Association of Serum Level of Vitamin D at Diagnosis With Breast Cancer Survival: A Case-Cohort Analysis in the Pathways Study.

IMPORTANCE: There are long-standing interests in the potential benefits of vitamin D for preventing breast cancer recurrence and mortality, yet data from prospective cohort studies are limited. OBJECTIVE: To investigate a serum biomarker of vitamin D status, 25-hydroxyvitamin D (25OHD) measured at the time of breast cancer diagnosis, to determine the association with prognosis. DESIGN, SETTING, AND PARTICIPANTS: The Pathways Study is a prospective cohort study of breast cancer survivors established in 2006. Enrollment was completed in 2013; follow-up is ongoing. The cohort was established in Kaiser Permanente Northern California, a large integrated health care delivery system in northern California. Women with a diagnosis of incident invasive breast cancer were typically consented and enrolled within 2 months of diagnosis. The overall enrollment rate was 46% (4505 of 9820). Participants are followed for health outcomes and comorbidities at 12, 24, 48, 72, and 96 months after baseline interview. A case-cohort design was used for efficiency assay of 25OHD, selecting 1666 cohort members with serum samples and ensuring representation in the subcohort of races and clinical subtypes. The data analysis was performed from January 5, 2014, to March 15, 2015. MAIN OUTCOMES AND MEASURES: Primary outcomes are breast cancer recurrence, second primary cancer, and death. RESULTS: Mean (SD) age was 58.7 (12.4) years. Serum 25OHD concentrations were lower in women with advanced-stage tumors, and the lowest in premenopausal women with triple-negative cancer. Levels were also inversely associated with hazards of disease progression and death. Compared with the lowest tertile, women with the highest tertile of 25OHD levels had superior overall survival (OS). This association remained after adjustment for clinical prognostic factors (hazard ratio [HR], 0.72; 95% CI, 0.54-0.98). Among premenopausal women, the association with OS was stronger, and there were also associations with breast cancer-specific survival and invasive disease-free survival (OS: HR, 0.45; 95% CI, 0.21-0.96; breast cancer-specific survival: HR, 0.37; 95% CI, 0.15-0.93; invasive disease-free survival: HR, 0.58; 95% CI, 0.34-1.01; all after full adjustment). CONCLUSIONS AND RELEVANCE: Serum 25OHD levels were independently associated with breast cancer prognostic characteristics and patient prognosis, most prominently among premenopausal women. Our findings from a large, well-characterized prospective cohort provide compelling observational evidence on associations of vitamin D with lower risk of breast cancer morbidity and mortality.

Impact of navigation on knowledge and attitudes about clinical trials among Chinese patients undergoing treatment for breast and gynecologic cancers.

Racial, ethnic and economic disparities in cancer rates, outcomes, and clinical trials participation persist despite significant research. We examined barriers to clinical trials enrollment among Chinese patients, and developed a navigation program for Chinese gynecologic and breast cancer patients. Six bilingual navigators were trained and a navigator assigned to each patient for at least 2 months. All patients received a clinical trials booklet in Chinese and English. Data collection included pre-and post-navigation surveys, intake forms, and documentation of navigation encounters. Between July 2010 and May 31, 2011, we recruited 28 breast and gynecologic cancer patients. Patients averaged 317 min of navigation (range 63-1,852) during 8 sessions (range 3-28). They improved in 4 of 10 true-false knowledge statements about clinical trials. A patient navigation program for Chinese-speaking cancer patients is feasible. It results in high patient satisfaction rates and modest improvements in clinical trials knowledge and participation.

Cancer research in Asian American, Native Hawaiian, and Pacific Islander populations: accelerating cancer knowledge by acknowledging and leveraging heterogeneity.

The Asian American, Native Hawaiian, and Pacific Islander population is large, growing, and extremely heterogeneous. Not only do they bear unique burdens of incidence and outcomes for certain cancer types, they exhibit substantial variability in cancer incidence and survival patterns across the ethnic groups. By acknowledging and leveraging this heterogeneity through investing in cancer research within these populations, we have a unique opportunity to accelerate the availability of useful and impactful cancer knowledge. See all the articles in this CEBP Focus section, "Cancer in Asian and Pacific Islander Populations."

