SAN FRANCISCO, July 9 — African-Americans are more likely to die from breast, prostate, and ovarian cancers than other races — even when they get identical medical care and after controlling for other socioeconomic factors, researchers found.

But no other major cancers produced the persistent racial disparity with equal treatment, and after adjustment for tumor prognostic factors, demographics, and socioeconomics, Kathy S. Albain, MD, of Loyola University Chicago in Maywood, Ill., and colleagues reported.

Their analysis of Southwest Oncology Group trials suggested that access to care, later stage diagnosis, and poverty — widely blamed for cancer disparities — don’t tell the whole story, they wrote online in the Journal of the National Cancer Institute.

For the sex-specific cancers, biologic and genetic factors are likely to play a role, they said.

• Explain to interested patients that clinical trial settings provide a “level playing field” with equal treatment, disease stage, and other factors.
• Note that the study could not determine reasons for the persistent racial disparities in survival of breast, ovarian, and prostate cancers, although biologic and genetic factors have been postulated to play a role.

In an accompanying editorial, Otis W. Brawley, MD, chief medical officer of the American Cancer Society, emphasized that race is not a scientific categorization and is rejected by many anthropologists.

Rather, it is “a surrogate for area of geographic origin, socioeconomic status, and culture, all of which can have correlations with disease risk,” he noted.

Dr. Brawley added, “Perhaps advances in our understanding of biology will lead us away from concerns about race and we will better define high-risk populations using pathological markers of disease.”

Dr. Albain’s group pooled findings from 35 Southwest Oncology Group randomized, phase III trials in which a total of 19,457 adult cancer patients (11.9% African American) got uniform treatment by protocol and met similar entry criteria, including disease stage.

After adjustment for each cancer’s prognostic factors, such as tumor size, the researchers found no significant association between African-American race and overall survival in the following:

• Acute myelogenous leukemia (P=0.12)
• Limited-stage small cell lung cancer (P=0.29)
• Advanced-stage non-small cell lung cancer (P=0.20)
• Multiple myeloma (P=0.34)
• Early-stage colon cancer (P=0.87)
• Advanced-stage non-Hodgkin lymphoma (P=0.10)

“Good care in good hands gives the same outcome for all patients for the most part,” Dr. Albain said.

But compared with all other racial and ethnic groups combined, African-Americans had significantly poorer adjusted overall survival for sex-specific cancers. The 20-year survival estimates were:

• 68% versus 77% for early-stage premenopausal breast cancer (HR for death 1.41, P=0.007)
• 52% versus 62% for early-stage postmenopausal breast cancer (HR for death 1.49, P<0.001)
• 13% versus 17% for advanced-stage ovarian cancer (HR for death 1.61, P=0.002)
• 6% versus 9% for advanced-stage prostate cancer (HR for death 1.21, P=0.001)

Adding income and education to these analyses did not substantially impact the associations of race with overall survival.

Nor did comparing cause-specific mortality or comparing African-American patients to whites with other groups excluded.

Notably, an analysis of breast cancer by histology showed elevated overall mortality after full adjustment in African-Americans, compared with other groups for both hormone receptor-positive and hormone receptor-negative tumors.

This suggested that “the triple-negative biology theory cannot be the sole explanation for the difference in breast cancer outcomes by race,” the researchers said.

They cautioned that the studies did not control how patients were diagnosed, making it possible that non-African American patients were more likely to be screen detected, resulting in lead-time bias.

But cause-specific mortality analysis showed this did not explain the findings, they noted.

Since population-based studies have shown significant racial disparities in survival of cancers beyond just breast, ovarian, and prostate cancers, Dr. Brawley said the findings provide further evidence that real-world care is not equal.

“Blacks are less likely to have their disease detected early, and when it is detected, they are less likely to receive adequate treatment,” he concluded.

The individual studies in the analysis were funded by the National Institutes of Health. The researchers reported no conflicts of interest. Dr. Brawley provided no information on conflicts of interest.

Primary source: Journal of the National Cancer Institute

Source reference:

Albain KS, et al “Racial disparities in cancer survival among randomized clinical trials patients of the Southwest Oncology Group” J Natl Cancer Inst 2009; 101: 984-92.

Additional source: Journal of the National Cancer Institute

Source reference:

Brawley O “Is Race Really a Negative Prognostic Factor for Cancer?” J Natl Cancer Inst 2009, 101: 970-971.

