Survival In African American Patients Research Articles

Outcomes of African American Women Undergoing APBI for Early-Stage Breast Cancer: A Matched Pair Analysis

There are little data evaluating outcomes with the use of APBI for breast conservation therapy in African American women. This matched pair analysis compares the long-term outcomes of African American versus white women who underwent APBI at our institution. One hundred fifty-six patients with DCIS (33%) or stage I/II invasive breast cancer (77%) who underwent APBI at our institution between 1993 and 2013 were included in this matched pair analysis. 39 African American and 117 white patients underwent a 1:3 match according to age (+/- 5 years), T-stage (Tis vs T1 vs T2), and estrogen receptor (ER) status (+/-). Clinical outcomes were compared using the Kaplan-Meier method. The median follow-up was 76 months. All patients received 34 Gy (brachytherapy) or 38.5 Gy (3D-CRT) in 10 B.I.D fractions. No significant differences were seen in tumor size, age at diagnosis, T-stage, N-stage, grade, margin status, ER/PR/HER 2 status, treatment type (interstitial, balloon-based, or 3D-CRT), adjuvant chemotherapy, or use of adjuvant hormone therapy by race (all P > 0.05). Local recurrence was higher for African American compared to white, with 5-year rate of 7.9% vs 1.1% (p = 0.03). Regional recurrence was also higher in African American, with 5-year rate of 5.8% vs 0% (p = 0.02). The 5-year contralateral breast failure and distant metastasis rates were 0% vs 0% (p = 0.6) and 2.7% vs 2.0% (p = 0.99), respectively. At 5 years, there were no statistically significant differences in OS (93% vs 88%, p = 0.27), CSS (96% vs 99%, p = 0.20), or DFS (92% vs 97%, p = 0.16) between the African American and white patients, respectively. On univariate analysis, age (p = 0.034) and tumor size (p = 0.025) were predictive for IBTR while nodal status (p = 0.049) and grade (p = 0.027) were predictive for regional recurrence in African American patients. No factors were predictive for white patients. On multivariate analysis, tumor size (p = 0.045) and age (p = 0.024) remained independent predictors of IBTR for African American patients. Our results show similar overall, cause-specific, and disease-free survival for African American patients undergoing APBI for breast conservation compared to matched White counterparts. In this small matched cohort, there was increased risk of locoregional recurrence in the African American patients and further study is needed to explore the biological, molecular, socioeconomic, and treatment related factors accounting for this difference.

Lack of reduction in racial disparities in cancer-specific mortality over a 20-year period.

To the authors' knowledge, it remains unknown whether race-based differences in cancer outcomes have changed with time. In the current study, the authors assessed whether racial disparities in cancer-specific mortality have improved over the last 20 years. The Surveillance, Epidemiology, and End Results program was used to identify 2,713,474 patients diagnosed between 1988 and 2007 with either lung, breast, prostate, or colorectal cancer (the leading 3 causes of cancer-related mortality among each sex). After exclusions, 1,001,978 patients remained eligible for analysis. The impact of race on cancer-specific mortality was assessed using the regression model of Fine and Gray; an interaction model evaluated trends over time. African Americans presented with a more advanced stage of disease (P < .001) and underwent definitive therapy less often (P < .001) than whites. After adjustment for demographics and year of diagnosis, African Americans were found to have higher estimates of cancer-specific mortality than whites for all cancers combined (hazards ratio, 1.28; 95% confidence interval, 1.26-1.30 [P < .001]) and within each individual cancer (each P < .05). These differences did not change significantly between 1988 through 1997 and 1998 through 2007, except among patients with breast cancer, in whom survival disparities increased. These findings remained significant after adjustment for stage of disease at presentation and receipt of definitive therapy (hazards ratio for breast cancer mortality in African Americans vs whites: 1.37 from 1988-1997 and 1.53 from 1998-2007; P for interaction, < .001). The survival gap for African Americans has not closed over time. Race-based differences in outcome persist independent of stage of disease and treatment, suggesting that additional strategies beyond screening and improving access to care, such as further research into tumor biologies disproportionately affecting African Americans, are needed to improve survival for African American patients with cancer.

