California Breast Cancer Survivorship Consortium - USC AABCS

Institution: University of Southern California
Investigator(s): Anna  Wu , Ph.D. - Scarlett  Gomez , PhD - Leslie  Bernstein , Ph.D. - Marilyn  Kwan , Ph.D. - Kristine  Monroe , Ph.D. -
Award Cycle: 2010 (Cycle 16) Grant #: 16ZB-8001 Award: $1,006,035
Award Type: SRI Program Directed Awards
Research Priorities
Community Impact of Breast Cancer>Disparities: eliminating the unequal burden of breast cancer

This is a collaboration with: 16ZB-8002 - 16ZB-8003 - 16ZB-8004 - 16ZB-8005 -

Initial Award Abstract (2010)

Overview:
The prognosis of female breast cancer patients varies according to race and ethnicity. Although scientists have tried to determine why these differences exist by studying variations in cancer stage, tumor characteristics, treatment received, and socioeconomic status of the patient, racial/ethnic differences in breast cancer survival still remain. Socioeconomic disparities and lifestyle factors including large body size and recreational physical inactivity, and a history of other diseases, have also been found to decrease survival. However, the impact of these factors on racial/ethnic differences in breast cancer mortality has not been determined.

Research questions:
The overall aim is to determine whether these four groups of exposures: contextual factors, physical activity, body size, and comorbidities, separately or in combination, explain the differences in stage-specific breast cancer survival by race and ethnicity. These four primary exposures were selected because of their modifiable nature, their documented variability across racial/ethnic groups, their associations with breast cancer mortality in general, their potential for broad impact in reducing disparities in breast cancer survival, and their consistent collection and availability across the studies.

Methods:
We will create the California Breast Cancer Survivorship Consortium (CBCSC), consisting of seven California-based breast cancer studies with over 16,000 breast cancer cases, including 2603 African Americans, 2113 Asian Americans, 2582 Latinas, and 9306 non-Latina Whites. Consortium members will pool data with the goal of understanding whether four modifiable factors are responsible, in part, for racial/ethnic differences in stage-specific breast cancer survival. These interrelated factors will be investigated among these racially and ethnically diverse breast cancer survivors in four projects:

  1. Contextual-level factors:
    • the impact of contextual-level socioeconomic status (SES) and the interaction with individual-level education on survival;
    • the impact of the built and obesogenic environment (neighborhood attributes that promote walking and healthy living, such as availability of parks, healthy eating places, mixed land use) and the interaction with individual-level body mass index (BMI) and physical activity on survival;
    • the impact of ethnic enclaves and the interaction with individual-level migration characteristics (nativity, age at migration, language usage) on survival; and
    • the impact of institutional (hospital-level) factors such as ownership status (private, public), academic affiliation, patient composition (SES and race/ethnicity), distance to medical facilities with individual-level education on survival.
  2. Physical activity:
    • determine whether recreational, pre-diagnosis physical activity is independently associated with death due to breast cancer and death due to any cause;
    • determine whether occupational, pre-diagnosis physical activity is independently associated with death due to breast cancer and death due to any cause;
    • determine whether total (recreational and non-recreational), pre-diagnosis physical activity is independently associated with death due to breast cancer and death due to any cause.
  3. Body size: examine the associations between body size measures (body mass index (BMI) around the time of diagnosis; waist and hip circumference around the time of diagnosis; waist-to-hip ratio around the time of diagnosis; and weight gain since age 18 years or since age 20 years until time of diagnosis) and all-cause and breast cancer mortality by race/ethnicity, stage, tumor receptor status, and overall, adjusting for prognostic and lifestyle factors
  4. Comorbidities:
    • determine the race/ethnic specific relationship between pre-diagnostic hypertension and risk of overall mortality and breast cancer-specific mortality;
    • determine the race/ethnic specific relationship between pre-diagnostic diabetes and risk of overall mortality and breast cancer-specific mortality;
    • determine the race/ethnic specific relationship between pre-diagnostic heart disease and risk of overall mortality and breast cancer-specific mortality;
    • determine the race/ethnic specific relationship between number of pre-diagnostic comorbid conditions and risk of overall mortality and breast cancer-specific mortality.

