JNCI Journal of the National Cancer Institute最新文献

Background: Women diagnosed with breast cancer at young ages (younger than 40 years) generally have lower survival than their older counterparts. With its young population structure, sub-Saharan Africa provides an informative setting to examine survival among young patients with breast cancer, including consideration of the extended reproductive lives and HIV comorbidities.

Methods: We established a prospective cohort of women aged 18 years and older newly diagnosed with breast cancer in five sub-Saharan African countries during 2014-2017, who were actively followed for up to 7 years. Overall survival, net survival, and Cox model hazard ratios (HRs) were used to assess the association between age at diagnosis and all-cause mortality.

Results: Among 2093 women, 459 (21.9%) were diagnosed under age 40 years ("young" women). Five-year net survival was 36% (95% confidence interval [CI] = 31% to 40%) in these young women, which was 8-14 percentage points lower than that for those diagnosed in their 40s, 50s, 60s, and 70s or older, being 43%, 45%, 47%, and 50%, respectively. Compared with women diagnosed at age 40-59 years, young women had 1.17-fold (95% CI = 1.02 to 1.35) higher mortality rates, unexplained by triple-negative breast cancer and HIV which were both less prevalent in young women than in those aged 40-59 years. Adjustment for sociodemographic, clinical, and treatment factors hardly altered results, except for adjustment for having had a pregnancy within the past 3 years (HR = 1.09, 95% CI = 0.93 to 1.28).

Conclusion: Early onset breast cancer in sub-Saharan Africa was associated with lower survival compared with women aged 40-59 years. This excess mortality was restricted to young women whose breast cancer was diagnosed within 3 years postpartum, thus identifying a patient group with specific early detection, treatment support and research needs.

Background: Fecal immunochemical test (FIT) performance for colorectal cancer screening varies by age and sex, yet most FIT-based screening programs use uniform positivity thresholds. This study assessed the potential benefits of stratifying FIT thresholds based on age and sex.

Methods: We conducted a meta-analysis of FIT sensitivity and specificity at various positivity thresholds by age and sex. We then used these estimates in 2 microsimulation models of colorectal cancer and projected lifetime clinical outcomes, incremental costs, and quality-adjusted life-years (QALYs) gained from age- and sex-stratified FIT strategies. FIT thresholds ranged from 10 to 50 µg hemoglobin per gram of feces.

Results: For current uniform FIT screening (20 µg hemoglobin/gram of feces), models projected 85.67 to 122.15 QALYs gained at incremental costs of ‒$982 to $504 per 1000 individuals compared with no screening. At equivalent costs to current uniform screening, only 1 model found stratified FIT approaches cost-effective, yielding a marginal increase of 1.04 and 1.10 QALYs gained/1000 female and male individuals, respectively. At a willingness-to-pay threshold of $100 000/QALYs gained, both models found stratified FIT cutoffs to be the best strategy, with cutoffs being equal to or higher for males and lowest at older ages (70-75 years). Uniform strategies showed comparable effectiveness, falling within 1 quality-adjusted life-day per person of efficient strategies at up to $112 more per person. Results were sensitive to FIT test performance characteristics and 1-time setup costs.

Conclusion: Stratifying FIT thresholds by age and sex may be cost-effective compared to current screening. The gain in expected health benefits with stratified FIT screening, however, is likely small.

Self-identified race and ethnicity (SIRE) and genetic ancestry are potentially associated with disparities in health outcomes; however, independent effects of SIRE and genetic ancestry on mortality in cancer survivors including when adjusting for multiple risk factors are understudied. Among 23 445 cancer survivors in the Prostate, Lung, Colorectal, and Ovarian Screening Trial, SIRE was associated with mortality among prostate, colorectal, lung, ovarian, and breast cancer survivors; genetic ancestry was associated with mortality among prostate, colorectal, and breast cancer survivors. Associations were strong when adjusting for age at cancer diagnosis, sex, and tumor characteristics but attenuated when adjusting for individual-level factors and population-level socioeconomic status. For example, mortality risk was higher among Black vs White prostate cancer survivors and African genetic ancestry vs European genetic ancestry, but associations were attenuated after multilevel adjustment. Results suggest that SIRE and genetic ancestry do not solely reflect biologic variation; rather, social factors may drive mortality differences by SIRE and genetic ancestry.

Background: Although emerging studies link air pollution to mortality in patients with breast cancer, large-scale evidence remains limited. We aimed to evaluate associations between chronic exposures to three key regulated air pollutants, fine particulate matter, ozone, and nitrogen dioxide, and mortality in a nationwide cohort of older patients with breast cancer.

Methods: We constructed a cohort of patients with primary diagnosis of breast cancer aged 65 years or older between 2000 and 2016 using the Surveillance, Epidemiology, and End Results-Medicare database. High-resolution ambient concentrations of annual fine particulate matter, warm-season ozone, and annual nitrogen dioxide were estimated using hybrid models and linked to patients' residential zip codes as proxy exposures. A 3-pollutant Cox model was fitted to estimate hazard ratios for mortality associated with each pollutant, adjusting for demographics, tumor characteristics, cancer treatments, comorbidities, lifestyle factors, meteorological variables, and neighborhood-level characteristics.

Results: Among 593 333 patients with breast cancer, a 1-µg/m3 increase in annual fine particulate matter, a 1-part per billion increase in warm-season ozone, and a 1-part per billion increase in annual nitrogen dioxide were associated with hazard ratios for mortality of 1.0048 (95% CI = 1.0026 to 1.0070), 1.0021 (95% CI = 1.0013 to 1.0029), and 1.0022 (95% CI = 1.0014 to 1.0030), respectively. This finding translated to 49 annual excess deaths attributable to fine particulate matter, 21 to ozone, and 22 to nitrogen dioxide within the cohort. Effects were substantially larger at low exposure levels. Fine particulate matter and nitrogen dioxide had greater effects in younger patients, individuals who received chemotherapy or radiation, and individuals with disease diagnosed at later stages.

Conclusion: Our findings identified air pollution as a risk factor for mortality in older patients with breast cancer. Protective measures and air pollution control strategies may help reduce exposure and improve outcomes.