Survival In Adult Acute Lymphoblastic Leukemia Survival By Age, Gender and Ethnicity

BackgroundStudies have shown improvement in survival in adult acute lymphoblastic leukemia (ALL) with the use of risk-directed therapy pediatric-inspired regimens. We analyzed US Surveillance, Epidemiology and End Results (SEER) cancer registry database to evaluate whether survival of adult ALL patients has improved in general population. MethodsWe analyzed US Surveillance, Epidemiology and End Results (SEER) 18 registries using survival session to calculate relative survival rates (RS) during 1973-1989, 1990-1999 and 2000-2009 among adult (≥20 years) ALL patients. We used Z-test in the SEER*Stat software to compare the relative survival rates in several cohorts categorized by race, gender, and age groups (20-39, ≥ 40 years). ResultsThere were 7,435 adult ALL patients reported in SEER 18 registries during 1973-2009. The majority of patients were Caucasian (85%) and Male (57%).The relative survival rates for adult ALL patients between 1973-2009 were 55.8±0.6% and 25.0±0.5% at 1 year and 5 years respectively. The relative survival rates improved significantly for each successive time periods, with an improvement from 45.4%, to 51.6%, to 60.6% at 1 year and, from 15.3%, to 23.7%, to 29.0% at 5 years for time periods 1973-1989, 1990-1999 and 2000-2009 respectively. For younger patients (age 20-39 years), 1- and 5-year RS rates improved from 1973-1989 to 1990-1999 but not from 1990-1999 to 2000-2009. For older patients (age ≥40 years) RS improved for each successive time periods.The 1- and 5- year relative survival rates improved significantly for both male and female patients during successive time periods. Interestingly, although there was significant improvement in survival rates at 1- and 5- years for Caucasians, improvement was not seen for AA adult ALL patients during subsequent time periods examined. ConclusionsAlthough adult ALL survival rates have improved for most cohorts examined, the survival of African American patients has not improved. Similarly, survival rates of younger patients (20-39 years) has not improved from 1990-1999 to 2000-2009. Disclosures:No relevant conflicts of interest to declare.

Clinical characteristics, response to therapy, and survival of African American patients diagnosed with chronic lymphocytic leukemia

Little is known regarding racial disparities in characteristics and outcomes among patients with chronic lymphocytic leukemia (CLL). The characteristics and outcomes of untreated African American (AA) patients with CLL (n = 84) were analyzed and compared with a reference nonblack (NB) patient population (n = 1571). At the time of presentation, AA patients had lower median hemoglobin levels (12.9 g/dL vs 13.7 g/dL), higher β2 microglobulin levels (2.7 mg/dL vs 2.4 mg/dL), greater frequency of constitutional symptoms (27% vs 10%), unmutated immunoglobulin heavy-chain variable region (IGHV) mutation status (65% vs 47%), ζ-chain-associated protein kinase 70 (ZAP70) expression (58% vs 32%), and deletion of chromosome 17p or chromosome 11q (28% vs 17%; P ≤ 02 for each comparison). Fifty-one percent of AA patients and 39% of NB patients required first-line therapy and 91% and 88%, respectively, received chemoimmunotherapy. Overall response rates to treatment were 85% for AA patients and 94% for NB patients (P = .06); and the complete response rates were 56% and 58%, respectively (P = .87). The median survival of AA patients was shorter compared with that of NB patients (event-free survival: 36 months vs 61 months; P = .007; overall survival: 152 months vs not reached; P = .0001). AA race was an independent predictor of shorter event-free and overall survival in multivariable regression models. The current results indicated that AA patients with CLL have more unfavorable prognostic characteristics and shorter survival compared with their NB counterparts.

