Characteristics Contributing to Survival Differences Between Black and White Patients Following Cystectomy.

PURPOSE: Examine patient, tumor, and treatment characteristics effect on the disparity between black and white patients with muscle-invasive bladder cancer (MIBC) who undergo radical cystectomy (RC). METHODS: 1,286 black patients in the 2004 to 2016 National Cancer Database fit inclusion criteria. A tapered match was performed from 17,374 white patients sequentially matched to the black cohort on demographics (age, gender, insurance, income, education, county, diagnosis year), presentation (demographic variables, stage, grade, tumor size, Charlson score), and treatment (demographic and presentation variables, lymph node count, hospital volume, neoadjuvant chemotherapy [NAC], treatment delay), creating 3 matched cohorts. Chi-square and Kruskal-Wallis tests were used to compare cohorts. Kaplan-Meier analysis was used to compare 5-year overall survival (OS). RESULTS: 5-year OS rate was 40.4% and 35.6% for unmatched white and black cohorts (P < 0.001), respectively. Following demographics and presentation match, 5-year OS rate for white patients decreased to 39.2% (P = 0.003) and 39.10% (P = 0.019), respectively. After treatment match, 5-year OS rate decreased to 36.7% for white patient (P = 0.32). Following presentation match, 7.2% of black patients vs. 5.8% of white patients had treatment delay, and 10.1% of black patients vs. 11.2% of white patients received NAC. The treatment match resulted in a 0.3% difference between groups for treatment delay and NAC. CONCLUSIONS: Our analysis demonstrates that disparity between black and white patients with muscle-invasive bladder cancer exists in demographic-, presentation-, and treatment-related variables. Treatment variables may be a large contributing factor to survival disparities. Further research is needed to identify social, biological, and organizational inputs that contribute to these disparities.

Racial differences in the risk of second primary bladder cancer following radiation therapy among localized prostate cancer patients.

OBJECTIVES: To investigate the race-specific second primary bladder cancer (SPBC) risk following prostatic irradiation. METHODS: Louisiana residents who were diagnosed with localized prostate cancer (PCa) in 1996-2013 and received surgery or radiation were included. Patients were followed until SPBC diagnosis, death, or Dec. 2018. The exposure variable was type of treatment (radiation only vs. surgery only). The outcome was time from PCa diagnosis to SPBC diagnosis, stratified by race. Fine and Gray's competing risk model was applied with death as a competing event and adjustment of sociodemographic and tumor characteristics. We used 5 years and 10 years as lag time in the analyses. RESULTS: A total of 26,277 PCa patients with a median follow-up of 10.7 years were analyzed, including 18,598 white and 7679 black patients. About 42.9 % of whites and 45.7 % of blacks received radiation. SPBC counted for 1.84 % in the radiation group and 0.90 % in the surgery group among white patients and for 0.91 % and 0.58 %, respectively, among black patients. The adjusted subdistribution hazard ratio of SPBC was 1.80 (95 % CI: 1.30-2.48) for radiation recipients compared to surgery recipients among white patients; 1.93 (95 % CI: 1.36-2.74) if restricted to external beam radiation therapy (EBRT). The SPBC risk was not significantly different between irradiated and surgically treated among blacks. CONCLUSIONS: The SPBC risk is almost two-fold among white irradiated PCa patients compared to their counterparts treated surgically. Our findings highlight the need for enhanced surveillance for white PCa survivors receiving radiotherapy, especially those received EBRT.

Does Health Insurance Modify the Association Between Race and Cancer-Specific Survival in Patients with Urinary Bladder Malignancy in the U.S.?

Background: Scientific evidence on the effect of health insurance on racial disparities in urinary bladder cancer patients' survival is scant. The objective of our study was to determine whether insurance status modifies the association between race and bladder cancer specific survival during 2007-2015. Methods: The 2015 database of the cancer surveillance program of the National Cancer Institute (n = 39,587) was used. The independent variable was race (White, Black and Asian Pacific Islanders (API)), the main outcome was cancer specific survival. Health insurance was divided into uninsured, any Medicaid and insured. An adjusted model with an interaction term for race and insurance status was computed. Unadjusted and adjusted Cox regression analysis were applied. Results: Health insurance was a statistically significant effect modifier of the association between race and survival. Whereas, API had a lower hazard of death among the patients with Medicaid insurance (HR 0.67; 95% CI 0.48-0.94 compared with White patients, no differences in survival was found between Black and White urinary bladder carcinoma patients (HR 1.24; 95% CI 0.95-1.61). This may be due a lack of power. Among the insured study participants, Blacks were 1.46 times more likely than Whites to die of bladder cancer during the 5-year follow-up (95% CI 1.30-1.64). Conclusions: While race is accepted as a poor prognostic factor in the mortality from bladder cancer, insurance status can help to explain some of the survival differences across races.

