Metropolitan Detroit Cancer Surveillance System Research Articles

The Epidemiology of Cancer Among Homeless Adults in Metropolitan Detroit.

BackgroundHomeless individuals suffer and die disproportionately from chronic diseases and disorders. We describe the epidemiology of cancer among homeless persons in metropolitan Detroit.MethodsA retrospective cohort study was performed using 1973–2014 data from the Metropolitan Detroit Cancer Surveillance System, a population-based cancer registry and member of the National Institutes of Health-National Cancer Institute’s Surveillance, Epidemiology, and End Results program. Homeless adults were identified through address at diagnosis listed as a homeless shelter, hospital, or supplemental field indicating homelessness. Age-adjusted, sex-specific proportional incidence ratios (PIR) compared cancer incidence proportions by primary tumor site of homeless patients to the nonhomeless referent population. Kaplan-Meier curves depicted unadjusted survival differences in a propensity score matched sample. Differences in 10-year survival were assessed using the score test with a sandwich estimator accounting for matched cluster effects. Statistical tests were two-sided.ResultsA total of 388 individuals experienced homelessness at first primary invasive cancer diagnosis. Statistically significantly higher proportions of respiratory system (PIR = 1.51; 95% confidence interval = 1.28 to 1.79) and female genital system (PIR = 1.83; 95% confidence interval = 1.31 to 2.55) cancers were observed among homeless men and women, respectively. Homeless persons had poorer overall and cancer-reported survival compared with a propensity score matched referent population (median: overall survival, 20.0 vs 38.0 months, respectively, P < .001; cancer-reported survival, 38.0 vs 64.0 months, respectively, P < .001).ConclusionDisparities in disease burden exist between adults who are experiencing homelessness compared with the nonhomeless population at cancer diagnosis. These findings provide clinically relevant information to understand the cancer burden in this medically underserved population and suggest an urgent need to develop cancer prevention and intervention programs to reduce disparities and improve the health of homeless persons.

Racial Differences in 21-Gene Recurrence Scores Among Patients With Hormone Receptor-Positive, Node-Negative Breast Cancer.

Purpose The 21-gene recurrence score (RS) breast cancer assay is clinically used to quantify risk of 10-year distant recurrence by category (low, < 18; intermediate, 18 to 30; high, ≥ 31) for treatment management among women diagnosed with hormone receptor-positive, human epidermal growth factor receptor 2-negative, lymph node-negative breast cancer. Although non-Hispanic black (NHB) women have worse prognosis compared with non-Hispanic white (NHW) women, the equivalency of 21-gene RS across racial groups remains unknown. Patients and Methods Using the Metropolitan Detroit Cancer Surveillance System, we identified women who were diagnosed with hormone receptor-positive, human epidermal growth factor receptor 2-negative, lymph node-negative invasive breast cancer between 2010 and 2014. Multinomial logistic regression was used to quantify racial differences in 21-gene RS category. Results We identified 2,216 women (1,824 NHW and 392 NHB) with invasive breast cancer who met clinical guidelines for and underwent 21-gene RS testing. The mean RS was significantly higher in NHBs compared with NHWs (19.3 v 17.0, respectively; P = .0003), where NHBs were more likely to present with high-risk tumors compared with NHWs (14.8% v 8.3%, respectively; P = .0004). These differences were limited to patients younger than 65 years at diagnosis, among whom NHBs had significantly higher RS compared with NHWs (20 to 49 years: 23.6 v 17.3, respectively; P < .001 and 50 to 64 years: 19.6 v 17.4, respectively; P = .023). NHBs remained more likely to have high-risk tumors compared with NHWs after adjusting for age, clinical stage, tumor grade, and histology (odds ratio [OR], 1.75; 95% CI, 1.18 to 2.59). Conclusion NHBs who met clinical criteria for 21-gene RS testing had tumors with higher estimated risks of distant recurrence compared with NHWs. Further study is needed to elucidate whether differences in recurrence are observed for these women, which would have clinical implications for 21-gene RS calibration and treatment recommendations in NHB patients.

Abstract A25: Benign breast disease and subsequent breast cancer risk: The Detroit cohort

