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Treatment Adherence and Outcome in

Women With Inflammatory Breast Cancer

Does Race Matter?

Fundagul Andic, MD1,2; Karen Godette, MD1; Ruth O’Regan, MD3; Amelia Zelnak, MD3; Tian Liu, PhD1; Monica Rizzo, MD4; Sheryl Gabram, MD4; and Mylin Torres, MD1

BACKGROUND: The authors compared treatment adherence rates and outcome in Caucasian and African American patients with inflammatory breast cancer (IBC). METHODS: The records of 55 (25 Caucasian and 30 African Ameri-can) IBC patients treated with curative intent from 1995 to 2009 were reviewed. All patients received neoadjuvant doxorubicin (Adriamycin) and/or taxane-based chemotherapy, and mastectomy with or without radiotherapy. The median follow-up period for Caucasian and African American patients was similar (39.5 months and 36.1 months, respectively). RESULTS: There was no difference between races in median age, tumor size, grade, and receptor status at diagnosis. The number of patients who completed neoadjuvant chemotherapy, surgery, and radiotherapy did not differ by race (84% of Caucasians vs 86.7% of African Americans) nor did the median length of time to complete tri-modality treatment (263 [range, 207-422] days for Caucasians vs 262 [range, 165-371] days for African Americans). There was a trend toward slightly higher pathological complete response rates in Caucasian than African American women (20% in Caucasians vs 6.7% in African Americans,P ¼ .23). Despite slightly better response rates to neoadju-vant chemotherapy, Caucasian patients did not have higher 3-year local control rates (70% in Caucasians vs 64% in African Americans, P ¼ .73). However, there was a trend toward higher 3-year overall survival in Caucasian versus African American patients (73% in Caucasians vs 55% in African Americans,P ¼ .09) and higher distant metastasis-free survival (60% in Caucasians vs 40% in African Americans,P ¼ .19). CONCLUSIONS: This study is among the larg-est to examine patients with IBC by race. Being Caucasian or African American did not appear to impact treatment adherence. However, African American patients tended to have poorer response to standard treatment and worse outcome than Caucasian patients. Cancer 2011;117:5485–92. VC 2011 American Cancer Society.

KEYWORDS: inflammatory breast cancer, combined therapy, race, African American, treatment adherence.

Inflammatory

breast cancer (IBC) is an aggressive, rare subtype of locally advanced breast cancer with rapid disease progression and clinical findings of skin erythema, edema (peau d’orange), breast induration, warmth, and asymmetric enlargement. Typically, extensive lymphovascular invasion by tumor emboli is present and involves the superficial dermal plexus of vessels in the papillary and high reticular dermis.1The National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database shows that IBC accounts for<1% to approximately 5% of all breast malignancies in the United States.2,3

Patients with IBC are typically younger at diagnosis than patients diagnosed with all other types of breast cancer (me-dian age, 57 vs 64 years).4IBC patients also have a worse clinical outcome than do other patients with T4 disease.3Median survival for a patient with IBC is approximately 30 months, and the 10-year survival rate is<30%.3The advent of multi-modality therapy, consisting of neoadjuvant chemotherapy, particularly anthracyclines and taxane-based treatment, sur-gery, radiotherapy (XRT), and hormonal therapy, has markedly improved outcomes over the past 2 decades.5,6Currently,

DOI: 10.1002/cncr.26187, Received: February 8, 2011; Revised: March 9, 2011; Accepted: March 10, 2011, Published online June 20, 2011 in Wiley Online Library (wileyonlinelibrary.com)

Corresponding author: Mylin Torres, MD, Department of Radiation Oncology, Emory University School of Medicine, 1365 Clifton Rd. NE, Building A, Rm1309, Atlanta, GA 30322; Fax: (404) 778-4139; matorre@emory.edu

1

Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia;2Department of Radiation Oncology, Cukurova University School of Medicine, Adana, Turkey;3

Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia;4 Depart-ment of Surgery, Winship Cancer Institute of Emory University, Atlanta, Georgia

This study was presented at the American Society for Therapeutic Radiology and Oncology 52nd Annual Meeting, San Diego, California, October 31-November 4, 2010.

