Cancer Screening in Low- and Middle-Income Countries.

The worldwide cancer burden is growing, and populations residing in low- and middle-income countries (LMICs) are experiencing a disproportionate extent of this growth. Breast, colorectal, and cervical cancers are among the top 10 most frequently diagnosed malignancies, and they also account for a substantial degree of cancer mortality internationally. Effective screening strategies are available for all three of these cancers. Individuals from LMICs face substantial cost and access barriers to early detection programs, and late stage at diagnosis continues to be a major cause for cancer mortality in these communities. This chapter will review the epidemiology of breast, colorectal, and cervical cancers, and will explore prospects for improving global control through novel approaches to screening in cost-constrained environments.

Landmark Series: The Cancer Genome Atlas and the Study of Breast Cancer Disparities.

Race-related variation in breast cancer incidence and mortality are well-documented in the United States. The effect of genetic ancestry on disparities in tumor genomics, risk factors, treatment, and outcomes of breast cancer is less understood. The Cancer Genome Atlas (TCGA) is a publicly available resource that has allowed for the recent emergence of genome analysis research seeking to characterize tumor DNA and protein expression by ancestry as well as the social construction of race and ethnicity. Results from TCGA based studies support previous clinical evidence that demonstrates that American women with African ancestry are more likely to be afflicted with breast cancers featuring aggressive biology and poorer outcomes compared with women with other backgrounds. Data from TCGA based studies suggest that Asian women have tumors with favorable immune microenvironments and may experience better disease-free survival compared with white Americans. TCGA contains limited data on Hispanic/Latinx patients due to small sample size. Overall, TCGA provides important opportunities to define the molecular, biologic, and germline genetic factors that contribute to breast cancer disparities.

Does the Type of Reconstruction Matter? A Propensity Score Analysis of Immediate Postmastectomy Implant and Flap Reconstruction.

BACKGROUND: No randomized controlled trials have compared implant and flap reconstruction. Recently, worse longitudinal outcomes have been suggested for flap reconstruction. The authors compared long-term oncologic outcomes of postmastectomy breast reconstruction using propensity score matching. METHODS: A retrospective study of postmastectomy reconstruction was achieved using the Weill Cornell Breast Cancer Registry between 1998 and 2019. Patients were matched using propensity scores based on demographic, clinical, and surgical characteristics. Kaplan-Meier estimates, Cox-regression models, and restricted mean survival times (RMST) were used to evaluate patient outcomes. RESULTS: Before matching, 1395 implant and 586 flap patients were analyzed. No difference in overall survival and recurrence were observed. Multivariable models showed decreased survival for Medicare/Medicaid [hazard ratio (HR), 3.09; 95% CI, 1.63 to 5.87; P < 0.001], pathologic stage II (HR, 2.98; 95% CI, 1.12 to 7.90; P = 0.028), stage III (HR, 4.88; 95% CI, 1.54 to 15.5; P = 0.007), 11 to 20 lymph nodes positive (HR, 3.66; 95% CI, 1.31 to 10.2; P = 0.013), more than 20 lymph nodes positive (HR, 6.41; 95% CI, 1.49 to 27.6; P = 0.013). RMST at 10 years after flap reconstruction showed 2 months of decreased survival time compared with implants (9.56 versus 9.74 years; 95% CI, -0.339 to -0.024; P = 0.024). After matching, 563 implant and 563 flap patients were compared. Reconstruction was not associated with overall survival and recurrence. RMST between implant and flap reconstruction showed no difference in each 5-year interval over 20 years. CONCLUSION: Postmastectomy breast reconstruction was not associated with a difference in long-term oncologic outcomes over a 20-year period. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Global Macroeconomic Burden of Breast Cancer: Implications for Oncologic Surgery.

