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Recruitment and Retention in Mexican- American Populations Breast Cancer in Hispanic/Latina Women Melissa Bondy, Ph.D. Professor of Epidemiology March.

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Presentation on theme: "Recruitment and Retention in Mexican- American Populations Breast Cancer in Hispanic/Latina Women Melissa Bondy, Ph.D. Professor of Epidemiology March."— Presentation transcript:

1 Recruitment and Retention in Mexican- American Populations Breast Cancer in Hispanic/Latina Women Melissa Bondy, Ph.D. Professor of Epidemiology March 4, 2011

2 Presentation Outline Breast Cancer in Hispanic/Latina Women Breast Cancer in Hispanic/Latina Women Incidence/morality rates Incidence/morality rates Unique disparities Unique disparities Breast Cancer Tumor Subtypes Breast Cancer Tumor Subtypes The ELLA Binational Breast Cancer Study The ELLA Binational Breast Cancer Study Study Objectives Study Objectives Organizational Structure and Milestones Organizational Structure and Milestones U.S.-Mexico Comparisons U.S.-Mexico Comparisons Recruitment and Retention of Study Participants Recruitment and Retention of Study Participants

3 Breast Cancer in Hispanic/Latina Women

4 Female Breast Cancer Incidence and Death Rates* by Race/Ethnicity, Arizona 1999-2001 *Age-adjusted rates per 100,000 Source: Arizona Cancer Registry

5

6 Breast Cancer in Hispanics Hispanic population in U.S. is largely underserved and under- represented in research studies and clinical trials. Hispanic population in U.S. is largely underserved and under- represented in research studies and clinical trials. The profile of tumor presentation among Hispanic women with breast cancer is consistent with a pattern of more aggressive disease and less favorable prognosis compared to white women: The profile of tumor presentation among Hispanic women with breast cancer is consistent with a pattern of more aggressive disease and less favorable prognosis compared to white women: Younger women Younger women More likely to have cancer with higher grade More likely to have cancer with higher grade More likely to have larger tumors More likely to have larger tumors A higher proportion of tumors with later stage A higher proportion of tumors with later stage A higher proportion of ER- and triple negative tumors A higher proportion of ER- and triple negative tumors More likely to die of their disease than NHWs More likely to die of their disease than NHWs No data exist on the prevalence of clinically distinct tumor subtypes (i.e., basal, luminal types). No data exist on the prevalence of clinically distinct tumor subtypes (i.e., basal, luminal types). Refs: Miller, 2002; Li, 2002; Howe, 2006; Bauer, 2007; Martinez, 2007

7 Breast Cancer in Hispanic/Latina Women Soraya 1969-2006

8 Thompson and Stopeck, 2008 Compiled from (Millikan, Newman et al.; Carey, Perou et al. 2006; Mullan and Millikan 2007).

9 PAR Estimates by Ethnicity PAR Estimates by Ethnicity Hines et al., 2010 PRE-MENOPAUSAL FactorNHWHispanic Age menop Age menop---- Nat menop ---- HRT use ---- Age menarche Age menarche22.218 FamHx BC 11.71.4 Parity Parity5.5-2.7 AFB AFB12.68.7 No breastfeed 6.210.7 Height37.2-2.6 BMI11.610.2 OC use 19.216.6 ETOH ETOH-8.3-15.5 Inactivity1.2-5.9 Summary75.436.4POST-MENOPAUSALFactorNHWHispanic Age menop Age menop5.93.8 Nat menop 4.18.4 HRT use 17.5-6 Age menarche Age menarche14.7-5.5 FamHx9.87.6 Parity Parity9.19.4 AFB AFB-2.13 No breastfeed 3.3-4.4 Height19.18.1 BMI0.2-23.7 OC use -2.30.8 ETOH ETOH9.1-8.4 Inactivity1.98.5 Summary62.16.6

10 Binational Breast Cancer Study Estudio Binacional de Cáncer de Mama Funded by the Avon Foundation and The National Cancer Institute US PIs: M. Bondy E. Martinez P. Thompson Mexico PIs: A.Daneri M. Meza L.E. Gutierrez

11 What We Would like to Understand What types of breast cancers are common in women of Mexican descent? What types of breast cancers are common in women of Mexican descent? What type of breast cancer occur in women migrating from Mexico to the U.S.? What type of breast cancer occur in women migrating from Mexico to the U.S.? Is the disease the same in the country of origin? Is the disease the same in the country of origin? Are certain risk factors more strongly associated with specific types of breast cancer? Are certain risk factors more strongly associated with specific types of breast cancer?

