Impact of breast cancer subtypes and treatment on survival: an analysis spanning two decades.

BACKGROUND: We investigated the impact of breast cancer molecular subtypes and treatment on survival in a cohort of medically insured women followed for more than 20 years. METHODS: We examined 934 female members of an integrated health care delivery system newly diagnosed with invasive breast cancer between 1988 and 1995 and followed them through 2008. Tumors were classified into four molecular subtypes on the basis of their expression profile: luminal A; luminal B; basal-like; and HER2-enriched. We followed women from the surgery date to death, health plan disenrollment, or study's end. HR and 95% confidence intervals (CI) were fit using Cox proportional hazards models adjusting for cancer treatments and tumor characteristics. RESULTS: A total of 223 (23.9%) women died because of breast cancer during the 21-year study period. Compared with women with luminal A tumors, women with HER2-enriched (HR 2.56, 95% CI 1.53-4.29) and luminal B tumors (HR 1.96, 95% CI: 1.08-3.54) had roughly a two-fold increased adjusted risk of breast cancer mortality. In addition, the survival curves suggest that risk of late mortality persists in women with luminal A tumors. CONCLUSION: Among women with health care coverage, molecular subtypes were important predictors of breast cancer mortality. Women with HER2-enriched tumors and luminal B subtypes had the poorest survival despite adjusting for important covariates. IMPACT: In a cohort followed for more than 20 years, women with HER2-enriched tumors had worse survival, but interestingly, the survival curve for women with luminal A tumors continued to steadily decline after 10 years of follow-up.

Correlates of screening sigmoidoscopy use among men in a large nonprofit health plan.

BACKGROUND: As the majority of patients diagnosed with colorectal cancer have no known risk factors, regular screening is strongly recommended. The authors examined factors associated with screening sigmoidoscopy use among participants in the California Men's Health Study (CMHS). METHODS: The authors conducted a cross-sectional study over a 5-year period nested within a prospective cohort study. The CMHS enrolled a large multiethnic cohort (n = 84,170) of men from 2 major California health plans. Because screening sigmoidoscopy was the preferred and most commonly used test for patients at average risk of colorectal cancer in the health plans, the authors excluded from the analysis men who completed a barium enema colonoscopy or a fecal occult blood test. RESULTS: Eligible subjects included 39,559 men at average risk for colorectal cancer. Prevalence of screening sigmoidoscopy use decreased with older age and increased with higher education and household income over the 5-year study period. Compared with whites, Asians (adjusted OR, 1.42; 95% CI, 1.30-1.56) and African Americans (adjusted OR, 1.18; 95% CI, 1.08-1.29) were more likely to undergo screening sigmoidoscopy. Screening increased with the number of outpatient visits and with having a primary care provider in internal medicine. Men who did not undergo prostate-specific antigen testing were also less likely to undergo sigmoidoscopy screening. Only 24.5% of current smokers had a screening sigmoidoscopy examination and were 25% less likely to undergo this procedure compared with nonsmokers (adjusted OR, 0.75; 95% CI, 0.69-0.82). CONCLUSIONS: In this insured population for whom financial barriers are minimized, screening sigmoidoscopy use was as low as reported in the general population. However, minority patients were not less likely to be screened.

Breast cancer treatment of older women in integrated health care settings.

PURPOSE: A substantial literature describes age-dependent variations in breast cancer treatment, showing that older women are less likely to receive standard treatment than younger women. We sought to identify patient and tumor characteristics associated with the nonreceipt of standard primary tumor and systemic adjuvant therapies. PATIENTS AND METHODS: We studied 1,859 women age 65 years or older with stage I and II breast cancer diagnosed between 1990 and 1994 who were cared for in six geographically dispersed community-based health care systems. We collected demographic, tumor, treatment, and comorbidity data from electronic data sources, including cancer registry, administrative, and clinical databases, and from subjects' medical records. RESULTS: Women 75 years of age or older and women with higher comorbidity indices were more likely to receive nonstandard primary tumor therapy, to not receive axillary lymph node dissection, and to not receive radiation therapy after breast-conserving surgery (BCS). Asian women were less likely to receive BCS, and African American women were less likely to be prescribed tamoxifen. Although nonreceipt of most therapies was associated with a lower baseline risk of recurrence, an important minority of high-risk women (16% to 30%) did not receive guideline therapies. CONCLUSION: Age is an independent risk factor for nonreceipt of effective cancer therapies, even when comorbidity and risk of recurrence are taken into account. Information regarding treatment effectiveness in this age group and tools that allow physicians and patients to estimate the benefits versus the risks of therapies, taking into account age and comorbidity burden, are critically needed.