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local control rates for patients treated with chemotherapy, mastectomy, and postmastectomy radiation now approach 70% to 80%, and 5-year survival rates are 30% to 40%.5,6

The proportion of African American women diag-nosed with IBC is higher than the proportion of Cauca-sian women diagnosed with IBC.7 African American breast cancer patients have worse survival rates compared with Caucasian patients in all stages of breast cancer.7,8 Socioeconomic disadvantages and decreased access to healthcare may contribute to lower survival rates in Afri-can AmeriAfri-cans, leading to delayed diagnosis and treat-ment, in addition to treatment noncompliance.9 Later stage breast cancer presentation appears to be the major contributor to the lower survival rates described in African American women.10,11However, even after adjusting for stage and age, the biologically aggressiveness of the disease may have a substantial impact on outcome.9 African American women with breast cancer are at increased risk for developing high-grade, estrogen and progesterone re-ceptor-negative disease and having lymph node positiv-ity.12-16 Triple negative tumors have been known to be most prevalent among younger African American women17 and more frequent in premenopausal African American women (39%) compared with postmenopausal African American women (14%).18 African American women also face an increased risk of being diagnosed at a younger age with breast carcinoma.17,19However, there is a lack of evidence confirming that African American women with IBC have a poorer prognosis than Caucasian women with IBC because of the overall low incidence of IBC and markedly aggressive disease course. Previous studies of outcome differences between African American and Caucasian IBC patients have analyzed heterogeneous groups of IBC patients (both nonmetastatic and meta-static) treated with different antiquated treatment modal-ities.2,8The goal of our study was to review the outcomes of African American and Caucasian patients with nonme-tastatic IBC treated with modern neoadjuvant chemother-apy agents, surgery, and radiation treatment at Emory University in inner city Atlanta.

In this study, we retrospectively analyzed our 15-year single-institution experience in treating nonmeta-static IBC patients. The primary objective of this study was to compare treatment adherence rates and outcome in Caucasian and African American nonmetastatic IBC patients treated with definitive intent. All received stand-ard neoadjuvant doxorubicin (Adriamycin) and/or

tax-ane-based chemotherapy, and mastectomy with or without XRT and endocrine therapy if indicated.

MATERIALS AND METHODS

Study Population

The records of 55 (25 Caucasian and 30 African Ameri-can) nonmetastatic IBC patients who were treated with curative intent from 1995 to 2009 at Emory University including the Emory Clinic, Emory Midtown Hospital, and Grady Memorial Hospital were analyzed. Patients were staged according to the sixth edition of the American Joint Committee on Cancer Classification and Staging of Tumors.20 Fifty-one patients had stage IIIB (T4d N0/ N1/N2a M0) disease, and 4 patients had stage IIIC (T4d N3b/c M0) disease: inflammatory carcinoma (T4d), no regional lymph node metastasis (N0), metastasis in mova-ble ipsilateral axillary lymph node(s) (N1), metastasis in ipsilateral axillary lymph nodes fixed to each other (mat-ted) or to other structures (N2a), metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) (N3b), metastasis in ipsilateral supraclavicular lymph node(s) (N3c), no distant metastasis (M0). This study was approved by the Emory University Institutional Review Board.

All patients had complete history, physical examina-tion, mammography, and ultrasound for the evaluation of regional nodes and breast tissue. Routine blood cell counts, serum chemistry tests, chest x-ray, computed to-mography (CT), and bone scan were performed to detect distant metastasis. Positron emission tomography/CT scan and breast magnetic resonance imaging were per-formed in some patients as a part of their workup.

The diagnosis of IBC was based on physical exami-nation in all patients. Dermal lymphatic invasion on pa-thology was seen in 32 patients (58.2%), unknown in 12 patients (21.8%), and absent in 11 patients (20%).

All patients received neoadjuvant doxorubicin (Ad-riamycin) and/or taxane-based chemotherapy and mas-tectomy. Because of poor response to neoadjuvant chemotherapy, adjuvant chemotherapy (mostly consisting of Adriamycin- or Taxol-based regimens) was adminis-tered to 14 Caucasian and 12 African American women. Clinical response to neoadjuvant chemotherapy was determined via physical examination and radiological studies and defined as either complete in cases where all clinical signs of IBC disappeared or partial response in cases with any improvement in clinical signs.

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After neoadjuvant chemotherapy, modified radical mastectomy (MRM) was performed in 23 Caucasian and 28 African American patients. Axillary lymph node dissec-tion was performed in all MRM patients except 2 Cauca-sian patients with negative sentinel lymph node. Simple mastectomy was performed in 2 Caucasian and 2 African American patients with clinically persistent T4d tumor and/or massive residual cancer in breast after neoadjuvant chemotherapy. A resection margin of 2 mm was accepted as negative margin and<2 mm as close/positive margin. A pathologic complete response was defined as no residual invasive carcinoma in the pathology report.