12 Study Objectives To compare profiles of tumor markers of prognostic and predictive clinical importance (ER, PR, HER2, Ki67, cytokeratins) between women in Mexico and Mexican- American women in the US (case-case study design). To compare profiles of tumor markers of prognostic and predictive clinical importance (ER, PR, HER2, Ki67, cytokeratins) between women in Mexico and Mexican- American women in the US (case-case study design). To assess whether differences in markers are more pronounced by To assess whether differences in markers are more pronounced by Menopausal status Menopausal status Duration of residence in U.S. or residence status during adolescence Duration of residence in U.S. or residence status during adolescence Factors associated with lifestyles more representative of the US (low parity, late age at first birth, adult weight gain pattern, and body composition). Factors associated with lifestyles more representative of the US (low parity, late age at first birth, adult weight gain pattern, and body composition).

13 Additional Objectives Secondary Objective To determine genetic admixture (i.e., level of population mixing of European and indigenous American ancestry) to be correlated with the panel of standard tumor markers and other clinical characteristics. To determine genetic admixture (i.e., level of population mixing of European and indigenous American ancestry) to be correlated with the panel of standard tumor markers and other clinical characteristics. Operational Objectives To strengthen our cancer research collaboration with investigators at academic centers in the states of Sonora and Jalisco, Mexico. To strengthen our cancer research collaboration with investigators at academic centers in the states of Sonora and Jalisco, Mexico. To enhance capacity for breast tumor immuno- histochemistry among academic medical centers in Mexico, both as a clinical research tool and as an aid to treatment planning. To enhance capacity for breast tumor immuno- histochemistry among academic medical centers in Mexico, both as a clinical research tool and as an aid to treatment planning.

14 Binational Breast Cancer Study Estudio Binacional de Cáncer de Mama

15 Eligibility and Data Collection Eligibility Criteria Women 18+ years of age Newly diagnosed with invasive breast cancer within the last 2 yrs Mexican descent Data Collection Risk Factor Questionnaire Medical Record Data Saliva/blood (DNA bank) FFPE tissue collection Recruitment as of 4/1/10: 1075 (480 US, 595 Mexico)

16 Advisory Committee Steering Committee Principal Investigators US Sites MDACC University of Arizona Mexico Sites Universidad of Sonora Universidad de Guadalajara Instituto Tecnológico de Sonora Tumor Tissue Collection Collection at each site TMA construction at MDACC Sample Collection Blood or Saliva DNA Extraction at each site IT/Data Management Questionnaire and Medical Record Data Web-based database housed at Arizona Tumor Tissue DNA Extraction and Genotyping Blood/Saliva DNA GenotypingStatistics ELLA Study Organizational Structure

17 Recruitment Screened 1871 women from 2007 to present, 1034 of which were eligible for the study To date, consented 850 patients with 810 actively participating Received 64 patient refusals at MDACC

18 Refusals 48 African American (AA) and 16 Mexican American (MA) 48 African American (AA) and 16 Mexican American (MA) Historical skepticism and mistrust of the medical research system in the AA community Historical skepticism and mistrust of the medical research system in the AA community Barriers in access to care Barriers in access to care Language barriers Language barriers Younger Hispanic population (both overall study population and refusals) Younger Hispanic population (both overall study population and refusals) Most common reason given is that the patient is too overwhelmed at time of diagnosis Most common reason given is that the patient is too overwhelmed at time of diagnosis Other reasons include belief that study gives no direct benefit to the patient, fear of interference with treatment Other reasons include belief that study gives no direct benefit to the patient, fear of interference with treatment