Patient-physician interaction and quality of life in recently diagnosed breast cancer patients.

Few studies have explored how patient-physician interactions influence patients' quality of life (QOL). In a prospective cohort study of 1,855 women diagnosed with invasive breast cancer in the Kaiser Permanente Northern California Medical Care Program from 2006 to 2011, we examined associations between patient-physician interactions during cancer treatment and QOL, overall and by racial/ethnic group. Participants completed the interpersonal processes of care (IPC) survey at approximately 8 months post-diagnosis to assess specific domains of the patient-physician interaction during the months after cancer diagnosis. Domains included: compassion, elicited concerns, explained results, decided together, lack of clarity, discrimination due to race/ethnicity, and disrespectful office staff. The functional assessment of cancer therapy-breast cancer was completed concurrently to measure QOL. Linear regression models examined the association of IPC with QOL, first adjusting for patient covariates including age, race, clinical factors, and psychosocial measures and then for physician characteristics such as age, sex, race/ethnicity, and specialty. For all participants (n = 1,855), IPC scores suggesting greater lack of clarity, discrimination due to race/ethnicity, and disrespectful office staff in patient-physician interactions were associated with lower QOL (P< 0.01). IPC scores suggesting physicians demonstrating compassion, eliciting concerns, or explaining results were associated with higher QOL (P< 0.01). Among Whites (n = 1,306), only the associations with higher QOL remained. African Americans (n = 110) who reported higher scores on physician compassion and elicited concerns had higher QOL, whereas higher scores for disrespectful office staff had lower QOL. No associations were observed among Asians (n = 201) and Hispanics (n = 186). After further adjustment for physician factors, the associations among Whites remained, whereas those among African Americans disappeared. In the breast cancer treatment setting, characteristics of the patient-physician interaction as perceived by the patient are associated with QOL, yet were not specific to patient race/ethnicity.

Results of a randomized controlled trial testing the efficacy of a culturally targeted and a generic video on mammography screening among chinese-american immigrants.

BACKGROUND: Research comparing the effects of culturally targeted and generic but linguistically appropriate intervention programs is limited. We conducted a randomized controlled trial comparing the efficacy of a culturally targeted video, a generic video, and a fact sheet (control) in promoting mammography screening among Chinese-American immigrants. METHODS: We randomized 664 Chinese-American women from the Washington, DC, and New York City areas who were older than 40 years and nonadherent to annual mammography screening guidelines to three study arms (each with ∼221 women). The outcome was self-reported mammography screening 6 months post intervention. Measures of knowledge, Eastern cultural views, and health beliefs were administered before and after the intervention. RESULTS: The culturally targeted video, the generic video, and the fact sheet increased mammography use by 40.3%, 38.5%, and 31.1% from baseline, respectively. A significant intervention effect was observed only in one subgroup: The culturally targeted video significantly increased mammography screening among low-acculturated women over the fact sheet [OR, 1.70; 95% confidence interval (CI), 1.04-2.78]. Overall, women who obtained a mammogram during the follow-up period reported significantly fewer barriers to screening after intervention than those who had not obtained screening. Both of the video groups reported fewer barriers after intervention than the control group. CONCLUSIONS: Both theoretically guided videos increased the likelihood of mammography use to a similar extent. Cultural targeting was only effective for low-acculturated women. Both videos reduced perceived barriers to screening and consequently increased screening behavior. IMPACT: The results of this study provide empirical evidence on the efficacy of cultural targeting for minority immigrants.

Epidemiology of breast cancer subtypes in two prospective cohort studies of breast cancer survivors.