Neoadjuvant chemotherapy was followed by mas-tectomy in the majority of patients; however, 2 patients with poor response to chemotherapy were treated with preoperative XRT.

Although all patients were prescribed XRT, 5 patients did not receive XRT because of progressive dis-ease and patient refusal (3 Caucasians and 2 African Americans). However, 3 patients with progressive disease received salvage chest wall XRT in their course of treat-ment. Ten patients in this cohort received their adjuvant XRT at a facility outside of the Emory system. Among patients who received XRT at Emory, 50 gray (Gy) was delivered to the chest wall and draining lymphatics (including internal mammary, axillary, and supraclavic-ular lymph nodes), followed by a 10- to 16-Gy boost to the scar and/or chest wall in 2-Gy fractions per day. A 10-Gy boost to the supraclavicular fossa was delivered in 1 patient with supraclavicular involvement. Tissue equiva-lent bolus was placed on the chest wall beginning with the first day of XRT until achieving skin erythema.

In all patients with estrogen receptor-positive tumors, hormone therapy was given (9 Caucasians and 9 African Americans). The number of human epidermal growth factor receptor 2 (HER-2/neu)-positive patients by race was 8 Caucasians versus 9 African Americans. However, trastuzumab was given to more Caucasian (6 of 8) than African American (1 of 9) patients (P¼ .02) due to the majority of HER-2/neu–positive Caucasian patients being diagnosed and treated after 2004 when tras-tuzumab use became routine at our institution. The me-dian follow-up period from the date of surgery for Caucasian and for African American patients was similar (39.5 [range, 7-167] and 36.1 [range, 4-108] months, P ¼ .31, respectively).

Patient and tumor characteristics by race are listed in Table 1. Treatment characteristics by race are displayed in Table 2.

Statistical Analysis

Patient, disease, and treatment characteristics were ana-lyzed using Statistics Package for the Social Sciences (SPSS, Chicago, Ill). Chi-square test was used to assess categorical variables and Mann-Whitney U test for ordi-nal variables. Differences in means were compared by in-dependent samples t test. Recurrence-free survival, distant metastasis-free survival, and overall survival (OS) were estimated using the Kaplan-Meier method. A P value <.05 was accepted as statistically significant. All statistical analysis was 2-sided.

RESULTS

There was no difference between races in median age (49 [range, 35-65] years for Caucasians vs 52.5 [range, 30-77] years for African Americans) or in the proportion of women<40 years or <50 years of age. Receptor status, HER-2/neu status, tumor size, and grade at diagnosis were also similar in both groups. However, Caucasian patients had significantly fewer clinically involved nodes (N2/N3) at diagnosis than African American patients (P ¼ .045). More Caucasian than African American patients were premenopausal (48% vs 23.3%, respectively, P ¼ .06).

A larger proportion of African American than of Caucasian women had significant comorbidities at diag-nosis (66.7% vs 32%, P¼ .01). The most prevalent was hypertension (50% in African Americans vs 16% in Cau-casians) and diabetes mellitus (26.7% in African Ameri-cans vs 12% in Caucasians). Furthermore, 1 African American woman had a history of liver transplant.

Despite the difference in pre-existing comorbidities, being African American or Caucasian did not appear to impact treatment adherence. The number of patients who completed neoadjuvant chemotherapy, surgery, and XRT did not differ by race (84% in Caucasians vs 86.7% in African Americans), nor did the median length of time to complete trimodality therapy (263 [range, 207-422] days for Caucasians vs 262 [range, 165-371] days for African Americans).

Although there was no difference in initial stage or receptor status at diagnosis, there was a trend toward slightly higher pathological complete response rates in Caucasian than in African American women (20% in Caucasians vs 6.7% in African Americans, P¼ .23). After neoadjuvant chemotherapy, Caucasian patients were less likely than African American patients to have ypT4 dis-ease (24% in Caucasians vs 43.3% in African Americans,

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Table 1. Patient and Disease Characteristics

Characteristic Caucasian

(n5 25)

African American

(n5 30) P

Age at diagnosis, y [range] 49 [35-65] 52.5 [30-77] NS

<50 years old 13 (52%) 13 (43.3%) NS Menopausal status .06 Premenopausal 12 (48%) 7 (23.3%) Postmenopausal 13 (52%) 23 (76.7%) Family history NS Positive 8 (32%) 8 (26.7%) Unknown 2 (8%) 4 (13.3%) BMI>25 NS Yes 19 (76%) 19 (63.3%) Unknown 2 (8%) 9 (30%) Comorbidities 8 (32%) 20 (66.7%) .01a Breast NS Left 14 (56%) 16 (53.3%) Right 11 (44%) 14 (46.7%)