19 Reasons for Refusal

20 Characteristics of Refusals Characteristic Refusals (N=64) Race African-American48 (75%) Mexican-American16 (25%) Age <40 Years7 (11%) 40-49 Years19 (30%) 50-59 Years15 (23%) 60+ Years23 (36%) Stage at Diagnosis I9 (15%) II22 (37%) III21 (35%) IV8 (13%) Subtype ER+/PR+39 (61%) HER2+8 (12%) ER-/PR-/HER2-17 (27%) Education Less than High School13 (24%) High School17 (31%) Post-High School25 (45%) Family History No46 (77%) Yes14 (23%)

21 Characteristics of Refusals by Race Characteristic African-Americans (N=48) Mexican-Americans (N=16)p-value Age <40 Years5 (10%)2 (12%)0.11 40-49 Years12 (25%)7 (44%) 50-59 Years10 (21%)5 (31%) 60+ Years21 (44%)2 (12%) Stage at Diagnosis I6 (14%)3 (19%)0.97 II16 (36%)6 (38%) III16 (36%)5 (31%) IV6 (14%)2 (12%) Subtype ER+/PR+28 (58%)11 (69%)0.84 HER2+6 (12%)2 (12%) ER-/PR-/HER2-14 (29%)3 (19%) Education Less than High School7 (17%)6 (46%)0.02 High School12 (28%)5 (39%) Post-High School23 (55%)2 (15%) Family History No34 (72%)12 (92%)0.26 Yes13 (28%)1 (8%)

22 Comparison of Refusals and Participants Characteristic Participants (N=788) Refusals (N=64)p-value Race African-American402 (51%)48 (75%)<0.001 Mexican-American386 (49%)16 (25%) Age <40 Years141 (19%)7 (11%)0.02 40-49 Years228 (31%)19 (30%) 50-59 Years213 (29%)15 (23%) 60+ Years149 (21%)23 (36%) Stage at Diagnosis I91 (21%)9 (15%)0.01 II210 (47%)22 (37%) III124 (28%)21 (35%) IV19 (4%)8 (13%) Subtype ER+/PR+408 (63%)39 (61%)0.10 HER2+130 (20%)8 (12%) ER-/PR-/HER2-111 (17%)17 (27%) Education Less than High School143 (18%)13 (24%)0.53 High School228 (29%)17 (31%) Post-High School408 (52%)25 (45%) Family History No623 (81%)46 (77%)0.44 Yes148 (19%)14 (23%)

23 Comparison of Refusals and Participants by Race African-AmericansMexican-Americans Characteristic Participants (N=402) Refusals (N=48)p-value Participants (N=386) Refusals (N=16) p-value Age <40 Years63 (17%)5 (10%)0.0278 (22%)2 (13%)0.68 40-49 Years111 (29%)12 (25%)117 (33%)7 (44%) 50-59 Years118 (31%)10 (21%)95 (27%)95 (31%) 60+ Years86 (23%)21 (44%)63 (18%)2 (12%) Stage at Diagnosis I43 (18%)6 (14%)0.0648 (24%)3 (19%)0.27 II124 (51%)16 (36%)86 (43%)6 (38%) III62 (26%)16 (36%)62 (31%)5 (31%) IV13 (5%)6 (14%)6 (3%)2 (12%) Subtype ER+/PR+201 (60%)28 (59%)0.37207 (65%)11 (69%)0.63 HER2+61 (18%)6 (12%)69 (22%)2 (12%) ER-/PR-/HER2-71 (21%)14 (29%)40 (13%)3 (19%) Education Less than High School27 (7%)7 (17%)0.06116 (30%)6 (46%)0.19 High School107 (27%)12 (29%)121 (32%)5 (38%) Post-High School262 (66%)23 (55%)146 (38%)2 (15%) Family History No317 (81%)34 (72%)0.17306 (81%)12 (92%)0.48 Yes75 (19%)13 (28%)73 (19%)1 (8%)