INTRODUCTION: The aim of this study was to describe breast tumor subtypes by common breast cancer risk factors and to determine correlates of subtypes using baseline data from two pooled prospective breast cancer studies within a large health maintenance organization. METHODS: Tumor data on 2544 invasive breast cancer cases subtyped by estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (Her2) status were obtained (1868 luminal A tumors, 294 luminal B tumors, 288 triple-negative tumors and 94 Her2-overexpressing tumors). Demographic, reproductive and lifestyle information was collected either in person or by mailed questionnaires. Case-only odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression, adjusting for age at diagnosis, race/ethnicity, and study origin. RESULTS: Compared with luminal A cases, luminal B cases were more likely to be younger at diagnosis (P = 0.0001) and were less likely to consume alcohol (OR = 0.74, 95% CI = 0.56 to 0.98), use hormone replacement therapy (HRT) (OR = 0.66, 95% CI = 0.46 to 0.94), and oral contraceptives (OR = 0.73, 95% CI = 0.55 to 0.96). Compared with luminal A cases, triple-negative cases tended to be younger at diagnosis (P < or = 0.0001) and African American (OR = 3.14, 95% CI = 2.12 to 4.16), were more likely to have not breastfed if they had parity greater than or equal to three (OR = 1.68, 95% CI = 1.00 to 2.81), and were more likely to be overweight (OR = 1.82, 95% CI = 1.03 to 3.24) or obese (OR = 1.97, 95% CI = 1.03 to 3.77) if premenopausal. Her2-overexpressing cases were more likely to be younger at diagnosis (P = 0.03) and Hispanic (OR = 2.19, 95% CI = 1.16 to 4.13) or Asian (OR = 2.02, 95% CI = 1.05 to 3.88), and less likely to use HRT (OR = 0.45, 95% CI = 0.26 to 0.79). CONCLUSIONS: These observations suggest that investigators should consider tumor heterogeneity in associations with traditional breast cancer risk factors. Important modifiable lifestyle factors that may be related to the development of a specific tumor subtype, but not all subtypes, include obesity, breastfeeding, and alcohol consumption. Future work that will further categorize triple-negative cases into basal and non-basal tumors may help to elucidate these associations further.

Complementary and alternative therapy use before and after breast cancer diagnosis: the Pathways Study.

Many women use complementary and alternative medicine (CAM) to maintain or improve their health. We describe CAM use among the first 1,000 participants enrolled in the Pathways Study, an ongoing prospective cohort study of women diagnosed with breast cancer (BC). Participants, identified by rapid case ascertainment in Kaiser Permanente Northern California, are women > or = 21 years diagnosed with first invasive BC. Comprehensive baseline data are collected on CAM use through in-person interviews. Study participants include 70.9% non-Hispanic whites, 10.2% Hispanics, 9.0% Asians, 6.5% African-Americans, and 3.4% others. Most women (82.2%) were diagnosed with AJCC stage I/II BC at average (+/-SD) age 59.5 (+/-12.0) years and reported prior use of at least one form of CAM (96.5% of participants). In the 5 years before diagnosis, CAM therapies used at least weekly by >20% of women included green tea, glucosamine, omega-3 fatty acids, prayer and religion. CAM use was high (86.1% of participants) in the period immediately following diagnosis; 47.5% used botanical supplements, 47.2% used other natural products, 28.8% used special diets, 64.2% used mind-body healing, and 26.5% used body/energy/other treatments. In multivariable analyses, frequent use of each CAM modality before and after diagnosis was associated with use of other CAM modalities and other health behaviors (i.e., high fruit/vegetable intake, lower BMI). CAM use before and after BC diagnosis is common in this diverse group of women. Our results emphasize the need for clinicians to discuss CAM use with all BC patients.

Dietary patterns using Traditional Chinese Medicine principles in epidemiological studies.

Dietary intake and nutritional factors have been shown to be associated with many chronic diseases, such as heart disease, obesity, diabetes, and cancer. There are many approaches to studying dietary intake in relationship to disease; each approach has its strengths and weaknesses. Examples of different methods of studying dietary patterns will be reviewed. In most cultures, consumed and preferred foods are based on cultural and societal influence. Thus, it is important to consider dietary patterns within the context of culture in addition to the standard nutrients or food groupings approach. Traditional Chinese Medicine (TCM) offers another dimension to food analysis. Our approach classifies dietary intake based on Traditional Chinese Medicine principles of yin and yang, hot and cold, and acidic and alkaline forming food concepts in a case-control study of dietary factors and breast cancer. Our results complement previously reported findings of an increased risk of breast cancer associated with dietary fats in Taiwanese women. Our discussion will focus on the implication of using this dietary pattern research and the challenge of combining this research with culturally sensitive messages to improve health. Our ultimate goal is to design an intervention strategy for disease prevention and health promotion that is culturally appropriate for specific populations.