The association of race with timeliness of care and survival among Veterans Affairs health care system patients with late-stage non-small cell lung cancer

BackgroundNon-small cell lung cancer is the leading cause of cancer-related mortality in the United States. Patients with late-stage disease (stage 3/4) have five-year survival rates of 2%–15%. Care quality may be measured as time to receiving recommended care and, ultimately, survival. This study examined the association between race and receipt of timely non-small cell lung cancer care and survival among Veterans Affairs health care system patients.MethodsData were from the External Peer Review Program, a nationwide Veterans Affairs quality-monitoring program. We included Caucasian or African American patients with pathologically confirmed late-stage non-small cell lung cancer in 2006 and 2007. We examined three quality measures: time from diagnosis to (1) treatment initiation, (2) palliative care or hospice referral, and (3) death. Unadjusted analyses used log-rank and Wilcoxon tests. Adjusted analyses used Cox proportional hazard models.ResultsAfter controlling for patient and disease characteristics using Cox regression, there were no racial differences in time to initiation of treatment (72 days for African American versus 65 days for Caucasian patients, hazard ratio 1.04, P = 0.80) or palliative care or hospice referral (129 days versus 116 days, hazard ratio 1.10, P = 0.34). However, the adjusted model found longer survival for African American patients than for Caucasian patients (133 days versus 117 days, hazard ratio 0.31, P < 0.01).ConclusionFor process measures of care quality (eg, time to initiation of treatment and referral to supportive care) the Veterans Affairs health care system provides racially equitable care. The small racial difference in survival time of approximately 2 weeks is not clinically meaningful. Future work should validate this possible trend prospectively, with longer periods of follow-up, in other veteran groups.

Improved Survival with HPV among African Americans with Oropharyngeal Cancer

A major limitation of studies reporting a lower prevalence rate of human papilloma virus (HPV) in African American patients with oropharyngeal squamous cell cancer (OPSCC) than Caucasian Americans, with corresponding worse outcomes, was adequate representation of HPV-positive African American patients. This study examined survival outcomes in HPV-positive and HPV-negative African Americans with OPSCC. The study cohort of 121 patients with primary OPSCC had 42% African Americans. Variables of interest included age, race, gender, HPV status, stage, marital status, smoking, treatment, and date of diagnosis. Caucasian Americans are more likely to be HPV positive (OR = 3.28; P = 0.035), as are younger age (age < 50 OR = 7.14; P = 0.023 compared with age > 65) or being married (OR = 3.44; P = 0.016). HPV positivity and being unmarried were associated with being late stage (OR = 3.10; P = 0.047 and OR = 3.23; P = 0.038, respectively). HPV-negative patients had 2.7 times the risk of death as HPV-positive patients (P = 0.004). Overall, the HPV-race groups differed (log-rank P < 0.001), with significantly worse survival for HPV-negative African Americans versus (i) HPV-positive African Americans (HR = 3.44; P = 0.0012); (ii) HPV-positive Caucasian Americans (HR = 3.11; P = < 0.049); and (iii) HPV-negative Caucasian Americans (HR = 2.21; P = 0.049). HPV has a substantial impact on overall survival in African American patients with OPSCC. Among African American patients with OPSCC, HPV-positive patients had better survival than HPV negative. HPV-negative African Americans also did worse than both HPV-positive Caucasian Americans and HPV-negative Caucasian Americans. This study adds to the mounting evidence of HPV as a racially linked sexual behavior life style risk factor impacting survival outcomes for both African American and Caucasian American patients with OPSCC.

A clinical and serologic comparison of African American and Caucasian patients with systemic sclerosis