24 Lessons Learned Employ study staff who are of the same race/ethnicity Employ study staff who are of the same race/ethnicity Support from physicians who are treating the populations of interest Support from physicians who are treating the populations of interest Study does not require extensive follow up participation Study does not require extensive follow up participation

25 Preliminary Results US-Mexico Comparisons

26 Sociodemographic Characteristics U.S. (N=364) Mexico (N=401) Age at interview, mean (SD)51.6 (12.2)55.5 (12.7)* Country of birth, No. (%) U.S.-born150 (41.2)-- Foreign-born214 (58.8)-- Language use, No. (%) English173 (47.5)-- Spanish191 (52.5)--

27 Reproductive Factors CharacteristicU.S. (N=364)Mexico (N=401) Age at menarche, mean (SD)12.8 (1.6)12.9 (1.6) Parous, No. (%)334 (91.8)366 (91.3) Age at first live birth, mean (SD)22.7 (5.6)23.0 (5.5) No. live births, mean (SD)3.2 (1.8)3.9 (2.4)* Ever breastfeeding, No. (%)210 (57.7)322 (80.5)* Up to 9 months87 (41.4)78 (24.2) 9+ months123 (58.6)244 (75.8)* Age at natural menopause, mean (SD)48.7 (4.7)48.3 (5.4) Contraceptive use, No. (%)219 (60.7)197 (50.1)* HRT use, No. (%)49 (23.3)21 (7.6)* Women in Mexico women have significantly more children, breast feed more often (and for longer duration), use less OCs and HRT.

28 Family History and Lifestyle Factors CharacteristicU.S. (N=364)Mexico (N=401) Fam. history breast cancer, No. (%)56 (15.7)35 (9.0)* Recent BMI, mean (SD)29.6 (6.9)28.8 (5.4) Overweight, No. (%)105 (32.0)127 (38.0) Obese, No. (%)138 (42.1)124 (37.1) BMI at age 30, mean (SD)24.7 (4.9)24.0 (4.3) Waist circumference, cm94.4 (16.6)95.6 (12.8) Current cigarette smoking, No. (%)29 (8.0)21 (5.2) Women in Mexico report a significantly lower percentage of family history of BC

29 Clinical and Marker Data CharacteristicU.S. (N=350)Mexico (N=399) Stage, n (%) I86 (26)46 (14)* IIA/IIB130 (40)162 (48) IIIA/IIIB/IIIC89 (27)118 (35) IV22 (7)13 (4) Tumor markers, n (%) ER + 220 (72.4)161 (58.1)* PR + 173 (56.9)155 (56.0) HER2 + 68 (22.4)65 (23.5) Triple negative49 (16.1)57 (20.6) Women in Mexico have a lower proportion of early stage BC and a lower proportion of ER positive tumors

30 Family History: How Accurate is Self-Report? Country of Residence and Level of Acculturation Family Hx of Breast Cancer Mexico9.0% U.S.15.7% Spanish-dominant10.8% Bilingual19.4% English-dominant23.1%

31 Summary of Country Differences Significant differences in risk factor profiles observed between Mexico and the US Significant differences in risk factor profiles observed between Mexico and the US Parity, breastfeeding, age at menopause, family history of breast cancer, OC use, HRT. Parity, breastfeeding, age at menopause, family history of breast cancer, OC use, HRT. Obesity a major problem for both countries. Obesity a major problem for both countries. Clinical/marker characteristics (preliminary): Clinical/marker characteristics (preliminary): Younger age at diagnosis in US vs. Mexico Younger age at diagnosis in US vs. Mexico Triple negative disease is high in both countries: 16% in US and 21% in Mexico; difference could reflect variation in lab performance Triple negative disease is high in both countries: 16% in US and 21% in Mexico; difference could reflect variation in lab performance