These factors were selected because they have been implicated to influence breast cancer mortality and the number of women with varying profiles of these factors differs by race/ethnicity.

Innovative elements:
This consortium project represents the first study of multiethnic breast cancer patients to study several interrelated factors at the same time using comparable methodologies. Most of the previous studies on prognosis were conducted in non-Latina Whites, with only limited data available for African Americans and almost no data on Latinas and Asian Americans. Most prior studies of breast cancer survival disparities have focused on differences between non-Latina Whites and African Americans. This is also an extremely cost effective study; the available questionnaire data from these seven studies represent a very large financial investment in breast cancer research funded by multiple agencies. We will be able to use this pooled dataset with more than 10 years of follow-up to address important questions in a timely manner so that there is economy of scale in both time and financial costs. Better understanding of these ‘modifiable’ risk factors will allow women of all races/ethnicities to consider lifestyle changes that may favorably influence breast cancer survival.

Advocacy involvement:
We have the support and commitment of a panel of five advocates and advisors (one additional advisor will be recruited). This panel will be involved at every step of the study and will be involved in our monthly conference calls and our yearly in-person meetings. Their advice will be sought in dissemination and translation of results from this study. Women with breast cancer want to know how they can improve their survival after being diagnosed with the disease and the CBCSC will help answer this important question.




Final Report (2016)

Overall: Compared with non-Latina Whites (NL Whites), Latinas and Asian Americans showed lower overall and breast cancer-specific mortality risks. Although African Americans and NL Whites showed similar overall mortality risks, African Americans had higher (HR 1.13, 95% CI=0.97-1.33) breast cancer-specific mortality risk . These results were observed after adjustment for a large number of clinical and lifestyle factors (Wu et al., 2013)

Project 1: Individual socioeconomic status (SES) based on education, and neighborhood SES (nSES) may interact with race/ethnicity in impacting mortality after breast cancer diagnosis. Compared to NL whites with high education and high nSES, significantly higher overall and breast cancer specific mortality were found among African Americans with high education and low nSES as well those with low education and low nSES. Latinas with low education and high nSES experienced significantly lower overall and breast cancer specific mortality. No significant findings were observed in Asian Americans (Shariff-Marco et al, 2015). Attributes of neighborhood environment were associated with obesity and mortality following breast cancer diagnosis, but these associations varied across racial/ethnic groups (Cheng et al., 2015).

Project 2: Compared to women with the lowest level of recent recreational physical (<0.5 hours/week), those with the highest level (>3 hours/week) experienced a significant decreased risk of mortality from causes other than breast cancer (HR=0.63, 95% CI=0.49-0.80), and particularly from cardiovascular disease. No association was observed for breast cancer-specific mortality. These risk patterns did not differ by racial/ethnic groups (Yani et al., 2015) Project 3: In NL Whites and Latinas, the morbidly obese (=40 kg/m2) had significantly higher all-cause mortality. No body mass index (BMI)-mortality associations were found in African Americans and Asian Americans. However, high waist-hip ratio (WHR) (=0.867 vs <0.763) was associated with significantly increased risk of all-cause mortality in African and Asian Americans but not in Latinas and NL Whites. Similar but attenuated BMI and WHR associations with breast cancer-specific mortality were observed. The impact of obesity and body fat distribution on breast cancer mortality varied across racial/ethnic groups (Kwan et al., 2014)

Project 4: History of previous cancer, diabetes, high blood pressure, and myocardial infarction (MI) were associated with a significantly increased risk of overall mortality after adjustment for tumor characteristics and lifestyle factors. Risk of breast cancer-specific mortality increased among breast cancer cases with a history of diabetes (HR=1.48, 95% CI=1.18, 1.87) or MI (HR=1.94, 95% CI=1.27-2.97). In subgroup analyses, risks of breast cancer-specific mortality were higher among those who did not receive radiation or chemotherapy treatment for their comorbidity. Thus, comorbidities may adversely affect treatment decisions and ultimately outcome (Wu et al., 2015). We compared self-reported information on diabetes, hypertension, myocardial infarction (MI), and other heart diseases to history based on electronic medical records for these comorbidities. Sensitivity was excellent (ranged from .96 to .99); sensitivity was also high (.81-.91) for diabetes, hypertension, and MI but was lower for other heart diseases (0.48), mainly because the questions were less precise, and included a broad range of conditions (Vigen et al., 2016).