Epidemiology studies suggest that systemic sclerosis (SSc) is more common, occurs at a younger age, and is more severe in African Americans than Caucasians. However, the scleroderma autoantibody profile is very different between these 2 ethnic groups. This study was undertaken to examine the demographic and disease features, frequency and severity of internal organ system involvement, and survival in African American patients compared to Caucasian patients with SSc, giving particular attention to their serum autoantibody profiles. Demographic features, clinical characteristics, autoantibody profile, organ involvement, and survival were studied in consecutive African American and Caucasian patients with SSc whose visits were recorded between 1972 and 2007 as part of the Pittsburgh Scleroderma Database. The Medsger Severity Score for SSc was used to determine the severity of disease. African American patients were more likely to have anti-topoisomerase I (anti-topo I), anti-U1 RNP, and anti-U3 RNP autoantibodies. In comparing African American and Caucasian patients with these antibodies, pulmonary fibrosis was found to be more frequent and more severe, and the rate of survival was decreased, in African American patients with anti-topo I antibodies compared to Caucasian patients with anti-topo I. Pulmonary fibrosis was also more severe in the anti-U1 RNP-positive patients, but this was not associated with a difference in survival between African Americans and Caucasians. Anti-U3 RNP was associated with more severe gastrointestinal involvement in African Americans compared to Caucasians. African Americans with SSc have more severe disease complications compared to Caucasians with SSc, and this is associated with both the type of autoantibody present and the severity of interstitial lung disease. Thus, it is hoped that early aggressive intervention in African Americans with interstitial lung disease will improve outcomes.

Race and Subset Analyses in Clinical Trials: Time to Get Serious About Data Integration

Colorectal cancer mortality rates have decreased in the last two decades primarily because of improved population screening rates and enhanced multimodality treatment of the disease (1). Because the decline in mortality rates among African American patients has not been as substantial as in white patients of European descent, the disparity in stage-specific survival between African Americans and whites continues to widen (2,3). Multiple factors contribute to the lower survival of African American patients, including reduced access to quality primary care that can lead to less preventative care, higher rates of comorbidities, diagnosis at later stages of disease, and lower utilization of potentially curative treatment after diagnosis (4–7). Unfortunately, there has been a paucity of integrated data at both the individual and population levels to develop effective policies to close the gap. In this issue of the Journal, Yothers et al. (8) sought to determine whether black (African American or of African ancestry) colon cancer patients with stage II and III disease treated in an equivalent manner within the setting of clinical trials achieved similar cancer-specific and overall outcomes compared with white patients. The authors examined the overall survival, recurrencefree survival, and recurrence-free interval of 13 393 whites and 1218 blacks from the Adjuvant Colon Cancer ENdpoinTs (ACCENT) collaborative group database. The strength of this study was the uniform collection of individual patient level data from participants in 12 adjuvant phase III clinical trials in North America from 1977 to 2002. The results of the study showed that under standardized treatment conditions, black patients still had statistically significant worse overall and recurrence-free survival compared with white patients, whereas both patient groups had a similar recurrence-free interval. Based upon these findings, the authors conclude that the worse survival of black patients is likely because of factors unrelated to response to adjuvant treatment, such as racial differences in comorbidities, general life expectancy, or potentially in care for recurrent disease. It is worth noting that despite the addition of a more contemporary cohort of patients, the results of this study are almost identical to those published in this Journal by Dignam et al. (9) more than a decade ago, which included only the first five National Surgical Adjuvant Breast and Bowel Project (NSABP) colon cancer trials (C-01 through C-05). Moreover, data within this study precede the adoption of biologic therapies for the treatment of advanced colorectal cancer and include outcome data from 5-fluorouracil (FU)-based therapies, which were broadly applied to patients without consideration of the molecular mechanisms driving disease progression. We now understand that colorectal cancers are of a heterogeneous nature (10–12) and should be treated as such. Therefore, studying the poorer overall and recurrence-free survival of African Americans compared with whites among a uniformly treated population without reference to the underlying heterogeneity in tumor biology limits interpretation of the study findings. Nevertheless, it is useful to examine what additive information is gleaned from each of the endpoints in this article (8). This study demonstrates a non-statistically significant 8% increase in the haz ard of recurrence for blacks compared with whites (hazard ratio = 1.08, 95% confidence interval = 0.97 to 1.19, P = .15) (8). The authors conclude that this supports either no difference in response to therapy or at best a very small difference. This conclusion has some caveats. Given the higher competing causes of death for black patients before potential recurrence (as evidenced by the poorer recurrence-free survival), recurrences that may have manifested will never occur, which biases the results toward the null hypothesis. More importantly, despite a very large sample size, the study still only included 1218 black patients, and of these, a little less than one-third had recurrence events. Given the heterogeneity in both tumor biology of colon cancer [eg, microsatellite instability