32 Factors that Influence Mammography Use and Detection: Findings from the ELLA Binational Breast Cancer Study RACHEL ZENUK, MPH R Zenuk 1, J Nodora 2, S Carvajal 1, A Wilkinson 4, I Komenaks 3, A Brewster 4, G Cruz 1, BC Wertheim 2, M Bondy 4, P Thompson 1,2, ME Martinez 1,2 1 University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, Arizona, USA; 2 Arizona Cancer Center, Tucson, Arizona, USA; 3 Maricopa Medical Center, Phoenix, Arizona, USA; 4 M.D. Anderson Cancer Center, Houston, Texas, USA

33 Breast Cancer Screening Guidelines ACS recommends: Average-risk women should receive mammography at age 40 years or older; and High-risk women receive annual screening mammography and MRI beginning at age 30 years. USPSTF recommends: Regular biennial screening mammography should begin at age 50 to 74 years for women at average risk; and Women under age 50 years should talk to their doctor about beginning screening earlier or more frequently than biennially.

34 Change in Detection Method by Diagnosis Year (N=6074) Malmgren et al. BMC Cancer 2008 8:131

35 Significance and Rationale Compared to non-Hispanic Whites (NHWs), African Americans (AAs) and Hispanics with BC are diagnosed with more advanced disease resulting in poorer prognosis (Smith-Bindman et al. 2006; Carey et al. 2006; Martinez et al. 2007). Compared to non-Hispanic Whites (NHWs), African Americans (AAs) and Hispanics with BC are diagnosed with more advanced disease resulting in poorer prognosis (Smith-Bindman et al. 2006; Carey et al. 2006; Martinez et al. 2007). Includes 17,558 women from the NCI–funded Breast Cancer Surveillance Consortium with BC who had mammogram between 1996-2002.

36 Significance and Rationale Younger age, socioeconomic factors, insurance status, and acculturation/language use have been shown to play a role in knowledge about BC risk and screening mammography receipt; and Younger age, socioeconomic factors, insurance status, and acculturation/language use have been shown to play a role in knowledge about BC risk and screening mammography receipt; and Foreign-born women are less likely to know their family history of cancer and receive a mammogram than U.S.- born women Foreign-born women are less likely to know their family history of cancer and receive a mammogram than U.S.- born women Refs: John et al. 2005; Jacobs et al. 2005; Friedman 2006; Ramirez et al. 2000

37 Specific Aims Specific Aims: Assess factors that influence screening behaviors among AA and MA women. Assess method of BC detection among AA and MA women

38 Methods: Study Population and Recruitment ELLA study population ELLA study population Inclusion criteria: Inclusion criteria: AA and MA women aged 40-86 years AA and MA women aged 40-86 years BC diagnosis within last 24 months prior to interview BC diagnosis within last 24 months prior to interview Recruited in U.S. between March 1, 2007 - March 1, 2010 Recruited in U.S. between March 1, 2007 - March 1, 2010

39 Methods: Data Collection Medical Record Abstraction Medical Record Abstraction Age at diagnosis Age at diagnosis Stage at diagnosis Stage at diagnosis Insurance status Insurance status Interviewer-administered RFQ Interviewer-administered RFQ Sociodemographic characteristics Sociodemographic characteristics Reproductive history and hormone use Reproductive history and hormone use Anthropometrics Anthropometrics Acculturation (language use/exposure) Acculturation (language use/exposure) Breast health history (mammography use and method of BC detection) Breast health history (mammography use and method of BC detection)

40 Methods: Data collection Bidimentional Acculturation Scale (Marin and Gamba, 1996) Bidimentional Acculturation Scale (Marin and Gamba, 1996) Highly reliable 8-item language-based scale; each item scored 1(never)-5(always) Highly reliable 8-item language-based scale; each item scored 1(never)-5(always) Participants were classified as high or low acculturation using average cutoff of 2.99 Participants were classified as high or low acculturation using average cutoff of 2.99 Acculturation groups were: Acculturation groups were: English LOW English HIGH Spanish LOW Marginalized reclassified according to interview language English-dominant scored 3.0 average or above in both English and Spanish scales Spanish HIGH Spanish-dominant scored 3.0 average or above in the Spanish scale only Bilingual scored 3.0 average or above in the English scale only

