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Original Contribution | June 10, 1998

Influence of Socioeconomic and Cultural Factors on Racial Differences in
Late-Stage Presentation of Breast Cancer FREE
Donald R. Lannin, MD; Holly F. Mathews, PhD; Jim Mitchell, PhD; Melvin S. Swanson,
PhD; Frances H. Swanson, MS; Maxine S. Edwards, RN
[+] Author Affiliations
JAMA. 1998;279(22):1801-1807. doi:10.1001/jama.279.22.1801.
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ABSTRACT
ABSTRACT | METHODS | RESULTS | COMMENT | REFERENCES
Context. Breast cancer mortality is higher among African American women than
among white women in the United States, but the reasons for the racial difference
are not known.
Objective. To evaluate the influence of socioeconomic and cultural factors on the
racial difference in breast cancer stage at diagnosis.
Design. Case-control study of patients diagnosed as having breast cancer at the
University Medical Center of Eastern Carolina from 1985 through 1992.
Setting. The major health care facility for 2 rural counties in eastern North
Carolina.
Subjects. Five hundred forty of 743 patients with newly diagnosed breast cancer
and 414 control women from the community matched by age, race, and area of
residence.
Main Outcome Measures. Breast cancer stage at diagnosis.
Results. Of the 540 patients, 94 (17.4%) presented with TNM stage III or IV
disease. The following demographic and socioeconomic factors were significant
predictors of advanced stage: being African American (odds ratio [OR], 3.0; 95%

confidence interval [CI], 1.9-4.7); having low income (OR, 3.7; 95% CI, 2.1-6.5);
never having been married (OR, 2.9; 95% CI, 1.4-5.9); having no private health
insurance (OR, 2.5; 95% CI, 1.6-4.0); delaying seeing a physician because of money
(OR, 1.6; 95% CI, 1.1-2.5); or lacking transportation (OR, 2.0; 95% CI, 1.2-3.6).
Univariate analysis also revealed a large number of cultural beliefs to be significant
predictors. Examples include the following beliefs: air causes a cancer to spread
(OR, 2.8; 95% CI, 1.8-4.3); the devil can cause a person to get cancer (OR, 2.1; 95%
CI, 1.2-3.5); women who have breast surgery are no longer attractive to men (OR,
1.9; 95% CI, 1.1-3.5); and chiropractic is an effective treatment for breast cancer
(OR, 2.4; 95% CI, 1.4-4.4). When the demographic and socioeconomic variables
were included in a multivariate logistic regression model, the OR for late stage
among African Americans decreased to 1.8 (95% CI, 1.1-3.2) compared with 3.0
(95% CI, 1.9-4.7) for race alone. However, when the belief measures were included
with the demographic and socioeconomic variables, the OR for late stage among
African Americans decreased further to 1.2 (95% CI, 0.6-2.5).
Conclusions. Socioeconomic factors alone were not sufficient to explain the
dramatic effect of race on breast cancer stage; however, socioeconomic variables in
conjunction with cultural beliefs and attitudes could largely account for the
observed effect.
REFERENCE
Baquet CR, Ringen K. Cancer Among Blacks and Other Minorities: Statistical Profiles.
Bethesda, Md: National Cancer Institute, National Institutes of Health; 1986.
Publication NIH 86-2785.
Clin Breast Cancer. 2002 Apr;3(1):65-72.
Young age as an independent adverse prognostic factor in premenopausal
patients with breast cancer.
Dubsky PC1, Gnant MF, Taucher S, Roka S, Kandioler D, Pichler-Gebhard B, Agstner
I, Seifert M, Sevelda P, Jakesz R.
Author information
Abstract
Breast cancer in younger patients appears to be more aggressive than disease
occurring in older patients. Even though large population-based studies
suggest poorer survival of patients younger than 35 years, data demonstrating the
relationship of age and prognosis within premenopausal cohorts are much more
scarce and conflicting. In this retrospective analysis of 885 premenopausal patients,
the relationship between age, typical prognostic factors, treatment, and patient
outcome was investigated. Eight hundred four patients (90.8%) > 35 years and 81
patients (9.2%) = 35 years who had been treated for stage I/II breast cancer were

evaluated. Median follow-up time was 71 months. The prevalence of adverse

prognostic features such as tumor size, tumor type, tumor grading, pathologic
lymph node status, and hormone receptor status were evenly distributed between
the two age groups. Age = 35 years proved to be a powerful independent
prognostic factor in multivariate analyses of recurrence-free (P < 0.0001; relative
risk [RR] = 2.5) and overall survival (P < 0.0039, RR = 2.2). Thus, in the face of
evenly distributed risk factors in this strictly premenopausal, homogeneous
population, young age was seen as the second most powerful risk factor after lymph
node status. According to these findings, patients diagnosed with breast cancer at =
35 years of age have a worse prognosis compared to premenopausal women above
this age. Future studies should focus on unveiling the young age surrogate in order
to improve treatment andprognosis.