Abstract B94: A10-year retrospective analysis of African American and white patients with diffuse large B cell lymphoma treated at the University of Alabama at Birmingham

Abstract Introduction: Diffuse large B cell lymphoma (DLBCL) is the commonest type of NHL and has variable clinical behavior because of distinct molecular signatures that have recently been identified. The treatment of this lymphoma has improved dramatically after the addition of rituximab to the commonly used first line chemotherapy CHOP but there is still a wide variation in response to treatment. Our study aim was to see if race as well as socioeconomic status played a role in diagnosis as well as treatment of this disease. Methods: We performed a retrospective analysis of all patients from 1997-2007 with a biopsy confirmed diagnosis of DLBCL that were treated at the University of Alabama at Birmingham (UAB) and analyzed various factors like age, sex, marital status, insurance status, Stage, B symptoms, extranodal sites, ECOG performance status (PS), type of treatment and survival after stratifying them by reported race as either white or African American(AA). We excluded patients that had evidence of transformation or mixed histology or incomplete information about demographics or treatment. Results: A total of 292 patients met the inclusion criteria.10 patients with race reported as ‘Other’ were further excluded. A total of 282 patients were analyzed out of which 240(85%) of patients were white and 15% of patients were AA. Of note, Jefferson County where UAB is located has an approximately 33% of AA residents. The mean age of diagnosis for AA patients was lower at 48 yrs as compared to 52 yrs for white patients (p=0.01). AA patients were more likely to be uninsured (5%) as opposed to white patients (3%)(p=0.02). AA patients seemed to have an inferior performance status (PS) at presentation with only 57% presenting at with an ECOG PS of 0-1 as compared to 73% of white patients.(p&amp;lt;0.001). They also seemed presented at a later stage of the disease.31% presented at Stage I/II vs 34% of white patients (p&amp;lt;0.012) with correspondingly higher LDH values (50% with values greater than upper limit of normal compared to 37% of White patients, p=0.024). There was no significant difference in the type of first chemotherapy regimen that both groups received with approximately similar proportions receiving CHOP (42% of white patients vs 35% of AA patients) or R-CHOP(35% of white patients vs 44% of AA patients). The median survival for AA patients was 2 years as compared to 3 years in the white patients but this was not statistically significant (p=0.2). In conclusion, DLBCL is a heterogeneous disease with distinct molecular subtypes that have been recently identified. Our single institution 10-year analysis shows that a significantly greater proportion of AA patients appear to present at a younger age, with more advanced disease but do not seem to have a significant difference in overall survival. We hypothesize that these findings may be due to socioeconomic status as well as inherent differences in the biology of the tumor. There is a well documented decreased incidence of various B cell NHL in the African American population and this is confirmed in our analysis with only a 15% incidence of DLBCL even in a county with a higher percentage of AA residents. These observations can help guide further research into identifying the different molecular subtypes of DLBCL in various ethnic populations and help us develop more targeted therapy for this disease. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B94.

Survival Disparities Between African American and Caucasian Patients With Multiple Myeloma Are Blunted in the Era of Novel Therapeutics and Autologous Stem Cell Transplantation