Racial and Socioeconomic Disparities in Bladder Cancer Survival: Analysis of the California Cancer Registry.

PURPOSE: To examine the California Cancer Registry (CCR) for bladder cancer survival disparities based on race, socioeconomic status (SES), and insurance in California patients. PATIENTS AND METHODS: The CCR was queried for bladder cancer cases in California from 1988 to 2012. The primary outcome was disease-specific survival (DSS), defined as the time interval from date of diagnosis to date of death from bladder cancer. Survival analyses were performed to determine the prognostic significance of racial and socioeconomic factors. RESULTS: A total of 72,452 cases were included (74.5% men, 25.5% women). The median age was 72 years (range, 18-109 years). The racial distribution among the patients was 81% white, 3.8% black, 8.8% Hispanic, 5.2% Asian, and 1.2% from other races. In black patients, tumors presented more frequently with advanced stage and high grade. Medicaid patients tended to be younger and had more advanced-stage, higher-grade tumors compared to patients with Medicare or managed care (P < .0001). Kaplan-Meier analysis demonstrated significantly poorer 5-year DSS in black, low SES, and Medicaid patients (P < .0001). When controlling for stage, grade, age, and gender, multivariate analysis revealed that black race (DSS hazard ratio = 1.295; 95% confidence interval, 1.212-1.384), low SES (DSS hazard ratio = 1.325; 95% confidence interval, 1.259-1.395), and Medicaid insurance (DSS hazard ratio = 1.349; 95% confidence interval, 1.246-1.460) were independent prognostic factors (P < .0001). CONCLUSION: An analysis of the CCR demonstrated that black race, low SES, and Medicaid insurance portend poorer DSS. These findings reflect a multifaceted socioeconomic and public health conundrum, and efforts to reduce inequalities should be pursued.

Demographic and Survivorship Disparities in Non-muscle-invasive Bladder Cancer in the United States.

OBJECTIVES: To examine survivorship disparities in demographic factors and risk status for non-muscle-invasive bladder cancer (NMIBC), which accounts for more than 75% of all urinary bladder cancers, but is highly curable with early identification and treatment. METHODS: We used the US National Cancer Institute's Surveillance, Epidemiology, and End Results registries over a 19-year period (1988-2006) to examine survivorship disparities in age, sex, race/ethnicity, and marital status of patients and risk status classified by histologic grade, stage, size of tumor, and number of multiple primary tumors among NMIBC patients (n=29 326). We applied Kaplan-Meier (K-M) and Cox proportional hazard methods for survival analysis. RESULTS: Among all urinary bladder cancer patients, the majority of NMIBCs were in male (74.1%), non-Latino white (86.7%), married (67.8%), and low-risk (37.6%) to intermediate-risk (44.8%) patients. The mean age was 68 years. Survivorship (in median life years) was highest for non-Latino white (5.4 years), married (5.4 years), and low-risk (5.7 years) patients (K-M analysis, p<0.001). We found significantly lower survivorship for elderly, male (female hazard ratio [HR], 0.96), Latino (HR, 1.20), and unmarried (married HR, 0.93) patients. CONCLUSIONS: Survivorship disparities were ubiquitous across age, sex, race/ethnicity, and marital status groups. Non-white, unmarried, and elderly patients had significantly shorter survivorship. The implications of these findings include the need for a heightened focus on health policy and more organized efforts to improve access to care in order to increase the chances of survival for all patients.

A review of bladder cancer in Sub-Saharan Africa: A different disease, with a distinct presentation, assessment, and treatment.

