Population Studies and Disparities - Breast & Endometrial Cancer Research

Distribution and Determinants of Breast and Endometrial Cancer Risk, Survivorship and Outcomes

Molecular Markers & Breast Cancer in African Americans

While breast cancer incidence rates are higher among white women than among African American women, deaths due to breast cancer continue to be higher in African American than white women. Program members are examining molecular markers in benign lesions that increase breast cancer risk. Increased risk of subsequent breast cancer among African American women with previously diagnosed atypical hyperplasia was reported; however, African American women were diagnosed with atypical hyperplasia at younger ages compared to a white cohort. An association with breast cysts and the development of subsequent breast cancer in younger African American, which may be unique to the African American population was also noted. Program members are currently collaborating with researchers at Mayo Clinic—Jacksonville to examine gene expression profiles in paired benign and tumor tissue, along with “control” tissue to identify markers that may be associated with the transition from benign disease to cancer.

  • Lead Researcher: Dr. Cote 
  • Collaborative Researcher: Dr. Raferty, Mayo Clinic—Jacksonville
  • Grant: Komen IIR2222547

Triple Negative Breast Cancer in African Americans

Triple negative (TN) breast cancer is more frequently diagnosed in African American women than in white women and has been a focus of research among program members. Program members are examining breast cancer subtypes and their relationship to clinical outcomes in African American women through genome-wide expression profiling of TN tumors from African American women. From these data, the distribution of known and agnostically-derived TN subtypes will be estimated, as will differences in observed subtype distributions in African American women compared to distributions in European Americans. Program members are also exploring differences in disease free survival, overall survival, and breast cancer specific survival among TN subtypes in African American women.

  • Lead Researcher: Dr. Purrington
  • Grant: KCI ACS Institutional Research Award #11-053-01-IRG

Breast Density & Breast Cancer

We are uniquely positioned to study breast density as a risk factor for breast cancer. A collaborative research team are studying breast density and familial breast cancer risk. This work will address the lack of information regarding the implications of breast density for African American women compared to European American women. They are conducting a retrospective pilot study within the very large and racially diverse screening population at the Karmanos Cancer Center Breast Imaging Clinic. Using volumetric density measures for 3500 African American women and 3000 white women, they are characterizing race-specific differences in density patterns and resulting breast cancer risk. Based on these preliminary data, they propose to investigate the impact of breast density knowledge on communication and breast cancer screening practices within families.

  • Lead Researchers: Drs. Albrecht, Duric, Helmer, Manning and Purrington
  • Research Program Collaboration: Molecular Imaging

Inflammatory Breast Cancer Occurrence Based on Different Populations

Inflammatory breast cancer is relatively rare and an aggressive form of the disease. SEER registry coding of this subtype has changed over time presenting potential issues in the use of registry data to follow this disease. Program Members compared SEER reported coding of inflammatory breast cancer to clinical criteria reported in the medical records of 915 invasive breast cancer cases and found that clinical reporting in the medical record captured inflammatory breast cancer in 8.1% of cases, while SEER coding identified this subtype in only 2.1% of cases. While under-reporting is possible based on SEER data, no data are available on the occurrence of this disease subtype in Arab American populations. Dr. K. Schwartz, using the Arab surname algorithm she developed, reported that Arab Americans were 1.5-fold more likely to have inflammatory breast cancer than non-Hispanic whites (95% CI 1.2-1.9). Non-Hispanic Blacks (OR=1.3, 95% CI 1.2-1.4) and American Indians/Alaskans (OR=1.9, 95% CI 1.1-3.4) were also at increased risk, while Asians (OR=0.6 95% CI 0.6-0.7) were at decreased risk compared to non-Hispanic whites. These data suggest racial variation in risk factors for this aggressive disease. In evaluating racial disparities in breast cancer survival, program members reported that differences in receipt of adjuvant therapy by race were diminished after adjustment for racial differences in comorbidities and an index of neighborhood deprivation. This study suggests that factors other than race are impacting treatment delay. We have also been able to use the SEER registry to identify a subgroup of Orthodox Jewish women using geo-coding. While this approach may be somewhat crude, this population tends to cluster in particular neighborhoods. We identified high rates of breast cancer, but not ovarian cancer, in this population necessitating additional study of screening and risk behaviors.