World J Clin Oncol. 2016 Jun 10;7(3):321-3. doi: 10.5306/wjco.v7.i3.321.

Awareness that early cancer lump is painless could decrease breast cancer
mortality in developing countries.
Garg P1.
Author information
Abstract
There are several factors which contribute to patients' reporting late to healthcare
facility even after detecting the breast lump (patient delay). Amongst these, one of
the important factors in low- and middle-income countries is lack of awareness that
early cancer lump is painless (ECLIPs). Pain is often taken as a danger sign and
absence of pain is often not taken seriously. The studies have shown that up to 98%
of women in low-income countries are unaware that a painless lump could be a
warning sign of early breast cancer. This fact is significant because this could be one
of the prime reasons for the women having discovered a painless lump in
the breast, accidentally or by breast self-examination, presume it to be harmless
and don't report early to health care facility. Therefore, creating awareness about
ECLIPs could be an effective strategy to reduce mortality due to breast cancer in
low- and middle-income countries. Moreover, unlike modifying risk factors which
requires long term behavior modification, creating awareness about ECLIPs is easy
and cost effective.
Breast cancer and hormone-replacement therapy in the Million Women
Study
Million Women Study Collaborators*

Summary
Background
Current use of hormone-replacement therapy (HRT) increases the incidence of
breast cancer. The Million Women Study was set up to investigate the effects of
specific types of HRT on incident and fatal breast cancer.
Methods
1084110 UK women aged 5064 years were recruited into the Million Women Study
between 1996 and 2001, provided information about their use of HRT and other
personal details, and were followed up for cancer incidence and death.
Findings
Half the women had used HRT; 9364 incident invasive breast cancers and 637
breast cancer deaths were registered after an average of 26 and 41 years of
follow-up, respectively. Current users of HRT at recruitment were more likely than
never users to develop breast cancer (adjusted relative risk 166 [95% CI 158
175], p<00001) and die from it (122 [100148], p=005). Past users of HRT were,
however, not at an increased risk of incident or fatal disease (101 [094109] and
105 [082134], respectively). Incidence was significantly increased for current
users of preparations containing oestrogen only (130 [121140], p<00001),
oestrogen-progestagen (200 [188212], p<00001), and tibolone (145 [125
168], p<00001), but the magnitude of the associated risk was substantially
greater for oestrogen-progestagen than for other types of HRT (p<00001). Results
varied little between specific oestrogens and progestagens or their doses; or
between continuous and sequential regimens. The relative risks were significantly
increased separately for oral, transdermal, and implanted oestrogen-only
formulations (132 [121145]; 124 [111139]; and 165 [126216], respectively;
all p<00001). In current users of each type of HRT the risk of breast cancer
increased with increasing total duration of use. 10 years' use of HRT is estimated to
result in five (95% CI 37) additional breast cancers per 1000 users of oestrogenonly preparations and 19 (1523) additional cancers per 1000 users of oestrogenprogestagen combinations. Use of HRT by women aged 5064 years in the UK over
the past decade has resulted in an estimated 20000 extra breast cancers, 15000
associated with oestrogen-progestagen; the extra deaths cannot yet be reliably
estimated.
Interpretation
Current use of HRT is associated with an increased risk of incident and fatal breast
cancer; the effect is substantially greater for oestrogen-progestagen combinations
than for other types of HRT

REFERENCE;
Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and
hormone replacement therapy: collaborative reanalysis of data from 51
epidemiological studies of 52705 women with breast cancer and 108411 women
without breast cancer. Lancet. 1997; 350: 10471059
PMCID: PMC2150175
Who and what influences delayed presentation in breast cancer?
C. C. Burgess, A. J. Ramirez, M. A. Richards, and S. B. Love
Abstract
This study aimed to examine the extent and determinants of patient and general
practitioner delay in the presentation of breast cancer. One hundred and eighty-five
cancer patients attending a breast unit were interviewed 2 months after diagnosis.
The main outcome measures were patient delay in presentation to the general
practitioner and non-referral by the general practitioner to hospital after the
patient's first visit. Nineteen per cent of patients delayed > or = 12 weeks. Patient
delay was related to clinical tumour size > or = 4 cm (P = 0.0002) and with a higher
incidence of locally advanced and metastatic disease (P = 0.01). A number of
factors predicted patient delay: initial breast symptom(s) that did not include a lump
(OR 4.5, P = 0.003), not disclosing discovery of the breast symptom immediately to
someone else (OR 6.0, P < 0.001), seeking help only after being prompted by others
(OR 4.4, P = 0.007) and presenting to the general practitioner with a non-breast
problem (OR 3.5, P = 0.03). Eighty-three per cent of patients were referred to
hospital directly after their first general practitioner visit. Presenting to the GP with a
breast symptom that did not include a lump independently predicted general
practitioner delay (OR 3.6, P = 0.002). In view of the increasing evidence that delay
adversely affects survival, a large multicentre study is now warranted to confirm
these findings that may have implications for public and medical education.
REFERENCE;