Background: Cancer of the bladder is the ninth leading cause of cancer in developed countries. It is the second most common urological malignancy. Transitional cell carcinoma (TCC) is the most common histological subtype in developed countries. In most of Africa, the most common type is squamous cell carcinoma (SCC). Cancer of bladder guidelines produced by the European Urological Association and the American Urological Association, including the tumor, node, and metastasis staging is focused on TCC of the bladder. Objectives: The purpose of the study is to review the pathogenesis, pathology, presentation, and management of cancer of the bladder in Africa and to use this information to propose a practical staging system for SCC. Methods: The study used the meta-analysis guideline provided by PRISMA using bladder cancer in Africa as the key search word. The study collected articles available on PubMed as of July 2017, Africa Online and Africa Index Medicus. PRISMA guidelines were used to screen for full-length hospital-based articles on cancer of the bladder in Africa. These articles were analyzed under four subcategories which were pathogenesis, pathology, clinical presentation, and management. The information extracted was pooled and used to propose a practical staging system for use in African settings. Results: The result of evaluation of 821 articles yielded 23 full-length papers on hospital-based studies of cancer of the bladder in Africa. Cancer of the bladder in most of Africa is still predominantly SCC (53%-69%). There has been a notable increase in TCC in Africa (9%-41%). The pathogenesis is mostly schistosoma-related SCC presents late with painful hematuria and necroturia (20%). SCC responds poorly to chemotherapy or radiotherapy. The main management of SCC is open surgery. This review allowed for a practical organ-based stage of SCC of the bladder that can be used in Africa. Conclusion: Bladder cancer in Africa presents differently from that in developed countries. Guidelines on cancer of the bladder may need to take account of this to improve bladder cancer management in Africa.

RésuméContexte: Le cancer de la vessie est la neuvième cause de cancer dans les pays développés. C'est le deuxième plus fréquent urologique malignité. Le carcinome à cellules transitionnelles (TCC) est le sous-type histologique le plus commun dans les pays développés. Dans la majeure partie de l'Afrique, le plus le type commun est le carcinome épidermoïde (SCC). Lignes directrices sur le cancer de la vessie produites par l'Association européenne d'urologie et American Urological Association, y compris la tumeur, le nœud, et la mise en scène de la métastase est axée sur le TCC de la vessie. Objectifs: Le Le but de l'étude est d'examiner la pathogenèse, la pathologie, la présentation et la gestion du cancer de la vessie en Afrique et d'utiliser cette information pour proposer un système de mise en scène pratique pour SCC. Méthodes: L'étude a utilisé la ligne de méta-analyse fournie par PRISMA en utilisant le cancer de la vessie en Afrique comme le mot clé de recherche. L'étude a recueilli des articles disponibles sur PubMed à partir de juillet 2017, Africa Online et Africa Index Medicus. Les directives PRISMA ont été utilisées pour dépister des articles hospitaliers complets sur le cancer de la vessie en Afrique. Ces articles ont été analysés sous quatre sous-catégories qui étaient la pathogenèse, la pathologie, la présentation clinique et la gestion. le les informations extraites ont été regroupées et utilisées pour proposer un système de mise en scène pratique à utiliser dans les contextes africains. Résultats: Le résultat de l'évaluation sur 821 articles, 23 articles complets ont été publiés sur les études hospitalières sur le cancer de la vessie en Afrique. Cancer de la vessie dans la plupart des L'Afrique est toujours principalement SCC (53% -69%). Il y a eu une augmentation notable du TCC en Afrique (9% -41%). La pathogenèse est principalement la SCC liée au schistosome se manifeste tardivement par une hématurie douloureuse et une nécroturie (20%). SCC répond faiblement à la chimiothérapie ou la radiothérapie. La gestion principale de SCC est la chirurgie ouverte. Cette revue a permis un stade pratique de la CEC de la vessie qui peut être utilisé. en Afrique. CONCLUSION: Le cancer de la vessie en Afrique présente différemment de celui des pays développés. Lignes directrices sur le cancer de la vessie Il faudra peut-être en tenir compte pour améliorer la gestion du cancer de la vessie en Afrique.

Population-based assessment of racial/ethnic differences in utilization of radical cystectomy for patients diagnosed with bladder cancer.