OBJECTIVE: In this study, we quantified the global macroeconomic burden of breast cancer to underscore the critical importance of improving access to oncologic surgical care internationally. SUMMARY BACKGROUND DATA: Breast cancer mortality in many low and middle-income countries (LMICs) is dramatically higher than in high-income countries. Prior to identifying solutions, however, it is important to first define the burden of disease. METHODS: Data from the Institute of Health Metrics and Evaluation (2005-2015) were used to assess epidemiologic trends for 194, middle, and low-income countries. Economic burden defined by Welfare Loss (WL) was calculated by measuring disability-adjusted-life-years lost to breast cancer alongside the dollar equivalent of a value of statistical life year and as a function of each country's gross domestic product (GDP). RESULTS: Annual mortality rates among breast cancer patients were significantly greater in LMICs in South Asia (3.06 per 100 women) and Sub-Saharan Africa (2.76 per 100 women), compared with high-income countries like the United States (1.69 per 100 women). From 2005-2015, mortality in South Asia increased by 8.20% and decreased by 6.45% in Sub-Saharan Africa; mortality rates in 2015 were observed as 27.9 per 100,000 in South Asia and 18.61 per 100,000 in Sub-Saharan Africa. Countries in South Asia demonstrated the greatest rise in WL due to breast cancer, from 0.05% to 0.08% of GDP. CONCLUSIONS: The burden of disease and economic impact of breast cancer is intensifying in LMICs. Global efforts to improve access to surgical care for women with breast cancer could reduce mortality and mitigate the social and financial impact of this disease in LMICs.

Similarities in Risk for COVID-19 and Cancer Disparities.

Coronavirus disease 2019 (COVID-19) is a novel infectious disease that has spread worldwide. In the United States, COVID-19 disproportionately affects racial and ethnic minorities, particularly African Americans, with an observed 2-fold higher rate for hospitalization and greater than 2-fold higher rate for death as compared with White Americans. The disparity seen with COVID-19 is consistent with patterns of disparities observed for cancer; it is well documented that 5-year survival rates for multiple cancers are lower in African Americans compared with White Americans. Root cause contributions for the disparity overlap between COVID-19 and cancer. While cancer is a genetic disease that is influenced by tissue microenvironment, COVID-19 is an infectious disease that is enabled by cellular expression of angiotensin-converting enzyme 2 receptors. However, socioeconomic disadvantages, level of education, lifestyle factors, health comorbidities, and limited access to medical care appear to fuel underlying risk for both cancer and COVID-19 disparities. In addition to African Americans demonstrating higher risk of acquiring and dying from either disease, they are underrepresented in clinical trials involving cancer or COVID-19. Long-term disparities are present with survivorship from cancer and may be likely with survivorship from COVID-19; both have revealed untoward effects on postdiagnosis economic viability for African Americans. Collaborative strategies that include community engagement, diverse participation in cancer and COVID-19 clinical trials, providing insurance for affected persons who lost employment due to either disease, and supporting safety-net and public hospitals for health care access will be critical to stem these disparities.

Triple-Negative Breast Cancer, Stem Cells, and African Ancestry.

Triple-negative breast cancers (TNBCs) are more common among African-ancestry populations, such as African Americans and western, sub-Saharan Africans, compared with European-ancestry populations. This phenotype prevalence contributes to disparities in breast cancer outcomes between African Americans and White Americans. Breast cancer stem cells represent the tumor subpopulation involved in metastatic virulence, and ongoing research seeks to characterize the extent to which TNBC versus non-TNBC stem cells may differ. This review summarizes the existing literature regarding TNBCs and stem cells as they pertain to the burden of breast cancer among African-ancestry populations. Additional research related to variations in somatic tumor genomics between the African-American and White-American populations is also summarized. This review furthermore explores the history of insights regarding breast cancer disparities related to racial/ethnic identity, socioeconomic status, and tumor biology.

Breast Cancer Disparities: Socioeconomic Factors versus Biology.

Disparities in poverty and health care access barriers have a negative impact on the health and wellness of population subsets that bear a disproportionate share of these socioeconomic disadvantages, such as African Americans and Hispanic/Latina Americans. The more advanced stage distribution of breast cancer in these two population subsets is likely related to imbalance in distribution of socioeconomic resources in the United States. However, differences in the breast cancer burden of population subsets defined by racial/ethnic identity are also influenced by race/ethnicity-associated variation in tumor biology and hereditary susceptibility. Compared with white Americans, African-American women have higher population-based breast cancer mortality rates, which are at least partly explained by an increased risk for the biologically aggressive triple-negative phenotype. International studies correlate West African ancestry with predisposition for triple-negative breast cancer. In contrast, Hispanic/Latina Americans have lower population-based incidence and mortality rates for breast cancer despite their increased rates of socioeconomic challenges. Genetic studies suggest that extent of Native American ancestry among Hispanic/Latina women may reduce breast cancer risk. Eradication of disparate access to breast cancer early detection and treatment strategies is a public health imperative, but research to elucidate the genetics of breast cancer related to racial/ethnic identity is equally important as we strive to comprehensively define this complex disease.