Abstract Introduction: Atypical hyperplasia (also known as proliferative disease with atypia), while categorized as a benign finding, has been consistently associated with an increased risk of subsequent breast cancer that persists for decades after initial diagnosis. There are various other lesions that are classified as benign breast disease (BBD) that are routinely identified by pathologists that may also increase risk and be of use to inform breast cancer risk models. We sought to identify which BBD lesions were associated with increased risk of breast cancer in an African American (AA) cohort. Methods: Benign breast biopsies from 3,895 AA women diagnosed with BBD between 1997 and 2010 in metropolitan Detroit were reviewed for 12 benign features including columnar alterations, ductal ectasia, ductal hyperplasia, fibrosis, apocrine metaplasia, lobular hyperplasia, calcifications, cysts, intraductal papilloma, radial scar, sclerosing adenosis, and fibroadenomas. Women were followed for subsequent breast cancer using the Metropolitan Detroit Cancer Surveillance System, part of the Surveillance, Epidemiology, and End Results (SEER) cancer registry. Associations between BBD features and subsequent breast cancer were examined using chi-square tests. Features that had a significant chi-square test result were also combined into scores describing the overall number of BBD features identified, termed busy breast score. Multivariable log-binomial regression with backward selection based on BIC criteria was performed to assess risk ratio and 95% confidence intervals of breast cancer on 12 candidate features. Multivariable log-binomial regression was performed for busy breast score as well. All regression models were adjusted for age at biopsy and overall impression for presence of proliferative disease with or without atypia using non-proliferative disease as the reference. Models were checked for multicollinearity using a variable inflation factor (VIF). Results: Of the 3,895 AA women in the BBD cohort, 210 developed a subsequent breast cancer. The median age at biopsy among those without a subsequent cancer (controls) was 47 years of age, while cases were 53 years of age (p-value&amp;lt;0.001). In univariate analyses, ductal hyperplasia (p-value=0.001), lobular hyperplasia (p-value&amp;lt;0.001), calcifications (p-value&amp;lt;0.004), cysts (p-value=0.003), intra-ductal papilloma (p-value=0.005), sclerosing adenosis (p-value=0.002), columnar alterations (p-value&amp;lt;0.001) and radial scar (p-value=0.001) were associated with subsequent breast cancer. Fibroadenomas were inversely associated with subsequent breast cancer (p-value&amp;lt;0.001). In multivariable model after backwards selection, presence of columnar alterations was associated with increased risk of breast cancer, (RR=1.57, 95% CI: 1.16, 2.13). Combining the 9 BBD features associated with subsequent breast cancer in univariate analysis, those with a busy breast score of 5+ was associated with 2.5 times increased risk compared to those with none of these features (RR=2.52, 95% CI: 1.41, 4.49). As a continuous variable for busy breast score, each additional feature conferred a 20% increase in risk of breast cancer (RR=1.20, 95% CI: 1.10, 1.31). Conclusions: Columnar alterations confer increased risk of breast cancer beyond the risks associated with atypical hyperplasia, as does the presence of multiple types of BBD lesions in a single biopsy. These estimates may help improve the current risk assessment models for African American women and highlight the need for additional research regarding the utility of closer surveillance and potentially chemoprevention for reduction of breast cancer in these women. Citation Format: Michele L. Cote, Wei Chen, Julie J. Ruterbusch, Eman Abdulfatah, Visakha Pardeshi, Asra N. Shaik, Marcel T. Ghanim, MHD Fayez Daaboul, Daniel W. Visscher, Sudeshna Bandyopadhyay, Rouba Ali-Fehmi. Benign breast disease and subsequent breast cancer risk: The Detroit cohort. [abstract]. In: Proceedings of the AACR Special Conference: Improving Cancer Risk Prediction for Prevention and Early Detection; Nov 16-19, 2016; Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(5 Suppl):Abstract nr A25.

Abstract C13: How does the financial impact of cancer differ by race? Results from the Cancer Survivorship in Metropolitan Detroit cohort study

Abstract Background: Previous research suggests that financial burdens due to cancer are more common in African-American than white survivors, but it is not known whether or how the types of burdens experienced differ by race. Methods: This study utilizes preliminary data from the Cancer Survivorship in Metropolitan Detroit (CSMD) cohort. African-American and white adults ages 20-79 are eligible to join the cohort if they were identified through the Metropolitan Detroit Cancer Surveillance System as having been diagnosed with a first primary breast, colorectal, lung, or prostate cancer since January 1, 2013 and were diagnosed and/or treated at the Karmanos Cancer Institute. To date, 695 (281 white, 414 African-American) of the targeted 1000 survivors have completed the baseline questionnaire online or over the phone. Data collected include demographic and socioeconomic characteristics, medical history, and financial burden measures including indicators of whether participants sold assets or borrowed money to pay for cancer care; limited care due to cost; experienced a decrease in income since diagnosis; and whether they are currently in debt due to cancer expenses. This abstract presents results of bivariate analyses and odds ratios (OR) and 95% confidence intervals (CI) from logistic regressions controlling for age, sex, treatment, and insurance. Results: Overall, 52.4% of survivors experienced some form of financial burden related to cancer, and prevalence was higher in African-American (56.6%) than in white survivors (46.3%; p=0.011). A marginally higher proportion of white (24.7%) than African-American survivors (19.2%; p=0.08) used existing assets to pay for cancer care, including higher proportions who withdrew money from savings (14.6% vs. 9.2%; p=0.027) or retirement accounts (7.8% vs. 3.4%; p=0.009). Although an identical proportion (9.8%) of white and African-American survivors borrowed money from family or friends, more African-American (31.2%) than white (18.1%; p&amp;lt;0.001) survivors were still in debt due to expenses related to cancer treatment. More African-American (21.3%) than white (14.6%; p=0.027) survivors also limited care due to cost concerns, including reporting that they needed to see a doctor in the past year but could not due to cost (15.1% vs. 9.1%; p=0.022) and that they skipped doses of prescribed medication to save money (8.8% vs. 5.4%; p=0.094). No differences were observed in the proportion of African-American and white survivors who sold stocks or other investments (1.2% vs. 2.1%), refused treatment due to cost (4.6% vs. 5.0%), or experienced a decrease in income due to cancer (30.2% vs. 27.3%). In adjusted analyses, African-American race remained associated with higher odds of being in debt due to cancer (OR: 2.09; 95% CI: 1.39, 2.14) and experiencing any form of economic burden (OR: 1.49, 95% CI: 1.04, 2.12) and marginally associated with skipping doses of prescribed medication (OR: 1.77 95% CI: 0.92, 3.42) and limiting care due to cost (OR: 1.46, 95% CI; 0.93, 2.28). Implications: These findings suggest that although large proportions of both white and African-American survivors experience some form of financial burden related to cancer, a larger proportion of white survivors may be able to utilize existing resources to pay for cancer treatment, while a larger proportion of African-American survivors experience lasting debt or forego necessary care due to cost concerns. As research into the economic consequences of cancer survivorship continues and expands into the development of interventions to reduce their impacts, it is important to identify not only disparities in the overall prevalence of economic burden, but also in the forms those burdens take for distinct groups. Citation Format: Theresa A. Hastert, Lauren M. Hamel, Tara Baird, Terrance L. Albrecht, Ann G. Schwartz, Michael S. Simon, Fawn Vigneau, Jennifer L. Beebe-Dimmer. How does the financial impact of cancer differ by race? Results from the Cancer Survivorship in Metropolitan Detroit cohort study. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C13.