Abstract Background Multiple myeloma (MM) accounts for approximately 10% of hematologic malignancies diagnosed annually in the United States. It is well documented that the African American population is disproportionately affected by MM in incidence and mortality. Survival data from the SEER database from 2001-2005 demonstrated higher mortality in African American patients compared to Caucasian patients. However, more recent retrospective reviews in the era of autologous stem cell transplantation (ASCT) did not support this finding. Thus the persistence of racial survival disparities in the era of ASCT and novel therapeutic agents is an evolving question. Patients and Methods We performed a retrospective review of 170 African American MM patients and 170 age-matched and gender-matched Caucasian patients initially seen at the M. D. Anderson Cancer Center from 1/1/2002 to 12/31/2008. Results Three hundred forty previously untreated patients were analyzed. Median age at diagnosis was 57 years for both groups. For evaluable patients, the International Staging System at diagnosis was determined. The percentage of stage I, II, and III patients in the African American group was 53%, 28%, and 19%, respectively. The percentage of stage I, II, and III patients in the Caucasian group was 40%, 30%, and 29%, respectively. These staging data were not significantly different between racial groups. In both groups, 89% of patients received a novel therapeutic agent (thalidomide, lenalidomide, or bortezomib) during their treatment course. We found a statistically significant difference in the percentage of African American and Caucasian patients who received high-dose chemotherapy and ASCT (65% and 76%, respectively; P = .04). There was no difference observed in the number of second transplantations performed in the two groups (19 in both groups). Response to therapy is detailed in Table 1 . There was no difference in overall response to any therapy of evaluable patients between the two groups. With a median follow-up time of 35 months, the median overall survival from diagnosis has not been reached in either group. Kaplan-Meir analysis shows that there is no difference in overall survival between African American and Caucasian patients (P = .1) Conclusion In this single-center, retrospective study of MM patients treated predominately with novel agents, with or without ASCT, no survival difference was observed between African American and Caucasian patients. To our knowledge, this is the largest number of African American myeloma patients analyzed for survival in a single-center study. Recognizing the potential disparities in healthcare access, this may not represent outcomes for all African American patients with myeloma. Since median overall survival has not been reached in this data, it is possible that survival differences will become apparent in the future, and further follow-up is needed. However, this review suggests that in the era of novel therapeutics and ASCT resulting in improved overall response rates, survival in African American patients may be equivalent to Caucasian patients. Further efforts are needed to enroll African American patients on clinical trials to validate this observation prospectively. Abstract 6 - Table 1 . Best Response to Any Therapy Race CR VGPR PR ORR African American 56/154 (36%) 15/154 (10%) 76/154 (49%) 147/154 (95%) Caucasian 57/162 (35%) 32/162 (20%) 64/162 (40%) 153/162 (94%)

Survival Disparities Between African-American and Caucasian Patients with Multiple Myeloma Are Blunted in the Era of Novel Therapeutics and Autologous Stem Cell Transplantation.

Abstract 1395Poster Board I-417 Background:Multiple myeloma accounts for approximately 10% of hematologic malignancies diagnosed annually in the U.S. It is well documented that the African-American population is disproportionately affected by multiple myeloma in incidence and mortality. Survival data from the SEER database from 2001-2005 demonstrated higher mortality in African-American patients compared to Caucasian patients. However, more recent retrospective reviews in the era of autologous stem cell transplant (ASCT) did not support this finding. Thus the persistence of racial survival disparities in the era of ASCT and novel therapeutics is an evolving question. Methods:We performed a retrospective review of 170 African-American multiple myeloma patients and 170 age and gender-matched Caucasian patients initially seen at the M.D. Anderson Cancer Center from 1/1/2002 to 12/31/2008. Results:Three hundred forty previously untreated patients were analyzed. Median age at diagnosis was 57 years for both groups. For evaluable patients, the International Staging System at diagnosis was determined. The percentage of stage I, II and III patients in the African-American group was 53%, 28% and 19% respectively. The percentage of stage I, II and III patients in the Caucasian group was 40%, 30% and 29% respectively. These staging data were not significantly different between racial groups. In both groups, 89% of patients received a novel therapeutic (thalidomide, lenalidomide or bortezomib) during their treatment course. We found a statistically significant difference in the percentage of African-American and Caucasian patients who received high dose chemotherapy and ASCT (65% and 76%, respectively, p=0.04). There was no difference observed in the number of second transplants performed in the two groups (19 in both groups). Response to therapy is detailed in Table 1. There was no difference in overall response to any therapy of evaluable patients between the two groups. With a median follow-up time of 35 months, the median overall survival from diagnosis has not been reached in either group. Kaplan-Meir analysis shows that there is no difference in overall survival between black and white patients (p =0.1) Conclusions:In this single-center, retrospective study of multiple myeloma patients treated predominately with novel agents, with or without ASCT, no survival difference was observed between African-American and Caucasian patients. To our knowledge, this is the largest number of African-American myeloma patients analyzed for survival in a single-center study. Recognizing the potential disparities in healthcare access, this may not represent outcomes for all African-American patients with myeloma. Since median overall survival has not been reached in this data, it is possible that survival differences will become apparent in the future, and further follow-up is needed. However, this review suggests that in the era of novel therapeutics and ASCT resulting in improved overall response rates, survival in African-American patients may be equivalent to Caucasian patients. Further efforts are needed to enroll African-American patients on clinical trials to validate this observation prospectively.Table 1Best Responses to Any TherapyRaceCRVGPRPRORRAfrican-American56/154 (36%)15/154 (10%)76/154 (49%)147/154 (95%)Caucasian57/162 (35%)32/162 (20%)64/162 (40%)153/162 (94%) Disclosures:No relevant conflicts of interest to declare.