Clinical stage at diagnosis NS

IIIB 24 (96%) 27 (90%)

IIIC 1 (4%) 3 (10%)

Tumor size at diagnosis

>5 cm 9 (36%) 8 (26.7%) NS

Unknown 10 (40%) 13 (43.3%)

Clinical nodal status at diagnosis .045a

N0 7 (28%) 4 (13.3%) N1 13 (42%) 8 (26.7%) N2 3 (12%) 8 (26.7%) N3 1 (4%) 3 (10%) Unknown 1 (4%) 7 (23.3%) Histology NS Invasive ductal 22 (88%) 24 (80%) Invasive lobular 3 (12%) 3 (10%)

Invasive ductal and lobular 0 (0%) 3 (10%)

Tumor grade at biopsy NS

1 0 (0%) 2 (6.7%) 2 7 (28%) 2 (6.7%) 3 13 (42%) 19 (63.3%) Unknown 5 (20%) 7 (23.3%) Estrogen receptor NS Positive 9 (36%) 9 (30%) Unknown 3 (12%) 4 (13.3%) Progesterone receptor NS Positive 7 (28%) 5 (16.7%) Unknown 3 (12%) 4 (13.3%) HER-2/neu NS Positive 8 (32%) 9 (30%) Unknown 7 (28%) 7 (23.3%) Triple negative NS Yes 5 (20%) 7 (23.3%) Unknown 4 (16%) 5 (16.7%)

Abbreviations: BMI, body mass index; HER-2/neu human epidermal growth factor receptor 2; NS, not significant.

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Table 2. Treatment Characteristics and Response Characteristic/Response Caucasian (n5 25) African American (n5 30) P Neoadjuvant chemotherapy NS

Dose dense (AC/T) 9 (36%) 3 (10%)

Regular (AC/T) 15 (60%) 11 (36.7%)

Unknown 1 (4%) 16 (53.3%)

Endocrine therapy in estrogen receptor-positive patients 9 (100%) 9 (100%) NS Trastuzumab use in HER-2/neu–positive patients 6 (75%) 1 (11.1%) .02a

Clinical imaging response NS

Partial 15 (60%) 16 (53.3%) Complete 8 (32%) 3 (10%) Unknown 2 (8%) 11 (36.7%) Pathological response .23 Partial 20 (80%) 28 (93.3%) Complete 5 (20%) 2 (6.7%) Surgery type NS Simple mastectomy 2 (8%) 1 (3.3%) MRM 23 (92%) 29 (96.7%) ypN stage .22 N0 7 (28%) 6 (20%) N1 6 (24%) 6 (20%) N2 7 (28%) 8 (26.7%) N3 3 (12%) 8 (26.7%) Unknown 2 (8%) 2 (6.7%)

Extracapsular nodal extension NS

Positive 7 (43.8%) 11 (50%) Unknown 1 (6.3%) 0 (0%) yp T stage .08 T0 6 (24%) 4 (13.3%) T1 9 (36%) 6 (20%) T2 1 (4%) 3 (10%) T3 3 (12%) 3 (10%) T4 6 (24%) 13 (43.3%) Unknown 0 (0%) 1 (3.3%) Grade at surgery .03a 1 2 (10.5%) 1 (4%) 2 6 (31.6%) 6 (24%) 3 4 (21.1%) 17 (68%) Unknown 7 (36.8%) 2 (8%) Lymphovascular invasion NS Yes 13 (52%) 14 (46.7%) Unknown 1 (4%) 0 (0%)

Dermal invasion at surgery 8 (32%) 12 (40%) NS

Close margin at surgery NS

Yes 0 (0%) 4 (13.3%) Unknown 1 (4%) 0 (0%) Adjuvant chemotherapy NS Yes 14 (56%) 12 (40%) Unknown 1 (4%) 7 (23.3%) Radiotherapy NS Yes 21 (84%) 26 (86.7%) No 3 (12%) 2 (6.7%) Unknown 1 (4%) 2 (6.7%)

Contralateral breast recurrence 0 (0%) 4 (13.3%) NS A, adriamycin; C, cyclophosphamide; T, taxol. HER-2/neu human epidermal growth factor receptor 2; MRM, modified radical mastectomy; NS, not significant.