Abstract C20: Understanding disparities in cancer survivorship: Introducing the Cancer Survivorship in Metropolitan Detroit Cohort Study

Abstract Background: Recent successes in cancer diagnosis and treatment have led to improved survival overall; however, African-Americans (AA) continue to experience worse survival outcomes than whites for many cancers, and AA survivors in Detroit often experience poorer outcomes than those in other parts of the country. The reasons underlying these differing survivorship outcomes and disparities relative to white survivors are not clear. We have established the Cancer Survivorship in Metropolitan Detroit cohort study to evaluate potential contributors to disparities in outcomes including socioeconomic factors, health behaviors, social support, and comorbidities. Methods: AA and white adults (ages 20-79) seen at the Karmanos Cancer Institute and identified through the Metropolitan Detroit Cancer Surveillance System as having been diagnosed with a first primary breast, colorectal, lung, or prostate cancer since January 1, 2013 are eligible to join the cohort. To date, 232 of the targeted 1,000 survivors have completed the self-administered online survey which collects information on demographic and socioeconomic characteristics, medical history, health behaviors, and social support. An interviewer-administered option is available to participants in need of assistance or without access to the Internet. Participants are also asked to consent to provide a saliva sample and access to medical records, and to participate in annual follow-up for up to four years. Data are available on both short-term outcomes such as quality of life and treatment, and long-term outcomes including cancer progression and recurrence and total and cancer-specific survival. Results: Of the first wave of participants contacted, 60% have completed the baseline questionnaire. The average age of participants is 62, 61% of initial respondents are AA and 66% are women. Overall, 30% of initial questionnaires have been completed online without assistance, including 46% completed by white survivors and 18% by AA survivors. Selected preliminary data suggest several differences between AA and white survivors in the cohort. The majority (62%) of white survivors reported household incomes of at least $40,000 compared with 18% of AA survivors (p&amp;lt;0.001). Relative to whites,fewer AA cancer survivors were married (21% vs 65%, p&amp;lt;0.001), or employed full time (11% vs. 24%, p=0.006) at baseline, and fewer owned or leased a vehicle (55% vs. 89%, p&amp;lt;0.001). A lower proportion of AA survivors (56%) had any form of private health insurance compared with whites (83%, p&amp;lt;0.001). AA survivors reported suffering from 3.3 comorbid conditions on average, compared with 2.7 among whites (p=0.014). A higher proportion of AA survivors reported that pain interfered with day-to-day activities (26% vs. 16%, p=0.06), while a higher proportion of whites reported high levels of fatigue (33% vs. 22%, p=0.06). A greater proportion of AA survivors reported current smoking (33% vs. 14%, p=0.005) and eating fast food regularly (46% vs. 25%, p=0.001), while a lower proportion participated in regular physical activity (24% vs. 42%, p=0.006). Alcohol and fruit and vegetable consumption were similar in white and AA survivors. Social support was also similar among the two groups, with a majority (75-80%) reporting usually or always having someone to help with chores, errands, or if they were confined to bed. Implications: These preliminary data suggest that AA and white cancer survivors in Detroit vary with regard to a number of health-related factors that may impact outcomes. These data can be used to further understand and address survival disparities and improve outcomes among AA cancer survivors, and may be instructive to other investigators implementing cohort studies among cancer survivors, particularly those wishing to incorporate online data collection. Citation Format: Theresa A. Hastert, Tara Baird, Julie J. Ruterbusch, Terrance L. Albrecht, Ann G. Schwartz, Jennifer L. Beebe-Dimmer. Understanding disparities in cancer survivorship: Introducing the Cancer Survivorship in Metropolitan Detroit Cohort Study. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C20.

Abstract A19: A mixed methods approach to assessing ehealth activity among African American cancer survivors

Abstract The research literature on eHealth activity across different patient populations is rapidly expanding, yet little is known about eHealth among diverse cancer survivors. Most existing measures of such activity are quantitative (QUAN). Compared to qualitative (QUAL) methods, QUAN methods are limited in capturing in-depth information regarding eHealth experiences that can inform user-centered design of technologies optimized for survivors' use. The goal of the pilot project reported here was to develop a mixed methods approach to assessing the full scope of eHealth activity among African American cancer survivors. Based on a literature review, study investigators created a measure that included 27 eHealth activities across 5 domains: informational, communal, self-care/management, expert care, and transactional. An embedded mixed methods design was used in which QUAN items represented the “primary strand” of data and QUAL probes represented the “secondary strand.” Within each domain, participants responded to QUAN items regarding each activity that asked if they were aware the activity was possible; if they had ever engaged in the activity personally; whether someone else (surrogate) had engaged in the activity on their behalf; the recency of the eHealth activity; how often the activity was related to their cancer; and their interest in engaging in the activity in the future. Then, QUAL probes were presented asking about the reasons they had participated in domain-specific activities and general problems or challenges within activities, or what had kept them from engaging in the activities and the support/resources needed to do so in the future. Participants were 23 African American breast, prostate, and colorectal (CRC) cancer survivors (12 breast; 7 prostate; 2 female CRC; 1 male CRC) identified through the Metropolitan Detroit Cancer Surveillance System, a member of NCI's SEER program. The mean age among participants was 60 years and time since end of primary treatment ranged from 13-46 months. In this pilot sample, 78% reported using the internet. Personal engagement in eHealth activities was highest in the informational domain (range: 9-72% across items) and the most reported activity was searching online for information about specific symptoms or problems. Personal engagement was lowest in the transactional domain. Across both personal and surrogate engagement, eHealth activities most often reported as related to cancer most or all of the time were searching online for information about how to reduce healthcare costs (60%), searching online for information about a hospital or healthcare facility (62.5%), and using technology to track medical symptoms (100%). Across all participants, interest in future engagement was greatest in the informational domain, including searching online for information about specific symptoms (86%), medical treatments or procedures (78%), and signing up to receive online, email or mobile updates on medical issues (74%). Interest in the future engagement was lowest for the communal domain. QUAL probes revealed several challenges within eHealth activities including difficulties in identifying credible health-related online resources; verifying the credibility of online health information; determining effective search terms to find relevant information; managing different policies across healthcare providers related to the electronic exchange of information; and technical problems with devices. Findings led to the revision of this mixed methods approach such that additional QUAN items and QUAL probes were added, with QUAL probes specific to eHealth activities rather than eHealth domains . The revised measure is currently being administered as part of an AHRQ-funded R01 study of eHealth activity among 1200 African American and white cancer survivors in the metropolitan Detroit area. Citation Format: Hayley S. Thompson, Anne Katz, Charity Barnes, Mary Smith, Tara Eaton. A mixed methods approach to assessing ehealth activity among African American cancer survivors. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A19.