The Pathways Study: a prospective study of breast cancer survivorship within Kaiser Permanente Northern California.

OBJECTIVE: With 2.3 million breast cancer survivors in the US today, identification of modifiable factors associated with breast cancer recurrence and survival is increasingly important. Only recently new studies have been designed to examine the impact of lifestyle factors on prognosis, including Pathways, a prospective study of women with breast cancer in Kaiser Permanente Northern California (KPNC). METHODS: Pathways aims to examine the effect on recurrence and survival of (1) lifestyle factors such as diet, physical activity, quality of life, and use of alternative therapies and (2) molecular factors such as genetic polymorphisms involved in metabolism of chemotherapeutic agents. Eligibility includes any woman diagnosed with invasive breast cancer within KPNC, no previous diagnosis of other invasive cancer, age 21 years or older, and ability to speak English, Spanish, Cantonese, or Mandarin. Newly diagnosed patients are identified daily from electronic pathology records and are enrolled within two months of diagnosis. An extensive baseline interview is conducted, blood and saliva samples are collected, and body measurements are taken. Women are followed for lifestyle updates, treatment, and outcomes by self-report and query of KPNC databases. RESULTS: Recruitment began in 9 January, 2006, and as of 16 January, 2008, 1,539 women have been enrolled along with collection of 1,323 blood samples (86%) and 1,398 saliva samples (91%). CONCLUSIONS: The Pathways Study will become a rich resource to examine behavioral and molecular factors and breast cancer prognosis.

Dietary assessment in the California Teachers Study: reproducibility and validity.

OBJECTIVE: To evaluate the reproducibility and validity of the food-frequency questionnaire (FFQ) used in the California Teachers Study (CTS) cohort and to use this data to quantify the effects of correcting nutrient-breast cancer relative risks for measurement error. METHODS: One hundred and ninety five CTS cohort members participated in a 10-month dietary validation study that included four 24-h dietary recalls and pre- and post-study FFQs. Shrout-Fleiss intraclass correlations for reproducibility were computed. Under several standard assumptions concerning the correlations of errors in the FFQs and 24-h recalls, we calculated energy-adjusted deattenuated Pearson correlations for validity and tested for differences in validity according to a number of demographic and other risk factors. For each nutrient, we compared the performance of the FFQ versus the 24-h recalls, estimating the number of days of recalls that give equivalent information about true intake as does a single FFQ. Finally, the effects of adjustment for measurement error on risk estimates were evaluated in 44,423 postmenopausal cohort members, 1,544 of whom developed breast cancer during seven years of follow-up. Relative risks (RR) and confidence intervals (CI) were calculated using Cox proportional hazards with and without correction for measurement error. RESULTS: Reproducibility correlations for the nutrients ranged from 0.60 to 0.87. With a few exceptions, validity correlations were reasonably high (range: 0.55-0.85), including r = 0.74 for alcohol. Performance of the FFQ differed by age for percent of calories from fat and by body mass index and hormone therapy use for alcohol consumption. For most nutrients examined, our FFQ is comparable to two to six recalls for each subject in capturing true intake. In the measurement error-adjusted risk analyses, corrected RRs were within 13% of uncorrected values for all nutrients examined except for linoleic acid. For alcohol consumption the corrected RR (per 20 g/1,000 kcal/d) was 1.36 (95% CI: 1.03-1.51) compared to the uncorrected estimate of 1.25 (95% CI: 1.10-1.42). CONCLUSION: The FFQ dietary assessment used in the CTS is reproducible and valid for all nutrients except the unsaturated fatty acids. Correcting relative risk estimates for measurement error resulted in relatively small changes in the associations between the majority of nutrients and the risk of postmenopausal breast cancer.

Development and evaluation of a culturally tailored educational video: changing breast cancer-related behaviors in Chinese women.

This study developed and evaluated a culturally tailored video guided by the health belief model to improve Chinese women's low rate of mammography use. Focus-group discussions and an advisory board meeting guided the video development. A 17-min video, including a soap opera and physician-recommendation segment, was made in Chinese languages. A pretest/posttest pilot was conducted to evaluate the efficacy of the video in changing knowledge, beliefs, and screening intentions among Chinese women (age >or= 40) who were nonadherent to current National Cancer Institute's mammography guidelines (n=52). The results showed that the video significantly increased these women's screening intentions, knowledge, perceived risk for breast cancer, and perceived benefits of mammography. Chinese immigrant women were less likely to hold an Eastern view of health care and report barriers to screening after viewing the video. This video might have the potential to increase adherence to mammography screening in Chinese women.