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P¼ .08), ypN3 disease (12% in Caucasians vs 26.7% in African Americans, P¼ .22), and grade 3 tumors (21.1% in Caucasians vs 68% in African Americans, P¼ .03).

Despite slightly higher response rates to neoadjuvant chemotherapy, Caucasian patients did not have signifi-cantly higher rates of local control at 3 years (70% in Cau-casians vs 64% in African Americans, P¼ .73). However, there was a trend toward higher 3-year distant metastasis-free survival (60% in Caucasians vs 40% in African Amer-icans, P¼ .19) and OS in Caucasian women (73% in Caucasians vs 55% in African Americans, P¼ .09). Fig-ures 1 to 3 show recurrence-free survival, distant metasta-sis-free survival, and OS for the Caucasian and African American patients.

Although more HER-2/neu–positive Caucasian than African American patients received trastuzumab, trastuzumab treatment on univariate analysis did not appear to influence outcome in this small patient cohort and could not account for the higher OS rate in Caucasian women.

DISCUSSION

IBC is a clinical diagnosis based on clinical presentation and the rapidity of onset, which often relies on the history provided by the patient. Diagnosis of IBC may show con-siderable variability, particularly in women with darker skin, where erythema and peau d’orange may be more

dif-ficult to assess or confused with lymphatic congestion. The strength of this study is its large number of IBC cases treated within a single institution with the systematic standardization of clinical and pathologic diagnosis crite-ria. Furthermore, we limited the study to nonmetastatic IBC patients who received neoadjuvant doxorubicin (Ad-riamycin) and/or taxane-based chemotherapy and mastec-tomy to evaluate a more uniform population treated with standard therapies.

Figure 1. Recurrence-free survival is shown for the Caucasian (C) and African American (AA) patients.

Figure 2. Distant metastasis-free survival is shown for the Caucasian (C) and African American (AA) patients.

Figure 3. Overall survival is shown for the Caucasian (C) and African American (AA) patients.

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This study reported a large, single-institution 15-year experience in nonmetastatic IBC patients treated with an initial intent to deliver multimodality curative treat-ment. We demonstrated that being African American or Caucasian did not appear to impact treatment adherence. However, similar to previous studies, African American patients had higher nodal burden at diagnosis and tended to have poorer response to standard treatment compared with Caucasian patients.8,12,13,16However, other adverse prognostic factors such as triple-negative receptor status, HER-2/neu status, and tumor size at diagnosis were simi-lar for African American and Caucasian women. Although poorer response rates to neoadjuvant chemotherapy did not translate into significantly lower rates of local control at 3 years, there was a trend toward poorer 3-year OS and distant metastasis-free survival in African American patients compared with Caucasian patients.

Previous studies of IBC by race have supported our findings. A recent study analyzing the SEER database showed that African American women with IBC had poorer survival than Caucasian women.7However, these patients were treated with several regimens at different institutions.7In an analysis of Florida cancer center regis-try data, treatment variabilities were high between African American and Caucasian IBC patients.8 A significantly greater fraction of Caucasian women underwent surgery than did African American women, and significantly more African American women were treated with chemo-therapy alone compared with Caucasian women.8 The authors concluded that when matched for all indicators of prognosis and treatment regimens, African American women still had overall worse survival outcomes.8

In our study, African Americans had significantly higher rates of comorbidities (P¼ .01), with hypertension and diabetes mellitus being most prevalent. Similar to our results, analysis of Florida cancer center registry data showed that African American IBC patients had nearly twice the rate of diabetes (P¼ .002), hypertension (P ¼ .001), and obesity (P¼ .002) than Caucasian patients.8

In our small study, the median age at diagnosis was not different between African American and Caucasian women with IBC. There was also no difference among the 2 groups in the proportion of women aged<40-years or <50 years. Furthermore, Caucasian women were more likely to be premenopausal than African American patients (P¼ .06) in our patient population. However, several other studies3,8have reported that African Ameri-can IBC women are often diagnosed at a younger age than Caucasian women.

Despite advances in multimodal therapies, IBC remains a therapeutic challenge, with rapid disease pro-gression and early distant metastasis. The etiology, biol-ogy, and molecular profile of IBC need further study to understand and overcome its aggressiveness and resistance to current treatment modalities, particularly in African American women.

Conclusions

Our single-institution experience is among the largest to examine IBC patients by race. Being African American or Caucasian did not appear to impact treatment adherence. However, with limited follow-up, there was a trend toward decreased response to standard multimodality treatment and worse outcome in African American patients than in Caucasian patients. Longer follow-up and future studies are warranted investigating the impact of race and new targeted agents in women with IBC.