41 Mammography use Prior to Breast Cancer Diagnosis

42 Odds Ratios for Mammography Use* Adj. for age Adj. for age, education Adj. for age, insurance * Compared to African Americans

43 Method of Detection among Screened Women

44 Delay between First BC Symptom(s) and Seeking Medical Attention p<0.001

45 Factors Influencing Health-seeking Behaviors Reasons for prolonging medical attention one month or more Discouraged6% Fear13% Doctor did not have any earlier appointments12% Unable to see a doctor due to other commitments6% Unable to afford or lack of health insurance31% Did not feel it was important33%

46 Study Findings Differences in mammography use prior to BC diagnosis observed in AA and MA women by level of acculturation are entirely explained by level of education. Differences in mammography use prior to BC diagnosis observed in AA and MA women by level of acculturation are entirely explained by level of education. Consistent with data in national surveys (70-80% based on BRFSS), AA and MA women in the ELLA Study report high rates of mammography; however, the majority of BC in the ELLA Study was NOT detected by mammography. Consistent with data in national surveys (70-80% based on BRFSS), AA and MA women in the ELLA Study report high rates of mammography; however, the majority of BC in the ELLA Study was NOT detected by mammography. 17% of women reported delaying more than 90 days between noticing their first BC symptom(s) and seeking medical attention from a health professional; the highest proportion was shown for Spanish dominant patients (33.3%). 17% of women reported delaying more than 90 days between noticing their first BC symptom(s) and seeking medical attention from a health professional; the highest proportion was shown for Spanish dominant patients (33.3%).

47 Conclusions Given that less acculturated MA women are less likely to have a usual source of medical care, they are less likely to follow the USPSTF recommendations to talk to their doctor about screening mammography. Given that less acculturated MA women are less likely to have a usual source of medical care, they are less likely to follow the USPSTF recommendations to talk to their doctor about screening mammography. AA and MA women must be educated about the importance of breast awareness and prompt reporting of any breast changes to a physician or health professional. AA and MA women must be educated about the importance of breast awareness and prompt reporting of any breast changes to a physician or health professional. Due to the large proportion of self-detected tumors among ELLA Study participants, additional work is needed to assess the degree of effectiveness of screening mammography in these underserved populations. Due to the large proportion of self-detected tumors among ELLA Study participants, additional work is needed to assess the degree of effectiveness of screening mammography in these underserved populations.

48 Ella Study Future Directions (N=5000) Epidemiological Risk Factors: Reproductive, Obesity, Physical Activity, Cultural Future Studies Genetic Risk Factors: BRCA germline mutation, GWAS hits, Ancestry X

49 BRCA Mutations in Hispanics 5-10% breast/ovarian cancers associated with BRCA1/BRCA2 mutations 5-10% breast/ovarian cancers associated with BRCA1/BRCA2 mutations City of Hope High-risk clinic (J. Weitzel, CEBP 2005): City of Hope High-risk clinic (J. Weitzel, CEBP 2005): Prevalence of deleterious mutations: 30.9% Prevalence of deleterious mutations: 30.9% Most common mutation (186delAG) also found in Ashkenazi Jewish families Most common mutation (186delAG) also found in Ashkenazi Jewish families Breast Cancer Family Registry BRCA1 Prevalence (E. John, JAMA 2008): Breast Cancer Family Registry BRCA1 Prevalence (E. John, JAMA 2008): 8.3% in Ashkenazi Jewish 8.3% in Ashkenazi Jewish 3.5% in Hispanics 3.5% in Hispanics 1.3% in African Americans 1.3% in African Americans

50 Summary Unique and tremendous (yet challenging) opportunities to address breast cancer disparities in Hispanic/Latina women. Unique and tremendous (yet challenging) opportunities to address breast cancer disparities in Hispanic/Latina women. Breast cancer rates are lower among Hispanic/Latina women, but unique disparities are evident. Breast cancer rates are lower among Hispanic/Latina women, but unique disparities are evident. Understanding of complex dynamic between tumor biology (i.e., aggressive disease types) and influence of poverty, culture, access to care (i.e., inadequate treatment) is important. Understanding of complex dynamic between tumor biology (i.e., aggressive disease types) and influence of poverty, culture, access to care (i.e., inadequate treatment) is important. Essential to involve the communities served. Essential to involve the communities served.