Lifestyle factors and survival in women with breast cancer.

With increasing longevity and more effective cancer therapies, the population of cancer survivors is increasing. For example, it is estimated that there are over 2 million breast cancer survivors in the United States. Among cancer survivors and their families, there is substantial interest in whether there is anything that they can do beyond conventional therapy to improve their prognosis. Chief among these is interest in diet and use of complementary and alternative therapies. Despite this interest, there is surprisingly little that is known about the effects of these factors on cancer survival. This is in part because of the usual approach to research on diet and breast cancer in human populations. Studies that have had food and nutrition as a main interest have focused almost exclusively on cancer etiology and prevention; there are literally hundreds of such studies. Meanwhile, studies of populations after a breast cancer diagnosis have rarely considered lifestyle factors. Such studies have focused largely on therapeutics, such as effects of different chemotherapy regimens, or prognostic factors, such as the effects of stage of disease, hormone receptor status, or gene expression signatures on prognosis. To the extent that lifestyle factors have been a focus of cancer prognosis studies, they have often been aimed at the question of whether they impact quality of life, and not on whether they influence cancer survival or recurrence. There have been a handful of studies that have had lifestyle factors such as diet and physical activity as a principal focus. In addition to 2 randomized trials, the Women's Intervention Nutrition Study (WINS) and the Women's Healthy Eating and Living Study, there are at least 5 ongoing prospective cohort studies in breast cancer survivors that have diet as a main focus. Although these studies differ in various aspects, they are all aimed at examining whether differences in diet may result in differences in recurrence and mortality rates. One such study, the Pathways Study, is a prospective cohort study that began recruitment of study participants in early 2006. This study is unique in that it is enrolling women as soon after breast cancer diagnosis as is practical, whereas other studies have generally enrolled women after completion of adjuvant therapy or later. This and other studies promise to provide some of the first objective information regarding diet and breast cancer prognosis and serve as models for studies of diet and prognosis of other cancers.

Improved survival of Asians with corpus cancer compared with whites: an analysis of underlying factors.

OBJECTIVE: To compare the clinicopathologic prognosticators and survival of Asians and whites with corpus cancer. METHODS: Demographic, clinicopathologic, and survival data were obtained from the 1992-2001 Surveillance, Epidemiology, and End Results Program. Statistical analyses were performed by Kaplan-Meier methods and Cox proportional hazards model. RESULTS: A total of 2,144 Asians and 32,999 whites with corpus cancer were identified. The age-adjusted incidence of uterine cancer in Asians compared with whites was 16.8 compared with 26.1 per 100,000. Asians presented at a younger age (mean 58.4 years compared with 65.1; P < .01) and with more advanced stage disease than whites (21.5% compared with 15.4%; P < .01). The 5-year survival rate for Asians was 79.4% compared with 75.2% for whites (P < .01). Asians with stage I-II and III-IV cancers had 5-year survival rates of 89.3% and 41.2% compared with 82.3% and 34.0% for the whites, respectively (P < .01, early stage; P < .01, advanced stage). The survival advantage of Asians persists in endometrioid (P < .01) and uterine papillary serous carcinomas (P < .01), but not in clear cell carcinoma (P = .62) or sarcomas (P = .78). In multivariate analysis, younger age (P < .01), earlier stage (P < .01), favorable histology (P < .01), and lower grade (P < .01) remained as significant independent prognosticators for improved survival. However, race was not an important prognosticator. CONCLUSION: The overall survival advantage experienced by Asians with uterine cancer is attributable to their younger age at diagnosis. Because Asian women present at a younger age with more advanced disease, physicians should have an increased index of suspicion for malignancy in young Asian women with suspicious symptoms and consider a lower age threshold for biopsy in this group. LEVEL OF EVIDENCE: II-2.

Reliability and validity of an assessment of usual phytoestrogen consumption (United States).