Abstract B43: Disparities in mortality and five-year survival by race and socioeconomic status in white and African American women diagnosed with breast cancer in metropolitan Detroit

Abstract Background: Racial and, to a lesser extent, socioeconomic disparities in breast cancer incidence and mortality have been well documented; however, little is known about whether observed racial disparities differ by socioeconomic status. Methods: We used data from the population-based Metropolitan Detroit Cancer Surveillance System to estimate hazard ratios of death for non-Hispanic white (N = 31,102, including 8,174 deaths) and African-American women (N = 9,257, including 3,133 deaths) ages 18 and older diagnosed with incident, invasive breast cancer with recorded stage between 2000 and 2013 in Oakland, Wayne, and Macomb counties in Michigan and to estimate 5-year survival percentages for women diagnosed between 2000 and 2008 (N = 18,922). Neighborhood poverty was measured using the proportion of households with incomes below the federal poverty level in 2000 in the women's census tracts of residence at diagnosis. We used Cox proportional hazards models controlling for age at diagnosis, year of diagnosis, and cancer stage at diagnosis to estimate hazard ratios (HR) and 95% confidence intervals (CI) associated with mortality. Standard errors were adjusted to account for unobserved correlation between residents of the same census tracts. Results: Risk of death in African-American women diagnosed with breast cancer was 57% higher than for white women (HR: 1.57, 95% CI: 1.48, 1.67), and this association attenuated when also controlling for neighborhood poverty (HR: 1.31, 95% CI: 1.20, 1.42). Living in high-poverty neighborhoods was associated with a 77% higher risk of death (HR: 1.77, 95% CI: 1.64, 1.91), and this association also attenuated when controlling for race (HR: 1.46, 95% CI: 1.33, 1.62). Risk of death was higher for African-American women than for white women at every level of neighborhood poverty, although the associations were stronger in the lowest poverty areas (HR associated with being African-American: 1.68, 95% CI: 1.33, 2.12) than in the highest-poverty areas (HR: 1.23, 95% CI 1.08, 1.40). Among white women, higher neighborhood poverty was associated with higher risk of death (HR for high- vs. low-poverty areas: 1.57, 95% CI: 1.37, 1.79), but living in higher-poverty areas was not associated with mortality among African-American women with breast cancer (HR for high- vs. low-poverty areas: 1.21, 95% CI: 0.96, 1.51). Five-year survival was higher in white women (77.6%) than in African-American women (65.3%) overall. This difference in 5-year survival was largest for women living in the lowest-poverty areas (81.5% for whites vs. 70.1% for African-Americans), but was much smaller for women in the highest-poverty areas (66.2% for whites vs. 62.3% for African Americans). Conclusions: Although important disparities in mortality exist for African-American women compared with white women with breast cancer, disparities also exist by socioeconomic status, particularly for white women. The extent to which these disparities could be due to treatment differences, age at diagnosis, and type of breast cancer is being examined. It is important to consider socioeconomic status in addition to race when identifying and addressing disparities in breast cancer outcomes. Citation Format: Theresa A. Hastert, Ann G. Schwartz, Terrance L. Albrecht. Disparities in mortality and five-year survival by race and socioeconomic status in white and African American women diagnosed with breast cancer in metropolitan Detroit. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B43.

Racial differences in breast cancer survival in a large urban integrated health system.

African American (AA) women are known to have poorer breast cancer survival than whites, and the differences may be related to underlying disparities in their clinical presentation or access to care. This study evaluated the relationship between demographic, treatment, and socioeconomic factors and breast cancer survival among women in southeast Michigan. The population included 2387 women (34% AA) with American Joint Committee on Cancer stage I to III breast cancer who were treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Linked data sets from the HFHS, the Metropolitan Detroit Cancer Surveillance System, and the US Census Bureau were used to obtain demographic and clinical information. Comorbidities were classified with the modified Charlson comorbidity index (CCI). Economic deprivation was categorized with a census tract-based deprivation index (DI), which was stratified into 5 quintiles of increasing socioeconomic disadvantage. Compared with whites, AA women were significantly more likely to have larger, hormone receptor-negative tumors and more comorbidities and to reside in an economically deprived area. In an unadjusted analysis, AAs had a significantly higher risk of death (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.16-1.59); however, after adjustments for clinical (age, stage, hormone receptor, and CCI) and societal factors (DI), the effect of race was not significant (HR, 1.13 [95% CI, 0.96-1.34] , and HR, 0.97 [0.80-1.19] respectively). Racial differences in breast cancer survival can be explained by clinical and socioeconomic factors. Nonetheless, AA women with breast cancer remain disproportionately affected by unfavorable tumor characteristics and economic deprivation, which likely contribute to their increased overall mortality.