FUNDING SOURCES No specific funding was disclosed.

CONFLICT OF INTEREST DISCLOSURES The authors made no disclosures.

REFERENCES

1. Haagensen Caucasian. Diseases of the Breast. 2nd ed. Phil-adelphia, PA: Saunders, 1971;576-584.

2. Levine P, Steinhorn S, Ries L, et al. Inflammatory breast cancer. The experience of the Surveillance Epidemiology and End Results (SEER) program. J Natl Cancer Inst. 1985;74:291-297.

3. Chang S, Parker S, Pham T, et al. Inflammatory breast car-cinoma incidence and survival. The Surveillance Epidemiol-ogy and End Results (SEER) Program of the National Cancer Institute, 1975-1992. Cancer. 1998;82:2366-2372. 4. Yang R, Cheung MC, Franceschi D, et al. African-American

and low-socioeconomic status patients have a worse progno-sis for invasive ductal and lobular breast carcinoma: do screening criteria need to change? J Am Coll Surg. 2009;208:853-868.

5. Fields JN, Perez CA, Kuske RR, et al. Inflammatory carci-noma of the breast: treatment results on 107 patients. Int J Radiat Oncol Biol Phys. 1989;17:249-255.

6. Krutchik AN, Buzdar AU, Blumenschein GR, et al. Com-bined chemoimmunotherapy and radiation therapy of inflammatory breast carcinoma. J Surg Oncol. 1979;11:325-332.

7. Hance KW, Anderson WF, Devesa SS, et al. Trends in inflammatory breast carcinoma incidence and survival: the surveillance, epidemiology, and end results program at the National Cancer Institute. J Natl Cancer Inst. 2005;97:966-975.

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8. Yang R, Cheung MC, Hurley J, et al. A comprehensive evaluation of outcomes for inflammatory breast cancer. Breast Cancer Res Treat. 2009;117:631-641.

9. Joslyn SA, West MM. Racial differences in breast carcinoma survival. Cancer. 2000;88:114-123.

10. Wojcik BE, Spinks MK, Optenberg SA. Breast carcinoma survival analysis for African American and white women in an equal-access health care system. Cancer. 1998;82:1310-1318.

11. Yood MU, Johnson CC, Blount A, et al. Race and differen-ces in breast cancer survival in a managed care population. J Natl Cancer Inst. 1999;91:1487-1491.

12. Henson DE, Chu KC, Levine PH. Histologic grade, stage, and survival in breast carcinoma: comparison of African American and Caucasian women. Cancer. 2003;98:908-917. 13. Elledge RM, Clark GM, Chamness GC, et al. Tumor

bio-logic factors and breast cancer prognosis among white, His-panic, and black women in the United States. J Natl Cancer Inst. 1994;86:705-712.

14. Mohla S, Sampson CC, Khan T, et al. Estrogen and proges-terone receptors in breast cancer in black Americans:

correla-tion of receptor data with tumor differentiacorrela-tion. Cancer. 1982;50:552-559.

15. Rizzo M, Lund MJ, Mosunjac M, et al. Characteristics and treatment modalities for African American women diag-nosed with stage III breast cancer. Cancer. 2009;115:3009-3015.

16. Chen VW, Correa P, Kurman RJ, et al. Histological charac-teristics of breast carcinoma in blacks and whites. Cancer Epidemiol Biomarkers Prev. 1994;3:127-135.

17. Lund MJ, Trivers KF, Porter PL, et al. Race and triple neg-ative threats to breast cancer survival: a population-based study in Atlanta, GA. Breast Cancer Res Treat. 2009;113: 357-370.

18. Carey LA, Perou CM, Livasy CA, et al. Race, breast cancer subtypes, and survival in the Carolina Breast Cancer Study. JAMA. 2006;295:2492-2502.

19. Aziz H, Hussain F, Sohn C, et al. Early onset of breast car-cinoma in African American women with poor prognostic factors. Am J Clin Oncol. 1999;22:436-440.

20. American Joint Committee on Cancer Staging Manual. 6th ed. New York, NY: Springer; 2002.

Şekil

Table 1. Patient and Disease Characteristics
Table 2. Treatment Characteristics and Response Characteristic/Response Caucasian (n 5 25) African American(n5 30) P Neoadjuvant chemotherapy NS
Figure 1. Recurrence-free survival is shown for the Caucasian (C) and African American (AA) patients.

Referanslar

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