title: What Predicts an Advanced-Stage Diagnosis of Breast Cancer? Sorting Out the Influence of Method of Detection, Access to Care, and Biologic Factors.
abstract: Multiple studies have yielded important findings regarding the determinants of an advanced-stage diagnosis of breast cancer. We seek to advance this line of inquiry through a broadened conceptual framework and accompanying statistical modeling strategy that recognize the dual importance of access-to-care and biologic factors on stage.
  
  
  
  The Centers for Disease Control and Prevention-sponsored Breast and Prostate Cancer Data Quality and Patterns of Care Study yielded a seven-state, cancer registry-derived population-based sample of 9,142 women diagnosed with a first primary in situ or invasive breast cancer in 2004. The likelihood of advanced-stage cancer (American Joint Committee on Cancer IIIB, IIIC, or IV) was investigated through multivariable regression modeling, with base-case analyses using the method of instrumental variables (IV) to detect and correct for possible selection bias. The robustness of base-case findings was examined through extensive sensitivity analyses.
  
  
  
  Advanced-stage disease was negatively associated with detection by mammography (P < 0.001) and with age < 50 (P < 0.001), and positively related to black race (P = 0.07), not being privately insured [Medicaid (P = 0.01), Medicare (P = 0.04), uninsured (P = 0.07)], being single (P = 0.06), body mass index > 40 (P = 0.001), a HER2 type tumor (P < 0.001), and tumor grade not well differentiated (P < 0.001). This IV model detected and adjusted for significant selection effects associated with method of detection (P = 0.02). Sensitivity analyses generally supported these base-case results.
  
  
  
  Through our comprehensive modeling strategy and sensitivity analyses, we provide new estimates of the magnitude and robustness of the determinants of advanced-stage breast cancer.
  
  
  