PURPOSE: Radical cystectomy is a surgical treatment for recurrent non-muscle-invasive and muscle-invasive bladder cancer; however, many patients may not receive this treatment. METHODS: A total of 27,578 patients diagnosed with clinical stage I-IV bladder cancer from 1 January 2007 to 31 December 2013 were identified from the Surveillance, Epidemiology, and End Results (SEER) registry database. We used multivariable regression analyses to identify factors predicting the use of radical cystectomy and pelvic lymph node dissection. Cox proportional hazards models were used to analyze survival outcomes. RESULTS: A total of 1,693 (6.1%) patients with bladder cancer underwent radical cystectomy. Most patients (92.4%) who underwent radical cystectomy also underwent pelvic lymph node dissection. When compared with white patients, non-Hispanic blacks were less likely to undergo a radical cystectomy [odds ratio (OR) 0.79, 95% confidence interval (CI) 0.64-0.96, p = 0.019]. Moreover, recent year of surgery 2013 versus 2007 (OR 2.32, 95% CI 1.90-2.83, p < 0.001), greater percentage of college education ≥36.3 versus <21.3% (OR 1.23, 95% CI 1.04-1.44, p = 0.013), Midwest versus West (OR 1.64, 95% CI 1.39-1.94, p < 0.001), and more advanced clinical stage III versus I (OR 29.1, 95% CI 23.9-35.3, p < 0.001) were associated with increased use of radical cystectomy. Overall survival was improved for patients who underwent radical cystectomy compared with those who did not undergo a radical cystectomy (hazard ratio 0.88, 95% CI 0.80-0.97, p = 0.008). CONCLUSION: There is significant underutilization of radical cystectomy in patients across all age groups diagnosed with bladder cancer, especially among older, non-Hispanic black patients.

The Influence of Race on Overall Survival in Patients with Newly Diagnosed Bladder Cancer.

BACKGROUND: Previous studies have reported significant lower incidence yet greater risk of death from bladder cancer (BCa) in African-Americans compared with Caucasians. In this study, the overall survival amongst African-Americans and Caucasians with BCa within the state of Florida is evaluated. MATERIALS AND METHODS: The Florida Cancer Data System and the Florida Agency for Health Care Administration data sets were linked on the basis of unique identifiers, which identified 28,786 patients (27,811 Caucasian and 975 African-Americans) with newly diagnosed BCa from January 1994-December 2009. Data in the database included race/ethnicity, age, smoking history, insurance status, treatment, tumor grade, tumor stage, and overall survival. Chi-square and Mann-Whitney U tests were used to compare variables between African-Americans and Caucasians. Survival rates were calculated by the Kaplan-Meier method while univariate effects were tested by the log-rank test, and multivariate effects were tested by Cox proportional-hazard regression model. P values less than 0.05 were considered statistically significant. RESULTS: Higher clinical stage bladder tumors including T3/4 disease (14.5 % vs. 8.0 %, p < 0.001), lymph node involvement (7.3 % vs. 3.4 %, p < 0.001), and metastatic disease (5.3 % vs. 1.7 %, p < 0.001), as well as higher grade disease (60.2 % vs. 48 %, p < 0.001) were more commonly reported in African-Americans than in Caucasians with newly diagnosed BCa. African-Americans tended to be treated with more aggressive therapies (e.g., radical cystectomy). After adjusting for all covariates, African-Americans actually had more favorable outcomes as related to overall survival (HR = 0.35, 95 % CI, 0.12-0.98, p = 0.045). CONCLUSIONS: Though African-Americans initially present with more aggressive BCa, African-Americans actually have an improved overall survival compared with Caucasians. Though contrary to previous reports, our results may signify a more complex relationship between race and BCa outcomes and thus warrants further attention.

Quantitative assessment of the association between MHTFR C677T (rs1801133, Ala222Val) polymorphism and susceptibility to bladder cancer.