Abstract B39: Clinical characteristics of breast cancers in African American women with benign breast disease: A comparison to the Surveillance, Epidemiology and End Results Program

Abstract Although the association between benign breast disease (BBD) and risk of subsequent breast cancer is well-established, no previous studies have compared characteristics of breast cancers in women with a history of BBD to characteristics of cancers in the general population. In this study, we compared the characteristics of 109 breast cancers that developed in a population of African-American women with a history of benign breast disease (BBD population) to 10,601 breast cancers that developed in a general population of African-American women whose cancers were recorded by the Metropolitan Detroit Cancer Surveillance System (MDCSS population). The populations were compared on demographic characteristics such as age, marital status, and previous cancers, as well as clinical characteristics such as tumor hormone receptor status, grade, stage, behavior, size, and treatment. Overall and breast cancer-specific survival were also compared between populations. Women in the BBD population developed lower grade, earlier stage cancers that were more likely to be hormone receptor-positive and less likely to exhibit invasive behavior. Women in the BBD population were also significantly less likely to die from breast cancer after ten years of follow-up. These results suggest that although women with a history of BBD are at greater breast cancer risk, their breast cancers may be more likely to be detected early, leading to better breast cancer-specific survival. Citation Format: Susanna D. Mitro, Rouba Ali-Fehmi, Sudeshna Bandyopadhyay, Baraa Alosh, Bassam Albashiti, Quratulain Ahmed, Derek C. Radisky, Marlene H. Frost, Amy C. Degnim, Julie J. Ruterbusch, Michele L. Cote. Clinical characteristics of breast cancers in African American women with benign breast disease: A comparison to the Surveillance, Epidemiology and End Results Program. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B39. doi:10.1158/1538-7755.DISP13-B39

Abstract P5-12-03: Racial differences in breast cancer survival in a large urban integrated health system

Abstract Background: Despite improvements in breast cancer outcomes, there continues to be a large gap in survival between African American (AA) and White women with breast cancer, which may be due at least in part to racial differences in access to care. In order to better understand breast cancer survival disparities, we evaluated factors that predict racial differences in survival among women treated at a large integrated health care system in Southeastern Michigan. Materials and Methods: The study population included 2,387 women (34% AA) with stage I through III breast cancer treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Linked datasets from the HFHS, the Metropolitan Detroit Cancer Surveillance System (MDCSS) and the U.S. Census Bureau were used to obtain socio-demographic and clinical information. Co-morbidity was assessed by the Charlson co-morbidity index (CCI), and economic deprivation was categorized into 5 quintiles of increasingly worse socioeconomic deprivation, using a census tract deprivation index (DI). Results: AA women were significantly more likely than Whites to have larger (41% vs. 32% &amp;gt; 2 cm) and hormone receptor (HR) negative tumors (30% vs 19%), to have a higher CCI (15% vs 9% &amp;gt; 2) and to reside in a more economically deprived area (46% vs. 5% residing in quintile 5). Unadjusted analysis showed that AA had a significantly higher risk of death than White women (hazards ratio [HR], 1.36, 95% confidence interval [CI], 1.16-1.59). After multivariable adjustment for clinical (age, stage, HR and CCI), and societal factors (insurance, DI), race was no longer significantly associated with overall survival, HR, 1.12, 95% CI, 0.94-1.33, p = 0.22, and 1.02, 95% CI 0.83-1.24, p = 0.88, respectively. Stratified analyses by DI showed no racial difference in survival for each of 5 levels of DI. Discussion: In a large urban integrated health care system, racial differences in breast cancer survival appear to be related to clinical and socioeconomic characteristics. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-12-03.

The impact of functional limitations on long-term outcomes among African-American and white women with breast cancer: a cohort study

ObjectivesWe examined the impact of functional limitations and functional decline during the first year following breast cancer diagnosis on the risk of mortality from breast cancer and other causes among...

Abstract A67: Differences in the cancer burden for foreign-born versus U.S.-born Arab Americans living in metropolitan Detroit.