Our summary analyses showed that although contextual factors, physical activity, body size, and comorbidities, influenced breast cancer-specific mortality, these variables did not explain racial/ethnic mortality disparity in this combined analysis (Sposto et al, 2016).



Diabetes and other comorbidities in breast cancer survival by race/ethnicity: The California Breast Cancer Survivorship Consortium (CBCSC). pii: cebp.1140.2014
Periodical:Cancer Epidemiology Biomarkers and Prevention
Index Medicus: Cancer Epidemiol Biomarkers Prev
Authors: Wu AH, Kurian AW, Kwan ML, John EM, Lu Y, Keegan TH, et al.
Yr: 2015 Vol: 24 Nbr: Abs: Pg:361-8

The California Breast Cancer Survivorship Consortium (CBCSC): prognostic factors associated with racial/ethnic differences in breast cancer survival.
Periodical:Cancer Causes Control
Index Medicus: Cancer Causes Contol
Authors: Wu AH, Gomez SL, Vigen C. et al.
Yr: 2013 Vol: 24 Nbr: 10 Abs: Pg:1821-1836

Obesity and mortality after breast cancer by race/ethnicty: The California Breast Cancer Survivorship Consortium
Periodical:American Journal of Epidemiology
Index Medicus: Am J Epidemiol
Authors: Kwan ML, John EM, Caan BJ et al.
Yr: 2014 Vol: 179 Nbr: 1 Abs: Pg:95-111

Contribution of the Neighborhood Environment and Obesity to Breast Cancer Survival: The California Breast Cancer Survivorship Consortium
Periodical:Cancer Epidemiology Biomarkers and Prevention
Index Medicus: Cancer Epidemiol Biomarkers Prev
Authors: Iona Cheng Salma Shariff-Marco Jocelyn Koo, Kristine R. Monroe Juan Yang
Yr: 2015 Vol: 24 Nbr: 8 Abs: Pg:1282-1280

History of Recreational Physical Activity and Survival After Breast Cancer: The California Breast Cancer Survivorship Consortium
Periodical:American Journal of Epidemiology
Index Medicus: Am J Epidemiol
Authors: Yani Lu Esther M. John, Jane Sullivan-Halley, Cheryl Vigen, Scarlett Lin Gomez, Marilyn
Yr: 2015 Vol: Nbr: Abs: Pg:

Intersection of Race/Ethnicity and Socioeconomic Status in Mortality After Breast Cancer
Periodical:Journal of Community Health
Index Medicus:
Authors: Salma Shariff-Marco, Juan Yang, Esther M. John, Allison W. Kurian,
Yr: 2015 Vol: 40 Nbr: Abs: Pg:1287-1299

Validation of self-reported comorbidity status of breast cancer patients with medical records: the California Breast Cancer Survivorship Consortium (CBCSC)
Periodical:Cancer Causes Control
Index Medicus: Cancer Causes Contol
Authors: Cheryl Vigen, Marilyn L. Kwan, Esther M. John, Scarlett Lin Gomez Theresa H.
Yr: 2016 Vol: Nbr: Abs: Pg:

Impact of neighborhoods and body size on survival after breast cancer diagnosis
Periodical:Health and Place
Index Medicus: Helth & Place
Authors: Salma Shariff-Marco, ScarlettL.Gomez, Meera Sangaramoorthy, Juan Yan
Yr: 2015 Vol: 36 Nbr: Abs: Pg:162-172