BACKGROUND: The association between Methylenetetrahydrofolate reductase (MTHFR) Ala222Val (rs1801133) has been implicated to alter the risk of bladder cancer, but the results are controversial. METHODS: A comprehensive databases of Pubmed, Embase, Web of Science, and the Chinese Biomedical Database (CBM) were searched for case-control studies investigating the association between MTHFR Ala222Val polymorphism and bladder cancer susceptibility. Odds ratios (OR) and 95% confidence intervals (95%CI) were used to assess this possible association. A χ2-based Q-test was used to examine the heterogeneity assumption. Begg's and Egger's test were used to examine the potential publication bias. The leave-one-out sensitivity analysis was conducted to determine whether our assumptions or decisions have a major effect on the results of the review. Statistical analysis was performed with the software program Stata 12.0. RESULTS: A total of 15 independent studies were identified, including 3,570 cases and 3,926 controls. Our analysis suggested that Ala222Val was not associated with bladder cancer risk in overall population under additive model (OR=0.96, 95%CI=0.76-1.21, P=0.731), dominant model (OR=1.00, 95%CI=0.87-1.15, P=0.975), recessive model (OR=0.92, 95%CI=0.79-1.07, P=0.279), and Ala allele versus Val allele (OR=0.96, 95%CI=0.86-1.07, P=0.427). In the subgroup analysis stratified by ethnicity and sources of controls, there were also no significant associations detected among different descent populations, population-based studies and hospital-based studies. CONCLUSION: This meta-analysis showed the evidence that MTHFR Ala222Val polymorphism was not contributed to the development of bladder cancer. VIRTUAL SLIDE: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/2117182849994994.

RETRACTED: Modified U-shaped ileal neobladder after radical cystectomy: assessment of functional outcomes and complications in Chinese patients.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief. After investigation, it was confirmed that there were considerably fewer cases with modified U-shaped ileal neobladder at the research institution than was written about in the manuscript.

Use of potentially curative therapies for muscle-invasive bladder cancer in the United States: results from the National Cancer Data Base.

BACKGROUND: Despite its lethal potential, many patients with muscle-invasive bladder cancer (MIBC) do not receive aggressive, potentially curative therapy consistent with established practice standards. OBJECTIVE: To characterize the treatments received by patients with MIBC and analyze their use according to sociodemographic, clinical, pathologic, and facility measures. DESIGN, SETTING, AND PARTICIPANTS: Using the National Cancer Data Base, we analyzed 28 691 patients with MIBC (stages II-IV) treated between 2004 and 2008, excluding those with cT4b tumors or distant metastases. Treatments included radical or partial cystectomy with or without chemotherapy (CT), chemoradiotherapy (CRT), radiation therapy (RT), or CT alone and observation following biopsy. Aggressive therapy (AT) was defined as radical or partial cystectomy or definitive RT/CRT (total dose ≥ 50 Gy). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: AT use and correlating variables were assessed by multivariable, generalized estimating equation models adjusted for facility clustering. RESULTS AND LIMITATIONS: According to the database, 52.5% of patients received AT; 44.9% were treated surgically, 7.6% received definitive CRT or RT, and 25.9% of patients received observation only. AT use decreased with advancing age (odds ratio [OR]: 0.34 for age 81-90 yr vs ≤ 50 yr; p<0.001). AT use was also lower in racial minorities (OR: 0.74 for black race; p<0.001), the uninsured (OR: 0.73; p<0.001), Medicaid-insured patients (OR: 0.81; p=0.01), and at low-volume centers (OR: 0.64 vs high-volume centers; p<0.001). Use of AT was higher with increasing tumor stage (OR: 2.23 for T3/T4a vs T2; p<0.001) and nonurothelial histology (OR: 1.25 and 1.43 for squamous and adenocarcinoma, respectively; p<0.001). Study limitations include retrospective design and lack of information about patient and provider motivations regarding therapy selection. CONCLUSIONS: AT for MIBC appears underused, especially in the elderly and in groups with poor socioeconomic status. These data point to a significant unmet need to inform policy makers, payers, and physicians regarding appropriate therapies for MIBC.

Quantitative assessment of the association between TP53 Arg72Pro polymorphism and bladder cancer risk.

Previous studies investigating the association between TP53 Arg72Pro polymorphism and bladder cancer risk reported controversial results. To quantify the strength of association between TP53 Arg72Pro polymorphism and bladder cancer risk, we performed this meta-analysis. We searched PubMed, Embase and Wangfang databases for studies relating the association between TP53 Arg72Pro polymorphism and bladder cancer risk. We used the pooled odds ratios (ORs) with their 95 % confidence intervals (95 % CIs) to assess the association. Finally, data were available from a total of 16 case-control studies including a total of 5, 545 subjects (2,345 cases and 3,200 controls). Meta-analysis of all 16 studies showed TP53 Arg72Pro polymorphism was not associated with bladder cancer risk (All P values were more than 0.10). Subgroup analyses by ethnicity showed that TP53 Arg72Pro polymorphism contributed to bladder cancer risk in East Asians in three genetic models (For Pro vs. Arg, Fixed-effects OR 1.18, 95 % CI 1.05-1.32; For ProPro vs. ArgArg, Fixed-effects OR 1.40, 95 % CI 1.11-1.77; For ProPro vs. ArgPro/ArgArg, Fixed-effects OR 1.32, 95 % CI 1.07-1.62). However, there was no significant association in Caucasians and the others (All P values were more than 0.05). Heterogeneity analyses suggested ethnicity was the major sources of heterogeneity. Thus, meta-analyses of available data suggest the Pro variant of TP53 Arg72Pro contributes to bladder cancer risk in East Asians. Besides, TP53 Arg72Pro polymorphism may have race-specific effects on bladder cancer risk and further studies are needed to elucidate this possible effect.