Abstract Introduction: Metropolitan Detroit is home to one of the largest populations of Arabs outside of the Middle East. However, cancer statistics for this population group are not available because Arab-Americans (ArA) are not considered a minority group by the federal government. Because of this limitation, little is known about the cancer burden among Arab Americans; furthermore there is no information on cancer by nativity status, which can often provide important clues to environmental factors in cancer etiology. Methods: We developed validated name lists as well as a methodology using Social Security Numbers to identify cancer cases of probable Arab ancestry by nativity status found in the Metropolitan Detroit Cancer Surveillance System database. ArA cancer cases diagnosed between the years of 1990-2009 were identified and compared to non-Hispanic white (NHW) cases using age-standardized proportional incidence ratios (PIRs) and 95% confidence intervals. PIRs were also calculated by country of origin (US-born versus foreign-born) for ArA. Results: A total of 9,327 Arab American cases were identified (4,463 men and 4,684 women). 46% of the ArA cases were born outside the United States. Compared to NHW, ArA men had a higher proportion of multiple myeloma, leukemia, kidney, liver, and bladder cancer. While the proportion of bladder cancer remained significantly higher among ArA men regardless of nativity status, ArA immigrants had a higher proportion of multiple myeloma, kidney, liver, and stomach cancer, while US-born ArA did not. ArA women had a higher proportion of lymphoma, leukemia, breast, gallbladder, liver, stomach, and thyroid cancer compared to NHW. This pattern remained for both foreign-born and US-born ArA females, except that female ArA immigrants had a higher proportion of breast and stomach cancer while US- born females did not. Conclusions: As expected, cancers such as liver and stomach, which can be related to infectious causes and have a relatively high incidence in developing countries, are seen proportionally higher in the foreign-born ArA than US-born ArA as compared to NHW. However, there are other patterns that deserve further investigation. An intriguing finding was foreign-born ArA women had proportionally higher breast cancer incidence while US-born ArA women did not when compared to NHW, a pattern that is opposite in other immigrant groups. We also are interested in the higher proportion of bladder cancer in ArA men regardless of nativity. The prevalence of this cancer is high in some Arab countries and is related to an infectious cause. However, the bladder cancer seen in the U.S. is of a different histological type (transitional cell), a type that is associated with the risk factor smoking. Although smoking prevalence among ArA men is uncertain, other smoking related cancers are not over-represented proportionally, which invites etiologic questions about bladder cancer risk factors in ArA men. Citation Format: Kendra Schwartz, Julie J. Ruterbusch, Fatima Khan. Differences in the cancer burden for foreign-born versus U.S.-born Arab Americans living in metropolitan Detroit. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A67.

P1-08-16: Benign Breast Disease (BBD) and Breast Cancer in African American Women.

Abstract African American (AA) women have higher mortality rates from breast cancer (BrCa) and are diagnosed at younger ages than their Caucasian counterparts. Women who have had a benign breast biopsy are at increased risk of the disease, although less is known about the risk of BrCa associated with benign breast disease in AA women. We examined 1428 breast biopsies from AA women which occurred from 1997–2000 and assessed various pathologic markers including: apocrine metaplasia, ductal hyperplasia including atypia, evidence of cysts, duct ectasia, fibrosis, intra-ductal papilloma, sclerosing adenosis, columnar alteration, and involution (atrophy). These women were followed for later BrCa through the Metropolitan Detroit Cancer Surveillance System, part of the Surveillance, Epidemiology and End Results (SEER) program through 2008. Women who developed BrCa were compared to those in the cohort who did not, and to other AA women with BrCa in the SEER registry. AA women in our study were also compared to Caucasian women in the Mayo Clinic cohort. Differences in variables were assessed by chi-squared tests and 95% confidence intervals. Of the 1428 biopsies, 52 (3.6%) subsequent incident breast cancers were reported in SEER. The mean age at diagnosis was 59, and the mean time from biopsy to BrCa diagnosis was 6.1 years. Individuals with atypical ductal hyperplasia at biopsy (n=37, 2.6%) were more likely to develop breast cancer (n=7, 13.5%, p&amp;lt;0.01). No other pathologic variables were associated with increased risk. Women in our cohort with breast cancer did not differ from AA in the SEER database with respect to age at diagnosis, stage at diagnosis, or receptor positivity. Compared to the Caucasian women in the Mayo Clinic BBD cohort, AA women in our study were younger at biopsy (p&amp;lt;0.01), but had similar percentages of involution and atypia (p=0.50 and 0.15, respectively). Our preliminary findings among a relatively small group of AA women with prior benign breast biopsies and incident breast cancers suggest that results from the Mayo Cohort study are likely to apply to AA populations. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-08-16.

P2-14-05: Racial Differences in the Use of Adjuvant Chemotherapy for Breast Cancer in a Large Urban Integrated Health System.

Abstract Background: Despite improvements in breast cancer treatment, there continues to be a gap in survival between African American (AA) and White women with breast cancer, which may be due at least in part to racial differences in the patterns of care. In order to better understand breast cancer survival disparities, we evaluated racial differences in the receipt of adjuvant chemotherapy among women treated at a large integrated health care system in Southeastern Michigan. Materials and Methods: The study population included 2,234 women (33 % AA) with stage I through III breast cancer treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Linked datasets from the HFHS, the Metropolitan Detroit Cancer Surveillance System (MDCSS) and the U.S. Census Bureau were used to obtain sociodemographic and clinical information. Co-morbidity was assessed by the Charlson co-morbidity index (CCI), and economic deprivation was categorized using a neighborhood deprivation index (DI). Results: AA women were significantly more likely than Whites to have larger tumors (40% vs. 31% &amp;gt; 2 cm), as well as more aggressive tumors (29% vs 19% estrogen and progesterone negative). AA women were also significantly more likely than Whites to have other co-morbid conditions (15 % vs. 8% with a CCI of 2+) and to reside in a more economically deprived area (45% vs. 5% reside in the most deprived area). While AA women were more likely to receive adjuvant chemotherapy (47% vs. 43%, p=0.0278), they were also more likely to have a delay in initiation of treatment (57% vs 45% delayed beyond 60 days from diagnosis, p=0.0004). After multivariable adjustment for age, DI, CCI, insurance and surgery, there were no racial differences in treatment delay (Odds Ratio 1.20, 95% confidence interval, 0.82−1.77). Discussion: In a large urban integrated health care system, racial differences in the delay in receipt of adjuvant chemotherapy for breast cancer can be explained by clinical and socioeconomic characteristics. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-14-05.

