half (47%) of employed survivors experienced a decrease in work participation. A greater proportion of survivors employed full time before diagnosis reported being on disability at ROCS baseline compared with those employed part time (20.4% vs. 14.3%), while unemployment was more common among survivors employed part time before diagnosis (16.9% vs. 7.9%; p&amp;lt;0.001). In adjusted models, older age (RR 65+ vs. &amp;lt;55: 1.5, 95% CI: 1.1, 1.9), lower income (RR $80,000+ vs. &amp;lt;$20,000: 0.3, 95%CI: 0.2, 0.4), cancer site (RR lung vs. breast: 1.6, 95% CI: 1.2, 2.0; RR colorectal vs. breast: 1.3, 95% CI: 1.0, 1.7) and receipt of chemotherapy (RR: 1.4, 95% CI: 1.1, 1.8) were associated with decreased work participation, as were taking at least one month of unpaid time off (RR: 1.4, 95% CI: 1.1, 1.8) and changing work duties related to cancer (RR: 1.4, 95% CI: 1.1, 1.7). Conclusions: Our findings of strong associations between low household incomes and receipt of chemotherapy and decreased employment participation may represent opportunities to improve employment outcomes. Possible interventions focused on rehabilitation or additional policy or employer-level supports could improve employment outcomes among survivors at greatest risk for financial difficulties. Citation Format: Theresa A Hastert, Mrudula Nair, Julia Mantey, Jennifer L Beebe-Dimmer, Stephanie Pandolfi, Tara E Baird, Ann G Schwartz. Work changes and predictors of decreased work participation among African American cancer survivors [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 A118.

Abstract B035: Health-related quality of life among Detroit lung cancer survivors: Findings from the Detroit ROCS studies

Abstract Background: Lung cancer continues to cause more deaths than other cancers, with mortality among African Americans higher than among whites. Despite this, research on the psychosocial aspects of lung cancer patients' quality of life lags behind that of other cancer types, such as breast or prostate. The Detroit Research on Cancer Survivors (ROCS) studies follow the experience of cancer survivors, including lung cancer patients, in Detroit, MI. The Detroit ROCS studies include the pilot study of whites and African Americans, and the ongoing study of African Americans only. Methods: Participants in the Detroit ROCS studies complete the Functional Assessment in Cancer Therapy (FACT) instrument to evaluate their health-related quality of life (QOL). FACT scores are derived from subscores evaluating physical, emotional, social, and functional well-being. Higher scores indicate better QOL. In addition, participants are asked to provide basic demographic information, health history, family history of cancer, and exposure history. Data related to their cancer diagnosis and census tract are gathered via the Metropolitan Detroit Cancer Surveillance System. We examined preliminary data collected from 227 (131 African American and 96 white) lung cancer survivors to assess racial differences in self-reported aspects of well-being. We compared descriptive characteristics using Pearson's Chi-square and Wilcoxon rank sum tests. We modeled adjusted mean well-being subscores using a general linear model. Results: The mean age of African American participants was 61.9 (SD=7.6) and the mean age of whites was 62.9 (SD=8.9). Among African American participants, 40.5% were male; of white participants, 45.8% were male. The distributions of age and sex did not differ significantly between groups. African American participants were less likely to have any college education (p=0.0480), and more likely to live in a census tract with at least 20% poverty (p&amp;lt;0.0001). In a general linear model adjusted for age, sex, cancer stage, and time from diagnosis to interview, race did not predict differences in mean physical and functional well-being subscores. Race significantly predicted differences in adjusted mean emotional and social well-being scores (p=0.0379 and p=0.0466, respectively). The estimated adjusted mean emotional well-being subscore was higher among African Americans than among whites, while the estimated adjusted mean social well-being score was higher among whites. Conclusions: While functional and physical well-being outcomes are similar for African American and white patients after a lung cancer diagnosis, emotional and social well-being outcomes diverge by race. These measures reflect disparities in QOL among lung cancer patients, whose QOL is minimally studied compared to survivors of cancers with lower mortality rates. Future analyses will identify factors influencing this disparity in emotional and social well-being, and describe additional determinants contributing to the QOL of lung cancer survivors. Citation Format: Julia Mantey, Angela Wenzlaff, Jennifer Beebe-Dimmer, Terrance Albrecht, Ann G. Schwartz. Health-related quality of life among Detroit lung cancer survivors: Findings from the Detroit ROCS studies [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 B035.