51 Acknowledgements MD Anderson Cancer Center MD Anderson Cancer Center M Bondy, A Sahin, K-A Do, C Amos, A Brewster, M Edgerton, G Hortobagyi M Bondy, A Sahin, K-A Do, C Amos, A Brewster, M Edgerton, G Hortobagyi University of Arizona University of Arizona ME Martínez, P Thompson, AM Lopez, AK Bhattacharyya, ER Greenberg, DS Alberts, R Nagle, R Livingston, I Komenaka ME Martínez, P Thompson, AM Lopez, AK Bhattacharyya, ER Greenberg, DS Alberts, R Nagle, R Livingston, I Komenaka Ventana Medical Systems Ventana Medical Systems Anne Lodge, Greg Stella, Eric Walk, Tom Grogan Anne Lodge, Greg Stella, Eric Walk, Tom Grogan Universidad of Sonora/Hermosillo Universidad of Sonora/Hermosillo LE Gutierrez-Millan, G Caire-Juvera (CIAD), E Urquieta-Hernandez, MI Arámbula-Rubio, MA Ortiz-Martínez LE Gutierrez-Millan, G Caire-Juvera (CIAD), E Urquieta-Hernandez, MI Arámbula-Rubio, MA Ortiz-Martínez Instituto Tecnológico de Sonora/Cd. Obregon Instituto Tecnológico de Sonora/Cd. Obregon MM Meza, A Gomez Alcalá, MA Ortiz Martinez, JM Ornelas Aguirre, MA Chávez Zamudio, L Pérez Michel MM Meza, A Gomez Alcalá, MA Ortiz Martinez, JM Ornelas Aguirre, MA Chávez Zamudio, L Pérez Michel Universidad de Guadalajara Universidad de Guadalajara A Daneri-Navarro, M Jimenez-Perez, R Franco-Topete, J Tavares, A Oceguera- Villanueva, G Morgan-Villela, G. Vazquez, MR Flores, A Barragan Ruiz, A Balderas, A Quintero-Ramos A Daneri-Navarro, M Jimenez-Perez, R Franco-Topete, J Tavares, A Oceguera- Villanueva, G Morgan-Villela, G. Vazquez, MR Flores, A Barragan Ruiz, A Balderas, A Quintero-Ramos Mexico Health Care Providers Mexico Health Care Providers Instituto Mexicano del Seguro Social, Hospital Civil de Guadalajara, Hospital Jaliscience de Cancerología Instituto Mexicano del Seguro Social, Hospital Civil de Guadalajara, Hospital Jaliscience de Cancerología

52 ¡¡Muchas Gracias!!

53 VariableAA (n=282) MA – English dominant (n=67) MA - bilingual (n=173) MA – Spanish dominant (n=148) Age at diagnosis, mean ± s.d.54.9 ± 9.655.3 ± 10.953.6 ± 9.754.4 ± 11.0 * Private insurance, n (%)131 (60.7)32 (62.8)81 (61.8)19 (19.4)* Foreign-born, n (%)13 (4.8)9 (13.4)70 (40.5)141 (95.3)* Less than high school, n (%)21 (7.6)7 (10.6)36 (20.8)106 (72.1) * Family history of BC, n (%)53 (20.7)14 (22.2)32 (18.9)15 (10.9) Oral contraceptive use, n (%)195 (73.3)41 (62.1)118 (68.2)67 (45.9) * BSE prior to diagnosis, n (%)250 (90.9)54 (80.6)146 (84.4)105 (71.0) * CBE prior to diagnosis, n (%)239 (87.2)61 (91.0)144 (83.2)102 (69.4) * Characteristics of Ella Study Population by Race/Ethnicity and Acculturation *P<0.05


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