Health Disparities and Triple-Negative Breast Cancer in African American Women: A Review.

Importance: Variation in cancer incidence and outcome has well-documented correlations with racial/ethnic identity. In the United States, the possible genetic and ancestral hereditary explanations for these associations are confounded by socioeconomic, cultural, and lifestyle patterns. Differences in the breast cancer burden of African American compared with European/white American women represent one of the most notable examples of disparities in oncology related to racial/ethnic identity. Elucidating the source of these associations is imperative in achieving the promise of the national Precision Medicine Initiative. Observations: Population-based breast cancer mortality rates have been higher for African American compared with white American women since the early 1980s, largely reflecting declines in mortality that have been disproportionately experienced among white American patients and at least partly explained by the advent of endocrine therapy that is less effective in African American women because of the higher prevalence of estrogen receptor-negative disease. The increased risk of triple-negative breast cancer in African American women as well as western, sub-Saharan African women compared with white American, European, and east African women furthermore suggests that selected genetic components of geographically defined African ancestry are associated with hereditary susceptibility for specific patterns of mammary carcinogenesis. Disentangling health care access barriers, as well as reproductive, lifestyle, and dietary factors from genetic contributions to breast cancer disparities remains challenging. Epigenetics and experiences of societal inequality (allostatic load) increase the complexity of studying breast cancer risk related to racial/ethnic identity. Conclusions and Relevance: Oncologic anthropology represents a transdisciplinary field of research that can combine the expertise of population geneticists, multispecialty oncologists, molecular epidemiologists, and behavioral scientists to eliminate breast cancer disparities related to racial/ethnic identity and advance knowledge related to the pathogenesis of triple-negative breast cancer.

Disparities in breast cancer and african ancestry: a global perspective.

Recognition of breast cancer disparities between African-American and White American women has generated exciting research opportunities investigating the biologic and hereditary factors that contribute to the observed outcome differences, leading to international studies of breast cancer in Africa. The study of breast cancer in women with African ancestry has opened the door to unique investigations regarding breast cancer subtypes and the genetics of this disease. International research efforts can advance our understanding of race/ethnicity-associated breast cancer disparities within the USA; the pathogenesis of triple negative breast cancer; and hereditary susceptibility for breast cancer.

Breast cancer disparities: high-risk breast cancer and African ancestry.

African American women have a lower lifetime incidence of breast cancer than white/Caucasian Americans yet have a higher risk of breast cancer mortality. African American women are also more likely to be diagnosed with breast cancer at young ages, and they have higher risk for the biologically more aggressive triple-negative breast cancers. These features are also more common among women from western, sub-Saharan Africa who share ancestry with African Americans, and this prompts questions regarding an association between African ancestry and inherited susceptibility for certain patterns of mammary carcinogenesis.

Development of an intraoperative pathology consultation service at a free-standing ambulatory surgical center: clinical and economic impact for patients undergoing breast cancer surgery.

BACKGROUND: Second surgeries represent a significant detriment to breast cancer patients. We examined the impact an intraoperative pathology consultation service had on multiple facets of breast cancer surgery. METHODS: We compared the 8 months before the establishment of a pathology laboratory, when intraoperative pathology consultation was not available, with the 8 months subsequent, when it was performed routinely. RESULTS: The average number of surgeries per patient decreased from 1.5 to 1.23, and the number of patients requiring one surgery increased from 59% to 80%. Re-excisions decreased from 26% to 9%. Frozen section allowed 93% of node-positive patients to avoid a second surgery for axillary lymph node dissection. A cost analysis showed savings between $400 and $600 per breast cancer patient, even when accounting for fewer axillary lymph node dissections based on the American College of Surgeons Oncology Group Z0011 data. CONCLUSIONS: Incorporation of routine intraoperative margin/sentinel lymph node assessment at an outpatient breast surgery center is feasible, and results in significant clinical benefit to the patient. Use of frozen section decreased both the time and cost required to treat patients.

