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1.  Surveillance mammography among female DoD beneficiaries: a study by race and ethnicity 
Cancer  2013;119(19):3531-3538.
Annual surveillance mammography is recommended after breast cancer diagnosis. Previous studies have suggested that surveillance mammography varies by demographics and initial tumor characteristics, which are related to access to healthcare. The Department of Defense's Military Health System (MHS) provides beneficiaries with equal healthcare access and thus offers an excellent opportunity to assess whether racial differences in surveillance mammography persist when access to care is equal.
Among female beneficiaries with a history of breast cancer logistic regression was used to assess racial/ethnic variation in surveillance mammography during three 12-month periods, beginning one year after diagnosis adjusting for demographic, tumor and health characteristics.
Overall surveillance mammography decreased from 70% during the first year to 59% during the third year (p<0.01). Although there was an overall tendency for surveillance mammography to be higher among minority women compared to non-Hispanic white women, after adjusting for covariates, the difference was significant only during the first year among blacks (odds ratio (OR)=1.46; 95% Confidence Interval (CI)=1.10-1.95) and the second year among Asian Pacific Islanders (OR=2.29; 95%CI=1.52-3.44) and Hispanics (OR=1.92; 95%CI=1.17-3.18). When stratified by age at diagnosis and type of breast cancer surgery, significant racial differences tended to be observed among younger women (<50 years) and only among women who had mastectomies.
Minority women were equally or more likely than non-Hispanic white women to receive surveillance mammography within the MHS. The racial disparities in surveillance mammography reported in other studies were not observed in a system with equal access to care.
PMCID: PMC3787997  PMID: 23913448
breast cancer; mammography; surveillance; survivor; epidemiology; healthcare access
2.  Breast Conserving Surgery versus Mastectomy: The Influence of Comorbidities on Choice of Surgical Operation in the Department of Defense Healthcare System 
American journal of surgery  2013;206(3):393-399.
Studies on the effect of comorbidities on breast cancer operation have been limited and inconsistent. This study investigated whether pre-existing comorbidities influenced breast cancer surgical operation in an equal access healthcare system.
This study was based on linked Department of Defense cancer registry and medical claims data. The study subjects were patients diagnosed with stage I–III breast cancer during 2001 to 2007. Logistic regression was used to determine if comorbidity was associated with operation type and time between diagnosis and operation.
Breast cancer patients with comorbidities were more likely to receive mastectomy (OR=1.27, 95% CI, 1.14–1.42) than breast conserving surgery plus radiation. Patients with comorbidities were also more likely to delay having operation than those without comorbidities (OR=1.27, 95% CI, 1.14–1.41).
In an equal access healthcare system, comorbidity was associated with having a mastectomy and with a delay in undergoing operation.
PMCID: PMC4148911  PMID: 23866763
Breast cancer; breast conserving surgery; comorbidity; Department of Defense health system; mastectomy; military
5.  Male Breast Cancer: A Population-Based Comparison With Female Breast Cancer 
Journal of Clinical Oncology  2009;28(2):232-239.
Because of its rarity, male breast cancer is often compared with female breast cancer.
Patients and Methods
To compare and contrast male and female breast cancers, we obtained case and population data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program for breast cancers diagnosed from 1973 through 2005. Standard descriptive epidemiology was supplemented with age-period-cohort models and breast cancer survival analyses.
Of all breast cancers, men with breast cancer make up less than 1%. Male compared with female breast cancers occurred later in life with higher stage, lower grade, and more estrogen receptor–positive tumors. Recent breast cancer incidence and mortality rates declined over time for men and women, but these trends were greater for women than for men. Comparing patients diagnosed from 1996 through 2005 versus 1976 through 1985, and adjusting for age, stage, and grade, cause-specific hazard rates for breast cancer death declined by 28% among men (P = .03) and by 42% among women (P ≈ 0).
There were three intriguing results. Age-specific incidence patterns showed that the biology of male breast cancer resembled that of late-onset female breast cancer. Similar breast cancer incidence trends among men and women suggested that there are common breast cancer risk factors that affect both sexes, especially estrogen receptor–positive breast cancer. Finally, breast cancer mortality and survival rates have improved significantly over time for both male and female breast cancer, but progress for men has lagged behind that for women.
PMCID: PMC2815713  PMID: 19996029
6.  Qualitative Age Interactions in Breast Cancer Studies: Mind the Gap 
Journal of Clinical Oncology  2009;27(32):5308-5311.
PMCID: PMC2773215  PMID: 19826117
7.  Underlying Causes of the Black–White Racial Disparity in Breast Cancer Mortality: A Population-Based Analysis 
In the United States, a black-to-white disparity in age-standardized breast cancer mortality rates emerged in the 1980s and has widened since then.
To further explore this racial disparity, black-to-white rate ratios (RRsBW) for mortality, incidence, hazard of breast cancer death, and incidence-based mortality (IBM) were investigated using data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results program on 244 786 women who were diagnosed with breast cancer from January 1990 through December 2003 and followed through December 2004. A counterfactual approach was used to examine the expected IBM RRsBW, assuming equal distributions for estrogen receptor (ER) expression, and/or equal hazard rates of breast cancer death, among black and white women.
From 1990 through 2004, mortality RRBW was greater than 1.0 and widened over time (age-standardized breast cancer mortality rates fell from 36 to 29 per 100 000 for blacks and from 30 to 22 per 100 000 for whites). In contrast, incidence RRBW was generally less than 1.0. Absolute hazard rates of breast cancer death declined substantially for ER-positive tumors and modestly for ER-negative tumors but were persistently higher for blacks than whites. Equalizing the distributions of ER expression in blacks and whites decreased the IBM RRBW slightly. Interestingly, the black-to-white disparity in IBM RRBW was essentially eliminated when hazard rates of breast cancer death were matched within each ER category.
The black-to-white disparity in age-standardized breast cancer mortality was largely driven by the higher hazard rates of breast cancer death among black women, diagnosed with the disease, irrespective of ER expression, and especially in the first few years following diagnosis. Greater emphasis should be placed on identifying the etiology of these excess hazards and developing therapeutic strategies to address them.
PMCID: PMC2710374  PMID: 19584327
8.  Cancer Incidence in the U.S. Military Population: Comparison with Rates from the SEER Program 
The U.S. active-duty military population may differ from the U.S. general population in its exposure to cancer risk factors and access to medical care. Yet, it is not known if cancer incidence rates differ between these two populations. We therefore compared the incidence of four cancers common in U.S. adults (lung, colorectum, prostate, and breast cancers) and two cancers more common in U.S. young adults (testicular and cervical cancers) in the military and general populations. Data from the Department of Defense's Automated Central Tumor Registry (ACTUR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) nine cancer registries for the years 1990-2004 for persons aged 20-59 years were analyzed. Incidence rates were significantly lower in the military population for colorectal cancer in white men, lung cancer in white and black men and white women, and cervical cancer in black women. In contrast, incidence rates of breast and prostate cancers were significantly higher in the military among both whites and blacks. Incidence rates of testicular cancer did not differ between ACTUR and SEER. Although the numbers of diagnoses among military personnel were relatively small for temporal trend analysis, we found a more prominent increase in prostate cancer in ACTUR than in SEER. Overall, these results suggest that cancer patterns may differ between military and non-military populations. Further studies are needed to confirm these findings and explore contributing factors.
PMCID: PMC2780333  PMID: 19505907
Active duty; cancer; incidence; military; SEER

Results 1-9 (9)