OBJECTIVE: To evaluate the reliability and validity of a food-frequency questionnaire (FFQ) and database designed to quantify phytoestrogen consumption. METHODS: This study included 195 members of the California Teachers Study (CTS) cohort who, over a 10-month period, completed four 24-h dietary recalls, a pre- and post-study FFQ, and provided two 24-h urine specimens. Participants (n = 106) in a parallel study (and 18 women who dropped out of the long-term study) completed a single recall and FFQ, and provided one 24-h urine specimen. Urinary phytoestrogens were determined using liquid chromatography-mass spectrometry. Reliability and validity were evaluated using Shrout-Fleiss intraclass correlations and energy-adjusted deattenuated Pearson correlations, respectively. RESULTS: Correlations reflecting the reproducibility of the FFQ phytoestrogen assessment ranged from 0.67 to 0.81. Validity correlations (FFQ compared to dietary recalls) ranged from 0.67 to 0.79 for the major phytoestrogenic compounds (i.e., daidzein, genistein, and secoisolariciresinol) and 0.43 to 0.54 for the less common compounds. Compared to urinary levels, validity correlations ranged from 0.41 to 0.55 for the isoflavones and 0.16 to 0.21 for total lignans. CONCLUSION: Our isoflavone assessment is reproducible, valid, and an excellent tool for evaluating the relationship with disease risk in non-Asian populations. Further research is needed before these tools can accurately be used to assess lignan consumption.

Breast cancer and dietary factors in Taiwanese women.

OBJECTIVES: To examine the effect of the consumption of dietary factors on the risk of breast cancer in a case-control study in Taiwan. METHODS: Two-hundred-and-fifty cases and 219 age-matched controls between the ages of 25 and 74 were interviewed in person between 1996 and 1999. Usual consumption of dietary habits including 100 foods was assessed using a food frequency questionnaire and a nutrient database developed and validated in Taiwanese populations. RESULTS: Cases consumed significantly more fat than controls. Cases also consumed statistically significant less supplements such as vitamins and mineral than controls. Food group analyses showed that highest quartile of beef and pork intake significantly increased risk in younger women (OR = 2.5, 95% CI = 1.0-6.0) and all women (OR = 2.5, 95% CI = 1.1-3.3). The age- education- and total calorie-adjusted odds ratio (OR) of breast cancer risk comparing the highest and second highest quartile of fat intake to the lowest quartile was 5.1, 95% confidence interval (CI): 2.1-13 and 3.5, 95% CI: 1.4-8.7 among those younger cases (< or =40). A multiple regression model indicates a protective effect of supplements (OR: 0.40, 95% CI: 0.3-07) and a harmful effect of dietary fat (OR: 2.6, 95% CI: 1.4-5.0) for the highest versus lowest quartile in all women. CONCLUSIONS: Our results indicate a strong protective effect of dietary supplements and a harmful effect of dietary fats on the risk of breast cancer among women in Taiwan. These findings should be confirmed in future follow-up studies. Specific amount of dietary supplements and dietary fats should be quantified for a more accurate evaluation on the risk for breast cancer in this population.

Potential mechanisms for altered iron metabolism in human immunodeficiency virus disease.

Recently, anemia associated with human immunodeficiency virus (HIV) disease has received more attention as our understanding of the significance of anemia in this population has grown and more emphasis is placed on the quality of life of people living with HIV/AIDS. Although the diagnosis and treatment of anemia in HIV disease has been discussed in great detail, the prevalence and pathophysiology of the two most common forms of anemia, iron deficiency anemia (IDA) and the anemia of chronic disease (ACD), have not received much attention despite the difficulty and importance of differentiating between these two anemias. In addition, little attention has been given to iron overload, which has serious implications in individuals with HIV disease. This article proposes a model of altered iron metabolism in HIV disease as a basis for explaining the pathophysiology and implications of IDA, ACD, and iron overload in this population. Implications for clinical practice and recommendations for future research are discussed.

Immigration and acculturation in relation to health and health-related risk factors among specific Asian subgroups in a health maintenance organization.