Assessment of Orofacial Strength in Patients with Dysarthria.

Assessment of orofacial weakness is common during the evaluation of patients with suspected dysarthria. This study addressed the validity of clinical assessments of orofacial weakness by comparing clinical (subjective) ratings to instrumental (objective) measures. Forty-four adults referred to a speech pathology clinic for dysarthria evaluation were tested for strength of the tongue during elevation, lateralization, and protrusion, and for the strength of the muscles of the lower face during buccodental and interlabial compression. Subjective assessment of weakness involved rating maximum resistance against a firmly held tongue depressor, using a 5-point scale. Objective assessment involved the Iowa Oral Performance Instrument (IOPI), measured as the maximal pressure generated against an air-filled bulb. A recent adaptation to the IOPI permitted testing of tongue and cheek strength using tasks that are comparable to the subjective tasks. Moderate correlations were found between the objective and subjective evaluations, with the strongest correlations for tongue lateralization. Lower pressure values were associated with higher subjective ratings of weakness for each task, although there was substantial overlap in the data. These results, combined with the notion that examiner bias is inherent to clinical assessment, support the use of instrumentation to improve objectivity and precision of measurement in the clinic.

A midpoint assessment of the American Cancer Society challenge goal to decrease cancer incidence by 25% between 1992 and 2015.

In 1998, the American Cancer Society (ACS) set a challenge goal for the nation to reduce cancer incidence by 25% over the period between 1992 and 2015. This report examines the trends in cancer incidence between 1992 and 2004. Trends were calculated using data on incident malignant cancer cases from the Surveillance, Epidemiology, and End Results (SEER) Registry. Delay-adjusted incidence trends for all cancer sites; all cancer sites without prostate cancer included; all cancer sites stratified by gender, age, and race; and for 20 selected cancer sites are presented. Over the first half of the ACS challenge period, overall cancer incidence rates have declined by about 0.6% per year. The greatest overall declines were observed among men and among those aged 65 years and older. The pace of incidence reduction over the first half of the ACS challenge period was only half that necessary to put us on target to achieve the 25% cancer incidence reduction goal in 2015. New understandings of preventable factors are needed, and new efforts are also needed to better act on our current knowledge about how we can prevent cancer, especially by continuing to reduce tobacco use and beginning to reverse the epidemic of obesity.

Breast cancer risk assessment and risk reduction.

Until recently, the primary message of breast health awareness programs was that early detection is a woman's best protection against breast cancer, because there was no way to prevent it. Currently, however, tamoxifen is approved for chemoprevention of breast cancer in high-risk women, and studies are underway evaluating other medications that may decrease breast cancer risk. Data have also become available regarding the efficacy of surgical strategies to reduce breast cancer risk. Any prevention method, however, will have associated risk of complications or adverse effects, and determining the net risk/benefit ratio depends on the ability to accurately quantify a woman's baseline likelihood of developing breast cancer. This article reviews available methods for assessing and reducing breast cancer risk.

Perceptions of clinical research participation among African American women.

BACKGROUND: Recruiting minority women into clinical research remains a significant challenge to conducting ethnically representative research. The main objective of this Office on Women's Health, DHHS-funded e-health database evaluation project was to examine African American women 's thoughts and perceptions about the clinical research process and about participation in the University of Michigan Women's Health Registry research database. METHODS: Thirty-one African American women were recruited from the community to participate in a total of five 90-minute focus group discussions. All sessions were audiotaped and transcribed verbatim. Thematic content analysis was used to identify relevant themes about participation in clinical research and the Women's Health Registry. RESULTS: Ten common trends were identified. (1) Information about the Women's Health Registry is not reaching the community. (2) Research is perceived as biased to benefit Caucasians. (3) Community involvement by the research team is critical for trust to develop. (4) Research directly relevant to African Americans or their community will encourage participation. (5) Researchers should use existing networks and advertise in appropriate locations. (6) The community needs more information concerning research. (7) Compensation is important. (8) Research that addresses a personal or family medical problem encourages involvement. (9) Minority representation on the research team is a motivator to participation. (10) There is limited time for healthcare-related activities. CONCLUSIONS: Successful recruitment strategies for African American women should feature community-based, culturally appropriate approaches. Online research databases for subject recruitment will likely be successful only if implemented within a broader community-oriented program.