Clinical/pathologic features and patient outcome in early onset endometrial carcinoma: A population based analysis and an institutional perspective from the Detroit metropolitan area, Michigan

ObjectiveAnalyze tumor characteristics and outcomes in patients with endometrial carcinoma (EC)<40years of age and compare them to the characteristics of patients≥40years of age. Methods10,700 patients (305 patients <40years of age) diagnosed between 1988 and 2007 with EC from the Metropolitan Detroit Cancer Surveillance System (MDCSS), and 884 patients (42 patients <40years of age) diagnosed between 1996 and 2008 with EC from our institutional database were identified. Differences in clinical and demographic variables by age (<40 vs. ≥40) were assessed for statistical significance by chi-square tests. Cox proportional hazards models were used to calculate adjusted hazard ratios (HR) and their 95% confidence intervals (95% CI) to assess the risk of death from all causes. ResultsMDCSS based analysis: Patients<40 were more likely to present with low grade tumors (p<0.0001) and endometroid histology (p=0.0004) but less likely to undergo surgery (p=0.0007) or radiotherapy (p=0.0007). A multivariate analysis confirmed the significance of age, grade, and stage in all patients, and that of histologic type, surgery, and race in patients≥40 as independent prognostic factors for overall survival. Institution based analysis: Patients<40 had a higher proportion of patients with BMI≥30 (p=0.04), and presented with a higher frequency of well differentiated (p=0.04) endometrioid tumors (p=0.004) that are less prone to have deep myometrial invasion (p=0.008). ConclusionThis study supports the hypothesis of a disease that is biologically and genetically heterogeneous among women of different ages and ethnicities.

Abstract 1137: Racial differences in oncogene mutations detected in endometrial cancers

Abstract Endometrial cancer is the most common gynecologic cancer, with an estimated 42,000 new cases in 2010. Histologic types of endometrial cancer and stage at diagnosis differ substantially between African Americans (AA) and whites, but AA women experience poorer survival even after accounting for these factors. Additionally, other research suggests this disparity persists after controlling for co-morbid conditions, access to care, and treatment decisions. We hypothesize that there are differences in the molecular biology of tumors from white and AA women, beyond histologic type and grade, which may lead to the increased risk of death seen in AA women after an endometrial cancer diagnosis. After IRB approval, we performed a case-only retrospective analysis of patients with endometrial cancer, for whom we had tumor blocks, diagnosed from 1990-2005 at a single institution. Demographic and clinical variables were obtained from medical record review. Tumor histologic type, stage, and grade were obtained from the Metropolitan Detroit Cancer Surveillance System, part of the SEER program. Tumor histologic type and grade were confirmed by a gynecologic pathologist by slide review. We selected 150 archived tumors, including all high grade cases of any race (35 white, 40 AA), all low grade, endometroid tumors from AA women (n=44), and 31 low grade tumors from white women. Tumor DNA was extracted from formalin fixed paraffin embedded tissue using standard methods. We examined 238 mutations in 19 common oncogenes using the OncoCarta Assay v1.0 (Sequenom). Chi-square tests and Fisher's exact tests were used to assess differences in distribution of clinical and demographic variables by race or oncogene mutation status. We identified 20 mutations in 2 oncogenes in tumors from 19 women (12.7%). The most common mutation was in PIK3CA, the gene coding for the catalytic subunit p110α of PI3K, representing 15/20 (75%) of detected mutations. In PIK3CA, the following mutations were identified: R88Q in the p85-binding domain, E542K, M1043I and P539R in the helical domain, and H1047R in the kinase domain. Previous data suggest these mutations induce a gain of PI3K function and prognosis may vary by location. An additional 4 samples had activating mutations in KRAS (1 G12D, 1 G12V and 2 Q61H). No other mutations were identified. 13% of endometroid tumors harbored mutations, (11 PIK3CA and 2 KRAS). Among tumors from women with low grade endometroid cancers, race was significantly associated with harboring a mutation (p=0.04), with all 7 PIK3CA mutations were identified in AA women. All 4 KRAS mutations were found in AA women (p=0.13). This study provides preliminary evidence that the underlying molecular biology of some subtypes of histologically similar endometrial cancers differ by race. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 1137. doi:10.1158/1538-7445.AM2011-1137

Outcome of Patients With Early Breast Cancer Receiving Nitrogen-Containing Bisphosphonates: A Comparative Analysis From the Metropolitan Detroit Cancer Surveillance System

Background Preclinical data suggest that bisphosphonates exhibit antitumor activity. However, clinical studies indicated conflicting results. In this study, we compared the overall survival (OS) of postmenopausal patients with nonmetastatic invasive breast cancer who received any of the second-generation nitrogen-containing bisphosphonates for osteopenia or osteoporosis, with the survival of those who did not. Patients and Methods We conducted a retrospective study at the Wayne State University/Karmanos Cancer institute (KCI) in Detroit, Michigan and extracted data from the Metropolitan Detroit Cancer Surveillance System (MDCSS), a Surveillance, Epidemiology and End Results (SEER) registry. Patients > 50 years of age with stage I, II, or III invasive breast cancer between the years 2000 through 2003 were included. Information regarding medications was extracted from the patients' medical records. Results A total of 696 women with stage I-III breast cancer were included. Ninety-seven women (14%) used nitrogen-containing bisphosphonates. The difference in OS between bisphosphonate users and nonusers was not statistically significant ( P = .32) at 3 years. After adjusting for differences between the groups in age, stage of disease, hormone receptor status, endocrine therapy, vitamin D, and calcium use, there was a marginally significant ( P = .07) difference in survival; bisphosphonate users had poorer survival than nonusers. Conclusion Our results indicate that the use of nitrogen-containing bisphosphonates is not associated with improved OS in patients with nonmetastatic breast cancer, even after adjusting for known prognostic factors, but with a marginally worse OS. Further research is awaited to clarify the role of bisphosphonates in the adjuvant setting.