Disparities in bladder cancer.

Among men, bladder cancer is the fourth most common malignancy and ninth leading cause of death from cancer in the United States. In contrast, it is the 11th most common malignancy and 12th leading cause of death from cancer among women. The successful management of bladder cancer largely depends on its timely diagnosis and treatment. Unfortunately, barriers disproportionately delay detection and treatment for individuals with social, economic, and community disadvantages. This imbalance creates health disparities (i.e., differences in health outcomes that are closely linked to these disadvantages), which negatively affect vulnerable populations, such as racial and ethnic minority groups, those from lower socioeconomic classes, and the uninsured. To obtain a better understanding of this issue, we review the current state of bladder cancer disparities research.

Survival disparities among African American women with invasive bladder cancer in Florida.

BACKGROUND: The authors sought to understand the effect of patient sex, race, and socioeconomic status (SES) on outcomes for bladder cancer. METHOD: The Florida Cancer Data System and the Agency for Health Care Administration data sets (1998-2003) were merged and queried. Survival outcomes for patients with bladder cancer were compared between different races, ethnicities, and community poverty levels. RESULTS: A total of 31,100 people with bladder cancer were identified. Overall median survival time was 62.7 months. Statistically significantly longer survival times were observed in men (62.8 months vs 62.3 months for women), whites (63.0 months vs 39.6 months for African Americans [AAs], P<.001), non-Hispanics (62.9 months vs 56.4 months for Hispanics, P<.001), and patients from more affluent communities (74.0 months where <5% live in poverty vs 53.0 months where >15% live in poverty, P<.001). Surgery was associated with dramatically improved survival. AA women diagnosed with bladder cancer were significantly less likely to have endoscopic surgical resection compared with white women (P<.001). On multivariate analysis, independent predictors of poorer outcomes were older age, AA race, female sex, degree of community poverty, histologic tumor grade, advanced tumor stage, and lack of surgical treatment. CONCLUSIONS: Racial and SES disparities in bladder cancer survival were not fully explained by late-stage presentation and undertreatment. Although earlier diagnosis and greater access to surgery would likely yield some improvement in outcomes for AA women, more research is needed to understand the remaining survival gap for this population.

Sex and racial differences in bladder cancer presentation and mortality in the US.

BACKGROUND: Sex, race, and age at diagnosis have a significant impact on mortality from bladder cancer (BC). Women, African Americans of both sexes, and the elderly, all experience higher mortality rates. Tumor grade, stage, and histologic type at presentation also affect outcome. To determine whether age and tumor characteristics alone explain the excess hazard of death from BC observed in some demographic groups, the authors queried the Surveillance, Epidemiology, and End Results (SEER) limited-use database for the presentations and outcomes from BC between 1990 and 2005. METHODS: Tumors were characterized by grade, stage, and histologic type. Hazards rates for BC-specific mortality were compared by race and sex using a piecewise Cox regression model, adjusting for factors (age, stage, grade, and histologic type) that differed significantly between the groups that were compared. RESULTS: Excess hazard of death from BC was present during the first 2 to 3 years of follow-up among women and during the first 4 years of follow-up among African Americans. Adjustment for age and tumor characteristics eliminated approximately 30% of this excess hazard in sex comparison among whites. In sex comparison among blacks and in racial comparisons within each sex, approximately 50% to 70% of excess hazard could be eliminated by adjustment. CONCLUSIONS: Significant differences in tumor characteristics and age at presentation did not fully account for the excess hazard of death from BC among women and African Americans. Other factors, such as choice and efficacy of therapies, differences within a given tumor characteristic group, and/or host factors also may play important roles.