OBJECTIVES: We sought to determine how risk factors for disease vary among Asian subgroups. METHODS: Using data from a case-control study conducted at Northern California Kaiser Medical Centers (from 1996 to 2001), we compared prevalence of selected risk factors among Asian subgroups and evaluated the associations of these risk factors with sociodemographic factors. RESULTS: Chinese and Japanese patients had a lower body mass index (kg/m(2)) than did other Asians. In all subgroups, being born in the United States was associated with having a body mass index greater than 25 kg/m(2). Compared with other Asians, more Japanese and multiple-race Asians smoked, and more Filipino and multiple-race Asian smokers started smoking at 18 years or younger. Filipinos and multiple-race Asians also were more likely to report diabetes. CONCLUSIONS: These data support the importance of efforts to distinguish among Asian subgroups in public health practice and research.

Bias in completeness of birthplace data for Asian groups in a population-based cancer registry (United States).

Data on place of birth are routinely collected by population-based cancer registries in the United States and are used to study effects of immigration on cancer patterns in Asian migrants, who comprise about a quarter of the US immigrant population. However, the quality of this research, which has the potential for informing cancer etiology and control, is unclear because registry birthplace information is incomplete, and its accuracy has not been examined. We quantified misclassification of birthplace data for Asian cancer patients in the Greater Bay Area Cancer Registry in northern California by comparing registry birthplace information with self-reported birthplace from interview, and then identified sociodemographic and hospital characteristics associated with birthplace completeness and misclassification. Of the 1836 eligible Asian patients, 649 (35%) had unrecorded registry birthplace. For all except Vietnamese, these persons were less likely than those with recorded birthplace to be foreign-born (OR = 0.5, 95% CI = 0.4-0.7), to be diagnosed in public than private hospitals (OR = 0.7, 95% CI = 0.5-0.8) and in teaching than non-teaching hospitals (OR = 0.8, 95% CI = 0.6-1.1), and were more likely to have been diagnosed at a large regional health maintenance organization (OR = 1.7, 95% CI = 1.3-2.2) and after 1995 (OR = 1.6, 95% CI = 1.1-2.1). Among Asians with registry birthplace information (n = 1187), sensitivity and predictive value positive for birthplace exceeded 90% for both US- and foreign-born, except for Japanese (predictive value positive = 85.7%). Among US-born Asians, those misclassified as foreign-born were more likely than those correctly classified to prefer a non-English primary language (OR = 29.4, 95% CI = 1.9-459.9). These results suggest that cancer registry birthplace data for Asians should not be used if they continue to be differentially incomplete for a large proportion of the subjects.

Socioeconomic status, immigration/acculturation, and ethnic variations in breast conserving surgery, San Francisco Bay area.

OBJECTIVE: Previous studies have demonstrated substantial variations in breast conserving surgery (BCS) across sociodemographic groups. This study explored the joint influences of socioeconomic, immigration/acculturation, and clinical factors on ethnic differences in breast cancer surgery for early-stage disease. DESIGN: The study used interview data for 297 women, under the age of 70, who resided in the San Francisco Bay area, and had been diagnosed with primary early-stage breast cancer (carcinoma in-situ or invasive) between January 1990 and December 1992. RESULTS: The proportion of patients who either had undergone BCS or had no surgery was 45%, 20%, 45%, and 34%, among Whites, Chinese, Blacks, and Hispanics, respectively. The proportion of patients diagnosed at in-situ or localized stages, with tumors of less than 4 centimeters, was higher among those who received BCS or no surgery, compared to those who had undergone a mastectomy. White women who received BCS/no surgery tended to be younger than their counterparts who underwent mastectomies, but Chinese and Black women who received BCS/no surgery were older. The proportion of women diagnosed in smaller, private hospitals was higher among those receiving BCS/no surgery, although these associations varied by ethnicity. Women who had undergone BCS/no surgery were characterized as being of higher socioeconomic status, more acculturated, and less likely to be recent immigrants. In a multivariate regression model adjusting for clinical, socioeconomic, and immigration/acculturation factors, Chinese women were more likely than Whites to have a mastectomy, rather than BCS/no surgery (odds ratio, 2.8; 95% confidence interval, 1.0-7.8). CONCLUSIONS: Use of BCS or no surgery was associated with various clinical, socioeconomic, and immigration/acculturation characteristics, although some of the associations varied by ethnicity. However, these factors did not account for the reduced presence of BCS, or no surgery, among Chinese women.