title: Racial and Ethnic Differences in Breast Cancer Survival: Mediating Effect of Tumor Characteristics and Sociodemographic and Treatment Factors.
abstract: OBJECTIVE
  To evaluate the relationship between race/ethnicity and breast cancer-specific survival according to subtype and explore mediating factors.
  
  
  METHODS
  Participants were women presenting with stage I to III breast cancer between January 2000 and December 2007 at National Comprehensive Cancer Network centers with survival follow-up through December 2009. Cox proportional hazards regression was used to compare breast cancer-specific survival among Asians (n = 533), Hispanics (n = 1,122), and blacks (n = 1,345) with that among whites (n = 14,268), overall and stratified by subtype (luminal A like, luminal B like, human epidermal growth factor receptor 2 type, and triple negative). Model estimates were used to derive mediation proportion and 95% CI for selected risk factors.
  
  
  RESULTS
  In multivariable adjusted models, overall, blacks had 21% higher risk of breast cancer-specific death (hazard ratio [HR], 1.21; 95% CI, 1.00 to 1.45). For estrogen receptor-positive tumors, black and white survival differences were greatest within 2 years of diagnosis (years 0 to 2: HR, 2.65; 95% CI, 1.34 to 5.24; year 2 to end of follow-up: HR, 1.50; 95% CI, 1.12 to 2.00). Blacks were 76% and 56% more likely to die as a result of luminal A-like and luminal B-like tumors, respectively. No disparities were observed for triple-negative or human epidermal growth factor receptor 2-type tumors. Asians and Hispanics were less likely to die as a result of breast cancer compared with whites (Asians: HR, 0.56; 95% CI, 0.37 to 0.85; Hispanics: HR, 0.74; 95% CI, 0.58 to 0.95). For blacks, tumor characteristics and stage at diagnosis were significant disparity mediators. Body mass index was an important mediator for blacks and Asians.
  