Isosorbide dinitrate-hydralazine combination therapy in African Americans with heart failure.

Despite significant improvement in therapy and management, heart failure remains a worrisome disease state that is especially problematic in special populations. African Americans suffer a disproportionately higher prevalence of heart failure when compared to other populations. It has been recently demonstrated that vasodilator therapy using the combination of isosorbide dinitrate (ISDN) and hydralazine (HYD) as an adjunct to background evidence-based therapy appears to display the strongest signal of benefit in reducing mortality and morbidity in the African American population. Through review of the retrospective and more recent prospective data, we will focus on the benefit of ISDN-HYD as adjunctive therapy for use in African Americans with systolic heart failure on concomitant appropriate evidence based therapy. This review also closely examines some of the potential contributions to endothelial dysfunction in African Americans, and the relationship of vascular homeostasis and nitric oxide. The role of oxidative stress in left ventricular dysfunction will also be explored as a reduction of oxidative stress offers particular promise in the management of heart failure. Although neurohormonal blockade has been responsible for notable event reductions in patients with systolic heart failure, the addition of ISDN-HYD, vasodilator therapy that enhances nitric oxide and reduces oxidative stress, further improves quality of life and survival in African American patients with heart failure. These findings strongly imply that nitric oxide enhancement and/or oxidative stress reduction may be important new therapeutic directions in the management of heart failure.

Improved survival in HIV-infected African-Americans with ESRD

To determine if there has been improvement in survival of HIV-infected patients with end-stage renal failure subsequent to widespread use of highly active antiretroviral therapy. The United States Renal Data System is a national data system funded by the National Institute of Diabetes and Digestive and Kidney Disease with the Centers for Medicare and Medicaid. Using the United States Renal Data System Standard Analysis Files, we analyzed all African-American end-stage renal failure patients in the United States from 1990-2001. We compared survival rates for patients with HIV disease, sickle cell anemia, diabetes, and all other diagnoses for the time periods 1990-1994 and 1995-2001. The main outcome measure was one- and five-year survival in each cohort. One-year survival of African-American patients with end-stage renal disease and HIV increased from 46.6% during 1990-1994 to 65.1% during 1995-2001 (odds ratio 2.139). One-year survival decreased in the sickle cell group (odds ratio 0.595) and decreased slightly in the diabetic group (odds ratio 0.927) and all others (odds ratio 0.941). Five-year survival in the HIV group increased from 13.3% in 1990-1995 to 30.4% in 1995-2001 (odds ratio 2.847). There was no corresponding increase in survival for the sickle cell group (odds ratio 0.987), the diabetic group (odds ratio 1.06), or all others (odds ratio 1.137). We conclude that survival in African-American end-stage renal disease patients and HIV infection has substantially improved subsequent to introduction of highly active antiretroviral therapy. Our data support aggressive multi-drug treatment of end-stage renal failure patients with HIV infection.

Racial differences in the outcome of patients with colorectal carcinoma.