  • Lead Researcher: Drs. Schwartz & Simon

Women's Health Initiative & Breast Cancer

Program members have participated in several ongoing, multi-center collaborative studies including the Women’s Health Initiative (WHI). The long term prospective follow-up data (up to 19 years) available in the WHI are well suited to address health related questions in postmenopausal women. Follow-up of 154,587 postmenopausal women identified 7,430 with breast cancer. Statins were used by 7.5% of the women at baseline and were not found to be associated with breast cancer incidence. Dr. Simon also led a team examining the relationship between mammography interval and breast cancer mortality among older women and found a strong need for continued mammography screening for women aged 75+ years. Longer term screening intervals (≥5 years or no prior mammograms) were associated with poorly differentiated, advanced stage and estrogen receptor negative tumors with an increased mortality risk. Karmanos investigators have participated in studies on the effect of sex hormone levels on breast cancer risk among women randomized to estrogen plus progesterone, racial and ethnic differences in the use of adjuvant hormonal therapy for early stage breast cancer, the effect of smoking and alcohol exposure on the risk of breast cancer subtypes, the interaction between smoking and obesity on the risk of breast cancer, the association between dietary glycemic load, glycemic index and carbohydrates on the risk of breast cancer and the relationship between prior non-melanomatous skin cancer and breast cancer risk. 

  • Lead Researcher: Dr. Simon 
  • Grant: WHI N01-WH-4-2118

Racial Disparities & Endometrial Cancer

The racial disparities seen in endometrial cancer survival are not fully explained by comorbid conditions; African American women diagnosed with endometrial cancer have a 2.3-fold higher risk of death from endometrial cancer than white women with the same diagnosis after adjustment for comorbid conditions. While in a larger, collaborative study with Memorial Sloan Kettering Cancer Institute, program members reported that African American women had poorer overall (HR=1.2) and disease-specific survival (HR=1.3) than white women adjusting for comorbidities. In morbidly obese women with endometrial cancer, hospital stays were longer among African American cases than white cases. In a comparison of clinical and pathologic features of endometrial cancer in women diagnosed under age 40 to those diagnosed at ages 40 or greater, women under age 40 had a higher BMI and a higher frequency of well differentiated endometrioid tumor that were less prone to deep myometrium invasion suggesting heterogeneity of this disease based on age. Among women with serous carcinomas, race was not an independent predictor of outcomes. In women with the most commonly diagnosed subtype of endometrial cancer (low grade endometrioid endometrial cancers), program members reported that tumors from African American women were more likely to harbor KRAS and PIK3CA mutations than those from white women,while women with endometriod tumors were 8-times more likely to have microsatellite instability than tumors from African American women. 

  • Lead Researcher: Dr. Cote

Intervention Research with African Americans to Reduce and Eliminate Disparities

Breast Cancer

Our research shows that a major cause of racial disparities in cancer treatment is poor communication in oncology visits between African American patients and their non-African American physicians; and second, that patient and oncologist racial attitudes contribute to this poor communication. In visits with African American patients, compared to visits with white patients, physicians spend less time planning treatment, providing health education, assessing health knowledge, engaging in informal conversation and providing treatment information. Further, African American patients participate less actively in the visits by asking fewer questions than white patients and less frequently bringing a companion to the visits, and they report less understanding of the topics discussed. Oncologists were shown to have implicit and explicit racial bias against African Americans; African American patients had higher levels of mistrust in their physicians and more concerns about discrimination than white patients. A randomized controlled trial is underway testing an intervention with breast cancer patients, developed using a community-engaged approach to improve the observed and patient reported quality of communication during the clinic visit, and the appropriateness, receipt, timing, and dosing of the treatment patients actually receive, using medical record data. Although data collection is ongoing, we have observed the video recorded clinic visits and conducted preliminary analyses of the effects of the intervention on the quality of communication.

  • Lead Researcher: Drs. Eggly and Penner
  • Grant: U54 CA153606

Intervention Research with the Ultra-Orthodox Jewish Community to Reduce and Eliminate Disparities

Breast Cancer

Our growing ultra-Orthodox Jewish population holds a strong cultural belief about cancer as a stigma on the family, which poses a serious barrier to access to screening, early detection and treatment. Supported by The Jewish Fund, program members are conducting a community based participatory pilot study designed to improve health knowledge and screening among ultra-Orthodox Jewish women. Using a community based participatory research approach, the survey phase of mahas has concluded. Four hundred and fifty randomly mailed surveys randomized to women in the community; the response rate was 58% (n= 260 women returned the survey). Working with local Jewish community organization, we have also had more than 100 women in the community contact us to participate in the health education program currently being piloted. In addition, program members have added the local Orthodox Jewish schools to engage in this project. On the national level they have engaged with a number of community collaborators in New York, including Bikur Cholim of Borough Park, Maimonides Hospital and Sharsheret (a national organization to education Jewish women about cancer) to educate Orthodox Jewish women about the importance of cancer screening.

  • Lead Researcher: Dr. Tkatch

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