  Statistical approaches frequently used to address observational data biases in treatment-outcome studies can be applied similarly in analyses of the determinants of stage at diagnosis. Cancer Epidemiol Biomarkers Prev; 25(4); 613-23. ©2016 AACR.
authors.affiliation: Department of Health Policy and Management, Rollins School of Public Health, Winship Cancer Institute, Emory University, Atlanta, Georgia. jlipsco@emory.edu.
authors.forename: Joseph
authors.initials: J
authors.lastname: Lipscomb
authors.affiliation: Department of Epidemiology, University of Kentucky College of Public Health, Lexington, Kentucky.
authors.forename: Steven T
authors.initials: ST
authors.lastname: Fleming
authors.affiliation: University of Wisconsin Carbone Cancer Center, Madison, Wisconsin.
authors.forename: Amy
authors.initials: A
authors.lastname: Trentham-Dietz
authors.affiliation: Department of Internal Medicine, Medical Oncology, Duke University Medical Center and Multidisciplinary Breast Cancer Program, Duke Cancer Institute, Durham, North Carolina.
authors.forename: Gretchen
authors.initials: G
authors.lastname: Kimmick
authors.affiliation: Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana.
authors.forename: Xiao-Cheng
authors.initials: XC
authors.lastname: Wu
authors.affiliation: California Cancer Registry, Institute for Population Health Improvement, UC Davis Health System, Sacramento, California.
authors.forename: Cyllene R
authors.initials: CR
authors.lastname: Morris
authors.affiliation: Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: Kun
authors.initials: K
authors.lastname: Zhang
authors.affiliation: American Cancer Society, Atlanta, Georgia.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Smith
authors.affiliation: Department of Public Health Sciences, University of Virginia School of Medicine, and UVA Cancer Center, Charlottesville, Virginia.
authors.forename: Roger T
authors.initials: RT
authors.lastname: Anderson
authors.affiliation: Division of Cancer Prevention and Control, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Susan A
authors.initials: SA
authors.lastname: Sabatino
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000473:pathology; D005260:Female; D006297:Health Services Accessibility / Q000639:trends*; D006801:Humans; D008875:Middle Aged
references.citation: Radiology. 2012 Mar;262(3):797-806
references.pmid: 22357883
references.citation: N Engl J Med. 1993 Jul 29;329(5):326-31
references.pmid: 8321261
references.citation: Cancer. 2008 Aug 1;113(3):582-91
references.pmid: 18613122
references.citation: JAMA. 1996 Jul 3;276(1):33-8
references.pmid: 8667536
references.citation: Med Care. 2005 Feb;43(2):141-8
references.pmid: 15655427
references.citation: Lancet. 2012 Nov 17;380(9855):1778-86
references.pmid: 23117178
references.citation: Int J Cancer. 2002 Mar 10;98(2):279-83
references.pmid: 11857420
references.citation: Cancer. 1996 Jan 15;77(2):301-7
references.pmid: 8625238
references.citation: Am J Epidemiol. 2007 Nov 1;166(9):1035-44
references.pmid: 17690220
references.citation: Ann Intern Med. 1997 Oct 15;127(8 Pt 2):757-63
references.pmid: 9382394
references.citation: Am J Epidemiol. 2001 Feb 1;153(3):284-91
references.pmid: 11157416
references.citation: Med Care. 2000 Jul;38(7):705-18
references.pmid: 10901354
references.citation: Health Serv Res. 2012 Dec;47(6):2377-97
references.pmid: 22524165
references.citation: Health Aff (Millwood). 2009 Jan-Feb;28(1):160-8
references.pmid: 19124866
references.citation: Cancer Epidemiol Biomarkers Prev. 2003 Oct;12(10):1074-80
references.pmid: 14578145
references.citation: Ann Intern Med. 1998 May 1;128(9):729-36
references.pmid: 9556466
references.citation: Cancer Epidemiol Biomarkers Prev. 2012 Sep;21(9):1479-88
references.pmid: 22956730
references.citation: J Med Screen. 2012;19 Suppl 1:5-13
references.pmid: 22972806
references.citation: JAMA. 1998 Jun 10;279(22):1801-7
references.pmid: 9628711
references.citation: Cancer. 1995 Apr 15;75(8):2103-13
references.pmid: 7697601
references.citation: J Clin Epidemiol. 2009 Dec;62(12):1226-32
references.pmid: 19356901
references.citation: Am J Public Health. 2006 Dec;96(12):2173-8
references.pmid: 17077391
references.citation: Stat Med. 1998 Oct 15;17(19):2265-81
references.pmid: 9802183
references.citation: AJR Am J Roentgenol. 2000 May;174(5):1251-5
references.pmid: 10789771
references.citation: CA Cancer J Clin. 2008 Jan-Feb;58(1):9-31
references.pmid: 18096863
references.citation: Am J Public Health. 1991 May;81(5):646-9
references.pmid: 2014871
references.citation: Am J Epidemiol. 2006 Feb 1;163(3):262-70
references.pmid: 16371515
references.citation: JAMA Intern Med. 2013 May 13;173(9):807-16
references.pmid: 23552817
references.citation: JAMA. 2001 Nov 7;286(17):2143-51
references.pmid: 11694156
references.citation: Med Care. 2005 Feb;43(2):132-40
references.pmid: 15655426
references.citation: J Natl Cancer Inst. 2010 Dec 1;102(23):1780-93
references.pmid: 20944078
references.citation: J Gen Intern Med. 2009 May;24(5):665-77
references.pmid: 19277790
references.citation: Ann Intern Med. 2006 Apr 18;144(8):541-53
references.pmid: 16618951
references.citation: J Registry Manag. 2011 Summer;38(2):75-86
references.pmid: 22096878
references.citation: J Natl Cancer Inst. 2005 Aug 17;97(16):1195-203
references.pmid: 16106024
references.citation: Med Care. 2009 Sep;47(9):948-58
references.pmid: 19704352
references.citation: J Natl Cancer Inst. 2008 Dec 3;100(23):1724-33
references.pmid: 19033562
references.citation: Comput Math Methods Med. 2012;2012:792375
references.pmid: 22291855
references.citation: Health Serv Res. 2013 Aug;48(4):1487-507
references.pmid: 23216471
references.citation: J Natl Cancer Inst Monogr. 2005;(35):67-71
references.pmid: 16287888
references.citation: MMWR Morb Mortal Wkly Rep. 2012 Jan 27;61(3):41-5
references.pmid: 22278157
references.citation: J Natl Cancer Inst. 1993 Jul 21;85(14):1129-37
references.pmid: 8320742
references.citation: Med Care. 2003 Jun;41(6):722-8
references.pmid: 12773838
references.citation: J Natl Cancer Inst. 2004 Oct 20;96(20):1518-27
references.pmid: 15494602
references.citation: JAMA. 1999 Feb 24;281(8):720-6
references.pmid: 10052442
references.citation: J Urban Health. 2012 Aug;89(4):614-27
references.pmid: 22322332
references.citation: J Natl Cancer Inst. 2013 Sep 18;105(18):1373-84
references.pmid: 24046390
references.citation: J Natl Cancer Inst. 1999 Aug 18;91(16):1409-15
references.pmid: 10451447
references.citation: Cancer Epidemiol Biomarkers Prev. 2012 Oct;21(10):1709-15
references.pmid: 22911332
references.citation: J Natl Cancer Inst. 2000 Jul 5;92(13):1081-7
references.pmid: 10880551
references.citation: Cancer Epidemiol Biomarkers Prev. 2012 Sep;21(9):1510-9
references.pmid: 22744339
references.citation: Ann Intern Med. 2009 Nov 17;151(10):727-37, W237-42
references.pmid: 19920273
references.citation: Breast Cancer Res Treat. 2013 Apr;138(2):519-28
references.pmid: 23417335
references.citation: Cancer. 2007 Jul 15;110(2):403-11
references.pmid: 17562557
references.citation: J Health Econ. 2008 May;27(3):531-43
references.pmid: 18192044
references.citation: Am J Public Health. 2006 Dec;96(12):2165-72
references.pmid: 17077392
references.citation: J Clin Oncol. 2010 Aug 20;28(24):3830-7
references.pmid: 20644098
references.citation: Cancer. 2014 Apr 15;120(8):1246-54
references.pmid: 24443159
references.citation: Cancer Control. 2007 Oct;14(4):369-79
references.pmid: 17914337
references.citation: Med Care. 2008 Jul;46(7):692-700
references.pmid: 18580388
references.citation: Radiology. 2011 Sep;260(3):658-63
references.pmid: 21712474
references.citation: Cancer Causes Control. 2009 May;20(4):417-35
references.pmid: 19002764
references.citation: JAMA. 2006 Jun 7;295(21):2492-502
references.pmid: 16757721
references.citation: CA Cancer J Clin. 2013 Mar-Apr;63(2):88-105
references.pmid: 23378235