African-American (AA) patients with colorectal carcinoma have a worse prognosis compared with Caucasians. To analyze the causes of this disparity in survival, a retrospective study of patients with colorectal carcinoma was undertaken. The impact of treatments received and the role of socioeconomic factors such as income, education, and poverty levels were studied. A retrospective analysis of patients with colorectal carcinoma at a single institution was conducted. The overall survival of AA and Caucasians, stage at presentation, treatment received, and socioeconomic factors were analyzed using the institutional tumor registry and 1990 census data. The overall survival of AA patients was worse compared with Caucasians, both due to all causes (P < 0.001) and cancer-related deaths (P < 0.001). The relative risk of death due to all causes was 1.4 (95% confidence interval [CI] 1.2-1.8) for AA, 4.3 for patients with Stage IV disease (95% CI 3.2-5.7), and 2.3 for patients not undergoing surgery (95% CI 1.7-3.1). After multivariate adjustment for gender, site, socioeconomic factors, and therapeutic modalities, the relative risks for death were 1.5 (95% CI 1.2) for AA, 1.4 (95% CI 1.1-1.7) for patients 60 years of age or older, and 4.2 (95% CI 3.4-5.2) for Stage IV disease. The survival difference between AA and Caucasians was not influenced by income, poverty level, and education. African Americans were treated less frequently with chemotherapy and radiation therapy compared with their Caucasian counterparts. African American patients with colorectal carcinoma have a poorer prognosis compared with Caucasians. This discrepancy may be due to decreased utilization of chemotherapy and radiation therapy. Socioeconomic factors and lack of access to health care do not entirely explain the worse prognosis of AA. These factors should be identified and dealt with to improve the health care of AA patients with various malignant disorders.

Outcome of kidney transplantation in African-Americans using tacrolimus

The Results of kidney transplantation in African-Americans have improved with better immunosuppressive regimens, but the overall graft survival is reported by many to be inferior to that of non-Black recipients.1–3 The underlying impact of such factors as HLA matching, immunosuppressive regimes, socioeconomic status, or center effect has remained in question as many examine the underlying cause for the poorer graft survival.2,4 Our early experience with the use of tacrolimus has shown no difference in kidney allograft survival when compared to the non-Black recipients.5 We examine the outcome of the use of tacrolimus, a better immunosuppressive agent, to evaluate the effect of graft survival in African-American patients undergoing renal transplantation alone at the University of Pittsburgh. Minimum follow-up is 12 months.

Relationships between arterial hypertension and renal allograft survival in African-American patients

In previous studies, we showed that in African-American patients arterial hypertension during the first 6 months after transplantation is associated with a high risk of renal allograft loss. In this study, we sought to examine the relationships between pretransplant blood pressure (preBP), blood pressure early after transplantation (postBP), and allograft function and survival. The study included 116 African-American recipients of first cadaveric renal allografts followed for 64 ± 40 months. Prior to transplantation, 78% of the patients required antihypertensive medications and 59% had poorly controlled BP (average mean arterial pressure, ≥107 mm Hg). Blood pressure levels increased significantly during the first month posttransplant, particularly in patients with poorly controlled preBP. During the first 6 months posttransplant, 95% of patients required antihypertensive drugs; after the transplant, patients required significantly more and higher doses of antihypertensives compared with pretransplant. In 38% of the patients, postBP remained high despite therapy. The level of postBP correlated with the patient's weight pretransplant and with the level of preBP. Pretransplant BP correlated with postBP 1 month after transplantation ( r = 0.4, P < 0.0001), and 70% of the patients with poorly controlled postBP had uncontrolled preBP. Patients with poorly controlled preBP had worse graft survival than patients with well-controlled preBP ( P = 0.03 by Cox regression). Furthermore, compared with patients with well-controlled postBP, patients with high postBP had higher serum creatinine at 10 days ( P = 0.04) and at 6 months ( P = 0.0004) posttransplant; these patients had reduced graft survival ( P = 0.0006 by Cox). We found no objective evidence of differences in patient compliance between individuals with high postBP and those with well-controlled postBP. This study confirms the association between high postBP and reduced renal allograft survival in African-American patients. In addition, these results show that the level of preBP can be used to identify patients at high risk of developing severe hypertension immediately after transplantation and those at risk for renal allograft failure.