Adam SA, Horner JK, Vessey MP. Delay in treatment for breast
cancer. Community Med. 1980 Aug;2(3):195201. [PubMed]

Breast Cancer and Lactation History in Mexican Women

1. Isabelle Romieu1,
2. Mauricio Hernndez-Avila2,
3. Eduardo Lazcano2,

4. Lizbeth Lopez2 and

5. Ricardo Romero-Jaime3
+Author Affiliations
1.

2.

3.

Centro Pan-Americano de Ecologia Humana y Salud, Organiza-cion PanAmericana de la Salud Metepec, Mexico State, Mexico
Centra de Investigaciones en Salud Publica, Instituto Nacional de Salud
Publica Cuernavaca, Morelos, Mexico
Instituto Mexicano del Seguro Social Mexico City, Distrito Federal, Mexico

1. Reprint requests to Dr. Mauricio Hernandez-Avila, Instituto Nacional de Salud

Publica, Av. Universidad 655, Col. Santa Maria Ahuacatitlan, C.P. 62508
Cuernavaca, Morelos, Mexico.

Received June 29, 1994.

Accepted June 30, 1995.

Abstract
The authors conducted a case-control study in Mexico City between September
1990 and December 1992 to determine whether a dose-response relation could be
observed between duration of lactation and the risk of breast cancer. Cases, women
aged 2075 years, were identified through six hospitals in Mexico City (n = 349) and
were interviewed to obtain data on risk factors for breast cancer, including a
detailed history of lactation. Controls (n = 1,005) were selected from the general
population using the Mexican national sampling frame. Parous women who had ever
lactated had a reduction in breast cancer risk (age-adjusted odds ratio (OR) = 0.39,
95% confidence interval (Cl) 0.250.62). A small decreasing trend of breast cancer
risk in relation to duration of lactation (p< 0.001) was observed. Compared with
parous women who had never breast-fed, women who had breast-fed for 1224
months had an age-adjusted odds ratio of 0.47 (95% Cl 0.270.83). A stronger
protective effect was observed with lactation duration for the first live birth among
pre- and postmenopausal women (for 412 months of lactation, OR = 0.56 (95
percent Cl 0.320.96) and OR = 0.48 (95 percent Cl 0.290.81) in pre- and
postmenopausal women, respectively). Adjusting for potentially confounding factors
modified these results only slightly. The declining trend in fertility and lactation
among Mexican women could lead to a major epidemic of breast cancer such as
that observed in Western countries.

European Journal of Cancer

Volume 41, Issue 3, February 2005, Pages 393397

A survey of breast cancer awareness and knowledge in a Western population: lots of

light but little illumination

Moya McMenamina,

Helen Barrya,

Ann-Marie Lennona,

Henry Purcellb,

Michael Baumc,

Denise Keegana,

Enda McDermotta,

Diarmuid ODonoghuea,

Leslie Dalyd,

Hugh Mulcahya, , ,

for the Irish National Cancer/Cardiac Awareness (INCA) survey

Abstract
There are conflicting data on breast cancer awareness and knowledge in specific
population groups. We assessed awareness and knowledge of breast cancer in the
general Irish population to identify sources of information on breast cancer and
determine factors associated with knowledge and awareness of the disease.
Participants (n = 2355, 53% female) completed a multi-part questionnaire. Most

(81%) had seen or heard something about breast cancer in the recent past and
knowledge of symptoms and treatment was good overall. However, 66% of females
overestimated their risk of developing disease, 88% underestimated the age at
which it was most likely to develop and 56% underestimated 5-year survival.
Knowledge of incidence and survival was higher in males (Odds Ratio (OR) 1.3, 95%
Confidence Interval (CI); 1.11.5), participants with higher education (1.5; 1.21.7)
and those who received information from television (1.3; 1.11.5). Ignorance
regarding incidence, outcome and risk makes it unlikely that the general public or at
risk females could currently make informed decisions on a range of breast cancer
issues.