Abstract B032: Which forms of financial hardship predict financial distress among African American and white cancer survivors?

Abstract Background: Financial hardship (FH) is common among cancer survivors and prevalence is often higher in non-white survivors. It is not known whether specific forms of FH are stronger predictors of financial distress than others, or if predictors of distress differ by race. Methods: We utilized data from 500 (196 white, 304 African American) participants in the Detroit Research on Cancer Survivors pilot cohort. Adults ages 20-79 were eligible if they were diagnosed with a first primary breast, colorectal, lung, or prostate cancer since January 1, 2013; identified through the Metropolitan Detroit Cancer Surveillance System; and diagnosed/treated at the Karmanos Cancer Institute. Measures of financial hardship included decreased income, cancer-related debt, utilizing assets or borrowing money to pay for cancer care, refusing treatment or not seeing a doctor when needed due to cost, and skipping doses of prescribed medication to save money. Financial distress was measured using the validated Comprehensive Score for Financial Toxicity (COST), coded so that lower scores indicate higher distress (lower financial quality of life). We used backward selection models including demographic and socioeconomic factors to identify predictors of financial distress overall and separately for white and African American survivors. Results: COST scores were 27.3 on average (SD: 10.9; 95% CI: 26.2, 28.3; range: 0-44), and were lower (more financial distress) in African American (24.5, 95% CI: 23.1, 25.8) than white survivors (31.0, 95% CI: 29.4, 32.5; p&amp;lt;0.001). Younger age, being unmarried, lower income, not being employed, and having Medicaid coverage were all associated with higher financial distress. Debt, decreased income, utilizing assets, skipping doses of prescribed medication, and needing a doctor but not going were each independently associated with more financial distress overall (all p=0.013). Debt was associated with distress among both white and African American survivors in race-specific models (p=0.005) and decreased income was associated with distress in white (p=0.013) and marginally associated (p=0.06) in African American survivors. Not going to the doctor when needed and utilizing assets (both p&amp;lt;0.001) predicted distress among white survivors, while refusing treatment due to cost (p=0.007) and skipping doses of prescribed medication to save money (p=0.007) predicted distress in African American survivors. Not going to a doctor when needed was more common in African American survivors, but more strongly associated with distress in white survivors (p-interaction=0.024). A similar pattern was observed for utilizing assets but was only marginally significant (p=0.08). Conclusions: Several forms of financial hardship were strongly associated with financial distress after cancer, but their association with distress differed by race. Some forms of financial hardship that are more common in African American survivors are more strongly associated with financial distress among white survivors. Citation Format: Theresa A. Hastert, Amanda R. Reed, Jennifer L. Beebe-Dimmer, Terrance L. Albrecht, Julia Mantey, Tara Baird, Ann G. Schwartz. Which forms of financial hardship predict financial distress among African American and white cancer survivors? [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 B032.

Racial differences in estrogen receptor staining levels and implications for treatment and survival among estrogen receptor positive, HER2-negative invasive breast cancers.

African American women (AAW) die more frequently from estrogen receptor (ER) positive breast cancer than European American women (EAW). We investigated the relationship between race, percent ER staining, treatment, and clinical outcomes. Percent ER staining (weakly ER+: 1-10%, moderately ER+: 11-50%, strongly ER+: > 50%) was abstracted from pathology reports for 1573 women with ER+/HER2- invasive breast cancer treated at a single cancer center in Detroit, MI from 2010 to 2017. Clinical outcomes and tumor characteristics were obtained from the Metropolitan Detroit Cancer Surveillance System. Associations of ER levels with demographic and clinical characteristics were evaluated using logistic regression. Overall and breast cancer-specific (BCS) survival were evaluated using Cox proportional hazards models. AAW were more likely to have tumors with lower ER staining levels than EAW (weakly ER+: Odds ratio (OR) 2.19, p = 0.019; moderately ER+: OR 2.80, p = 0.005). Women with weakly compared to strongly ER+ tumors were less likely to receive endocrine therapy (ET) regardless of race (OR 0.79, p < 0.001). Mortality was predicted by both AA race (Overall hazard ratio (HR) = 1.72, p < 0.001; BCS HR 1.45, p = 0.08) and low (1-50%) ER (Overall HR 1.57, p = 0.083; BCS HR 2.11, p = 0.017) adjusting for clinic-pathologic characteristics. ET was associated with improved BCS survival in all women (1-50%: HR 0.11, p < 0.001; > 50%: HR 0.24, p < 0.001). The biology of ER+/HER2- tumors varies by race, although this does not appear to account for racial differences in survival. Although ET substantially reduces mortality among women with weakly ER+ tumors, these women are less likely to be treated with ET and have poorer outcomes.