Abstract A111: Race is a predictor for endometrioid endometrial cancer cause-specific survival, but not all-cause survival

Abstract Endometrial cancer is the most common gynecologic cancer, with an estimated 42,000 new cases in 2010. The reported difference in overall five year survival between white women and African American (AA) women represents significant survival disparity in cancer. Histologic types of endometrial cancer and stage at diagnosis differ substantially between AAs and whites, but AA women experience poorer survival even after adjusting for these factors. After IRB approval, we performed a case-only retrospective analysis of 362 patients with surgically treated endometrioid endometrial cancer. Data from 120 AA and 242 white women, diagnosed from 1990-2005 at a single institution were analyzed to examine risk factors associated with survival. Age at diagnosis, co-morbid conditions in the 5 years prior to diagnosis, BMI, and smoking history were obtained from medical record review. Tumor histologic type, 1988 FIGO stage, grade, vital status and number of months surviving were obtained from the Metropolitan Detroit Cancer Surveillance System, part of the SEER program. Differences in stage, co-morbid conditions (using a modified Charlson Comorbidity Index, CCI), and BMI were examined by race. Chisquare tests were used to assess differences in distribution of clinical and demographic variables. Log-rank tests and Cox proportional hazards models were used to assess the risk of all-cause and endometrial cancer-related deaths. AA women were more likely than white women to have high grade tumors (p=0.009), hypertension (p=0.0005) and higher mean BMI (p=0.009). No differences by race were identified among the total group for age (p=0.98), stage at diagnosis (p=0.78), categorical modified CCI (p=0.51) or smoking history (p=0.96). When data were stratified by grade, hypertension (p=0.0009) and high BMI (p=0.002) were more frequent among AAs compared to whites with low grade tumors, but not high grade tumors. Among women with high grade tumors, AAs had a greater number of co-morbid conditions (p=0.005) and were more likely to be current or former smokers compared to whites (p=0.003). In univariate survival analysis, age at diagnosis, CCI, stage, and grade were all significantly associated with any cause survival, whereas race was not. When examining deaths due to endometrial cancer, only stage (HR=3.37,95% CI: 2.52-4.51), grade (HR=4.32,95% CI: 2.89-6.47) and race (HR=2.12,95% CI: 1.13-3.97) were predictors of survival. Analysis of endometrial cancer-related deaths by grade suggest this difference in survival by race is seen for high grade (p=0.03) but not low grade (p=0.87) tumors. In this single institution study, race was not a predictor of overall survival, but was associated with endometrial cancer-related survival. Excess of co-morbid conditions was associated with AA race, and overall survival, but not endometrial cancer-related survival in this population. A larger, more comprehensive study, including information regarding socio-economic factors, molecular tumor markers, and treatment modality is necessary to elucidate the causes underlying the large disparity in endometrial cancer survival between AA and white women. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A111.

Work task disability in employed breast and prostate cancer patients

Nearly 60% of cancer survivors are of working age, making inquiries into work-related disabilities particularly relevant. This paper describes work-related physical and cognitive disability estimates 12 and 18 months after diagnosis and treatment in a sample of employed breast and prostate cancer patients. We recruited employed, newly diagnosed patients (n=447 breast, n=267 prostate) from the Metropolitan Detroit Cancer Surveillance System for telephone interviews 12 and 18 months after diagnosis. We defined disability by work task activity limitation. Disability estimates and employment were compared using Pearson chi-square tests. Duration of hours worked was compared by disability status using t-tests. Approximately 60% of women reported physical disability at 12 months which decreased to 36% at 18 months. Cognitive disability was reported by 34% and 22% of women at 12 and 18 months, respectively. Fewer men reported physical disability, only 29% at 12 months, decreasing to 17% at 18 months. Cognitive disability was reported by 12% and 7% of men at 12 and 18 months, respectively. More individuals with disability left the workforce at each timeframe than those without disability. A significant proportion of breast and prostate cancer patients experienced work-related disabilities 1 year or more following treatment. Physical disability was more problematic than cognitive disability.

Outcome of patients with nonmetastatic breast cancer receiving nitrogen-containing bisphosphonates: A comparative analysis from the Metropolitan Detroit Cancer Surveillance System (MDCSS).

654 Background: Preclinical data suggest that bisphosphonates exhibit antitumor activity. However, clinical studies indicated conflicting results. In this study, we compared overall survival (OS) of postmenopausal patients with nonmetastatic invasive breast cancer who received any of the new generation nitrogen-containing bisphosphonates for osteopenia or osteoporosis, with the survival of those who did not. Methods: We conducted a retrospective study at the Wayne State University/Karmanos Cancer institute (KCI) in Detroit, Michigan and extracted data from the Metropolitan Detroit Cancer Surveillance System (MDCSS), a Surveillance, Epidemiology, and End Results (SEER) registry. Patients > 50 years with stage I, II, or III invasive breast cancer between the years 2000 and 2003 were included. Information regarding medications was extracted from the patients' medical records. Results: 696 women with stages I–III breast cancer were included. 97 women (14%) used nitrogen-containing bisphosphonates. The difference in OS between bisphosphonate users and non-users was not statistically significant (p = 0.32) at 3 years. After adjusting for differences between the groups in age, stage of disease, hormone receptor status, endocrine therapy, and vitamin D and calcium use, there was a marginally significant (p = 0.07) difference in survival; bisphosphonate users had poorer survival than non-users. Conclusions: Our results indicate that the use of the newer generation nitrogen-containing bisphosphonate is not associated with improved OS in patients with nonmetastatic breast cancer, even after adjusting for known prognostic factors, but with a marginally worse OS. Further research is awaited to clarify the role of bisphosphonates in the adjuvant setting. No significant financial relationships to disclose.