LITTLE FALLS, N.J., July 9 — Early age at menarche and a high number of lifetime ovulatory cycles may decrease a woman’s chance of survival after ovarian cancer, researchers say.

• Explain that a higher number of lifetime ovulatory cycles and earlier age at menarche carried a respective 67% and 51% increased risk of death for ovarian cancer patients.
• Note that this study did not find any protective effects of other reproductive factors, such as parity or oral contraceptive use, although the findings trended that way.

A higher number of cycles carried a 67% increased risk of death, while reaching menarche before age 12 carried a 51% increased risk, Cheryl L. Robbins, PhD, of the CDC, and colleagues reported in the July issue of Cancer Epidemiology, Biomarkers, and Prevention.

Dr. Robbins said that relatively little was known about factors that may influence survival after ovarian cancer diagnosis, although previous studies have found that fewer lifetime ovulatory cycles, higher parity, oral contraceptive use, and hysterectomy were associated with a decreased risk of ovarian cancer.

To determine if reproductive factors influence survival, the researchers conducted a longitudinal analysis of 410 women ages 20 to 54 who participated in the Cancer and Steroid Hormone (CASH) study as ovarian cancer cases between 1980 and 1982.

Outcomes were tracked using Surveillance, Epidemiology, and End Results (SEER) data.

Over a median follow-up of 9.2 years, 212 women died, and 80% of the deaths were recorded as deaths due to ovarian cancer.

Of the reproductive factors examined, the researchers said that only age at menarche and the number of lifetime ovulatory cycles significantly predicted ovarian cancer survival in a multivariate analysis.

Women with the fewest cycles had the highest 15-year survival (56.7%, 95% CI 47.8 to 64.6) and those with the highest number had the poorest (33%, 95% CI 25.3 to 41.5).

Women who reached menarche before age 12 had a higher risk of death compared with those whose menses began at age 14 or older (HR 1.51, 95% CI 1.02 to 2.24).

No other reproductive factors were independent prognostic indicators, which the researchers called “puzzling,” particularly regarding parity or oral contraceptive use.

However, they said the trends were in the protective direction, and the study may have had insufficient statistical power.

They said the findings may be explained by the influence of other hormones including estrogens, androgens, and progesterones.

They noted a number of limitations, including the possibility that the results were biased by inaccurate recall of reproductive history. Also, they could not assess whether the effect of lifetime ovulatory cycles on survival had been influenced by cancer treatment.

They concluded that additional research was “needed to explore the associations between reproductive factors and ovarian cancer survival in other study populations, particularly those that included older women and contain more detailed menstrual cycle information and complete data on cancer treatment.”

The Cancer and Steroid Hormone study was supported by the CDC, the National Institute of Child Health and Human Development, and the National Cancer Institute. The researchers reported no conflicts of interest.

Primary source: Cancer Epidemiology, Biomarkers, & Prevention

Source reference:
Robbins CL, et al “Influence of reproductive factors on mortality and epithelial ovarian cancer diagnosis” Cancer Epidemiol Biomarkers Prev 2009; 18(7): 2035-41.

Iatrogenic perforation of cancer of the esophagus or the gastroesophageal (GE) junction is a severe complication. Its incidence has increased most likely because of more aggressive palliative endoscopic therapy and the current widespread use of endoscopic ultrasound (EUS) for accurate preoperative staging. Therapy, i.e. conservative versus surgical treatment remains controversial.

Professor Jorg Kleeff from the Munich (Germany) report a case of 82-year-old man with iatrogenic perforation of adenocarcinoma of the GE junction. This article was published in the World Journal of Gastroenterology.

Given serious complications brought by initial endoscopic intervention, they decided to choose immediate explorative laparotomy. Intraoperatively, the tumor was localized and removed completely by resection of the cardia and part of the distal esophagus. For reconstruction, a partial proximal gastric tube was constructed using linear staplers. After treatment, the patient recovered quickly and discharged from hospital within 2 wk. On a further follow-up after 4 wk, the patient held no complaint of reflux or dysphagic symptoms.

The study revealed that the management of esophageal perforation in the context of an underlying malignancy demands an individual approach that depends upon the site and etiology of the perforation. Irrespective of the therapeutic approach, the prognosis after tumor perforation is dismal.

Reference: Gillen S, Friess H, Kleeff J. Palliative cardia resection with gastroesophageal reconstruction for perforated carcinoma of the gastroesophageal junction. World J Gastroenterol 2009; 15(24): 3065-3067;

Source:
Lai-Fu Li

World Journal of Gastroenterology