Abstract P2-10-04: Racial differences in estrogen receptor expression, treatment, and survival among estrogen receptor positive, HER2-negative invasive breast cancers

Abstract Background: African American women (AAW) are more likely to die from hormone receptor positive, HER2-negative breast cancer than European American women (EAW), even when accounting for factors including tumor stage and other clinical characteristics, although the mechanisms underlying this disparity are unclear. We recently showed that AAW with this breast cancer subtype are 75% more likely to have high predicted risk of distant recurrence than EAW using a 21-gene recurrence score, providing evidence for underlying racial differences in tumor biology. Estrogen receptor (ER) positive tumors can vary widely in the percentage of cells staining positive for ER (1-100%), and tumors with lower percent ER staining are more likely to display basal-like features typically associated with triple negative disease, a subtype that is more common among AAW. The relationship between race, ER staining levels, and clinical treatment and outcomes remains unknown. Methods: We identified 1,625 women with ER+, HER2- invasive breast cancer who received treatment at the Karmanos Cancer Institute in Detroit, MI from 2010-2017 via the Metropolitan Detroit Cancer Surveillance System (MDCSS) registry. Percentage of cells staining positive for ER (weakly ER+ = 1-10%, moderately ER+ = 11-50%, strongly ER+ = &amp;gt;50%) was abstracted from pathology reports. Clinical outcomes and tumor characteristics were linked via the MDCSS registry. Associations between ER levels and demographic/clinical characteristics were evaluated using logistic regression models and breast cancer-specific survival was evaluated using Cox proportional hazards models. Results: Weakly, moderately, and strongly ER+ tumors accounted for 3.2%, 2.7%, and 94.1% of the sample, respectively. AAW were more than twice as likely to have weakly ER+ tumors (Odds ratio (OR)=2.39, 95% confidence interval (CI) 1.28-4.49, p=6.4 × 10−3) and moderately ER+ tumors (OR=2.79, 95% CI 1.40-5.58, p=3.7 × 10−3) than EAW. AAW with weakly ER+ tumors were 4-fold more likely to be node positive than EAW (OR=4.35, p=0.045) and AAW with moderately ER+ tumors were 3-fold more likely to be node positive than EAW (OR=3.01, p=0.28). Adjustment for tumor size at surgery did not affect the relationship between race and node status. In a multivariable logistic model predicting whether a women received endocrine therapy, women with weakly ER+ tumors were 20% less likely to receive endocrine therapy compared to those with strongly ER+ tumors (OR=0.77, p=9.4 × 10−8), and lymph node positive tumors were 15% less likely to receive endocrine therapy (OR=0.85, p=7.2 × 10−11). In contrast, receiving chemotherapy and having later stage tumors were each associated with a 10% increase in receiving endocrine therapy (chemo: OR=1.08, p=1.9 × 10−5; stage: OR=1.13. p=6.1 × 10−5). In a multivariable Cox regression analysis, race (Hazard ratio (HR)=1.70, 95% CI 1.15-2.51, p=0.0074), ER staining levels (1-10%: HR=2.72, p=0.0029; 11-50%: HR+2.41, p=0.062), node positivity (HR=3.36, p=0.0017), distant stage (HR=18.6, p=6.0 × 10−14), and endocrine therapy (HR=0.26, p=4.1 × 10−9) were significantly associated with breast cancer specific survival. While not statistically significant, the effects of both race (HR=3.94, 95% CI 0.62-25.2, p=0.15) and endocrine therapy (HR=0.11, 95% CI 0.01-1.06, p=0.056) were strongest among the weakly HR+ tumor group. Conclusions: The biology of ER+, HER2- tumors varies by race, and AAW are more likely to have weakly ER+, node-positive tumors- which are less likely to be treated with beneficial endocrine therapy- and predict poorer outcomes. A better understanding of the role of hormone signaling in these tumors would substantially affect racial differences in survival among with ER+/HER2- tumors. Citation Format: Kristen S. Purrington, David Gorski, Michael S. Simon, Seongho Kim, Rayna Rosati, Ann Schwartz, Manohar Ratnam. Racial differences in estrogen receptor expression, treatment, and survival among estrogen receptor positive, HER2-negative invasive breast cancers [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 P2-10-04.