  
  CONCLUSIONS
  Racial disparities in breast cancer survival vary by tumor subtype. Interventions are needed to reduce disparities, particularly in the first 2 years after diagnosis among black women with estrogen receptor-positive tumors.
authors.affiliation: Erica T. Warner and Rulla M. Tamimi, Harvard School of Public Health; Erica T. Warner, Rulla M. Tamimi, Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Brigham and Women's Hospital; Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Dana-Farber Cancer Institute, Boston, MA; Rebecca A. Ottesen and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte; Douglas W. Blayney, Stanford University Cancer Center, Palo Alto, CA; Yu-Ning Wong, Fox Chase Cancer Center, Philadelphia, PA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; and Richard L. Theriault, University of Texas MD Anderson Cancer Center, Houston, TX. ewarner@hsph.harvard.edu.
authors.forename: Erica T
authors.initials: ET
authors.lastname: Warner
authors.affiliation: Erica T. Warner and Rulla M. Tamimi, Harvard School of Public Health; Erica T. Warner, Rulla M. Tamimi, Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Brigham and Women's Hospital; Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Dana-Farber Cancer Institute, Boston, MA; Rebecca A. Ottesen and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte; Douglas W. Blayney, Stanford University Cancer Center, Palo Alto, CA; Yu-Ning Wong, Fox Chase Cancer Center, Philadelphia, PA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; and Richard L. Theriault, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Rulla M
authors.initials: RM
authors.lastname: Tamimi
authors.affiliation: Erica T. Warner and Rulla M. Tamimi, Harvard School of Public Health; Erica T. Warner, Rulla M. Tamimi, Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Brigham and Women's Hospital; Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Dana-Farber Cancer Institute, Boston, MA; Rebecca A. Ottesen and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte; Douglas W. Blayney, Stanford University Cancer Center, Palo Alto, CA; Yu-Ning Wong, Fox Chase Cancer Center, Philadelphia, PA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; and Richard L. Theriault, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Melissa E
authors.initials: ME
authors.lastname: Hughes
authors.affiliation: Erica T. Warner and Rulla M. Tamimi, Harvard School of Public Health; Erica T. Warner, Rulla M. Tamimi, Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Brigham and Women's Hospital; Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Dana-Farber Cancer Institute, Boston, MA; Rebecca A. Ottesen and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte; Douglas W. Blayney, Stanford University Cancer Center, Palo Alto, CA; Yu-Ning Wong, Fox Chase Cancer Center, Philadelphia, PA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; and Richard L. Theriault, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Rebecca A
authors.initials: RA
authors.lastname: Ottesen
authors.affiliation: Erica T. Warner and Rulla M. Tamimi, Harvard School of Public Health; Erica T. Warner, Rulla M. Tamimi, Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Brigham and Women's Hospital; Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Dana-Farber Cancer Institute, Boston, MA; Rebecca A. Ottesen and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte; Douglas W. Blayney, Stanford University Cancer Center, Palo Alto, CA; Yu-Ning Wong, Fox Chase Cancer Center, Philadelphia, PA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; and Richard L. Theriault, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Yu-Ning
authors.initials: YN
authors.lastname: Wong
authors.affiliation: Erica T. Warner and Rulla M. Tamimi, Harvard School of Public Health; Erica T. Warner, Rulla M. Tamimi, Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Brigham and Women's Hospital; Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Dana-Farber Cancer Institute, Boston, MA; Rebecca A. Ottesen and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte; Douglas W. Blayney, Stanford University Cancer Center, Palo Alto, CA; Yu-Ning Wong, Fox Chase Cancer Center, Philadelphia, PA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; and Richard L. Theriault, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Edge
authors.affiliation: Erica T. Warner and Rulla M. Tamimi, Harvard School of Public Health; Erica T. Warner, Rulla M. Tamimi, Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Brigham and Women's Hospital; Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Dana-Farber Cancer Institute, Boston, MA; Rebecca A. Ottesen and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte; Douglas W. Blayney, Stanford University Cancer Center, Palo Alto, CA; Yu-Ning Wong, Fox Chase Cancer Center, Philadelphia, PA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; and Richard L. Theriault, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Theriault
authors.affiliation: Erica T. Warner and Rulla M. Tamimi, Harvard School of Public Health; Erica T. Warner, Rulla M. Tamimi, Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Brigham and Women's Hospital; Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Dana-Farber Cancer Institute, Boston, MA; Rebecca A. Ottesen and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte; Douglas W. Blayney, Stanford University Cancer Center, Palo Alto, CA; Yu-Ning Wong, Fox Chase Cancer Center, Philadelphia, PA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; and Richard L. Theriault, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Douglas W
authors.initials: DW
authors.lastname: Blayney
authors.affiliation: Erica T. Warner and Rulla M. Tamimi, Harvard School of Public Health; Erica T. Warner, Rulla M. Tamimi, Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Brigham and Women's Hospital; Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Dana-Farber Cancer Institute, Boston, MA; Rebecca A. Ottesen and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte; Douglas W. Blayney, Stanford University Cancer Center, Palo Alto, CA; Yu-Ning Wong, Fox Chase Cancer Center, Philadelphia, PA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; and Richard L. Theriault, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Joyce C
authors.initials: JC
authors.lastname: Niland
authors.affiliation: Erica T. Warner and Rulla M. Tamimi, Harvard School of Public Health; Erica T. Warner, Rulla M. Tamimi, Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Brigham and Women's Hospital; Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Dana-Farber Cancer Institute, Boston, MA; Rebecca A. Ottesen and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte; Douglas W. Blayney, Stanford University Cancer Center, Palo Alto, CA; Yu-Ning Wong, Fox Chase Cancer Center, Philadelphia, PA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; and Richard L. Theriault, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Eric P
authors.initials: EP
authors.lastname: Winer
authors.affiliation: Erica T. Warner and Rulla M. Tamimi, Harvard School of Public Health; Erica T. Warner, Rulla M. Tamimi, Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Brigham and Women's Hospital; Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Dana-Farber Cancer Institute, Boston, MA; Rebecca A. Ottesen and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte; Douglas W. Blayney, Stanford University Cancer Center, Palo Alto, CA; Yu-Ning Wong, Fox Chase Cancer Center, Philadelphia, PA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; and Richard L. Theriault, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Jane C
authors.initials: JC
authors.lastname: Weeks
authors.affiliation: Erica T. Warner and Rulla M. Tamimi, Harvard School of Public Health; Erica T. Warner, Rulla M. Tamimi, Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Brigham and Women's Hospital; Melissa E. Hughes, Eric P. Winer, Jane C. Weeks, and Ann H. Partridge, Dana-Farber Cancer Institute, Boston, MA; Rebecca A. Ottesen and Joyce C. Niland, City of Hope Comprehensive Cancer Center, Duarte; Douglas W. Blayney, Stanford University Cancer Center, Palo Alto, CA; Yu-Ning Wong, Fox Chase Cancer Center, Philadelphia, PA; Stephen B. Edge, Baptist Cancer Center, Memphis, TN; and Richard L. Theriault, University of Texas MD Anderson Cancer Center, Houston, TX.
authors.forename: Ann H
authors.initials: AH
authors.lastname: Partridge
mesh_terms: D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D001213:Asian / Q000706:statistics & numerical data; D014408:Biomarkers, Tumor / Q000032:analysis; D015992:Body Mass Index; D001943:Breast Neoplasms / Q000737:chemistry / Q000208:ethnology* / Q000401:mortality / Q000473:pathology / Q000628:therapy; D002423:Cause of Death; D018572:Disease-Free Survival; D005006:Ethnicity / Q000706:statistics & numerical data*; D005260:Female; D054624:Health Status Disparities; D054625:Healthcare Disparities / Q000208:ethnology; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008875:Middle Aged; D015999:Multivariate Analysis; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D016016:Proportional Hazards Models; D044469:Racial Groups / Q000706:statistics & numerical data*; D012307:Risk Factors; D012959:Socioeconomic Factors; D013997:Time Factors; D016896:Treatment Outcome; D064726:Triple Negative Breast Neoplasms / Q000208:ethnology; D014481:United States / Q000453:epidemiology; D044465:White People / Q000706:statistics & numerical data
chemical_list: D014408:Biomarkers, Tumor