1. Maria C. Mejia de Grubb, MD, MPH; Barbara Kilbourne, PhD; Courtney Kihlberg, MD, MSPH; and Robert Levine, MD. Department of Family and Community Medicine Meharry Medical College Nashville, TN October 30, 2012

2.  The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: “No relationships to disclose”

3.  Breast cancer is the leading cause of cancer death among Hispanic women.  Hispanic women have a 20 % greater risk of dying from breast cancer than non-Hispanic whites once a diagnosis is made even though incidence and mortality are lower.  Several factors might contribute to variations of breast cancer mortality by place.

4.  Describe demographic and geographic variations in Hispanic mortality from malignant neoplasm of the breast among US women ages 35-64 and 65-85+ years.

5.  Age-adjusted (Year 2000 standard) mortality rates and 95% confidence intervals were obtained from the Compressed Mortality File as presented on the public US Centers for Disease Control and Prevention WONDER (Wide-ranging Online Data for Epidemiologic Research) internet website.  ICD-10 code C50 (Malignant neoplasm of the breast)  All analyses were performed using SAS, v9.23  OLS regression models with dependent variable= age adjusted mortality rates (35-64 and 65-85+ years), and independent variables % Hispanics ≥25 years = annual income below poverty, not high school graduates, and renters.

6. Results

7. Age Group Hispanic Age- Adjusted Rate Non- Hispanic Age- Adjusted Rate Hispanic: Non- Hispanic MRR* 35-85+ Years AI/AN 4.7 (3.3 – 6.4) AI/AN 29.6 (28.1 – 31.1) 0.16 AA 13.3 (11.9 – 14.8) AA 64.3 (63.8 – 64.8) 0.21 API 21.4 (17.4 – 25.4) API 23.5 (23 – 24) 0.91 W 30.7 (30.3 – 31.2) W 47.5 (47.3 – 47.6) 0.65 Key: AA = Black or African American; AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander; W = White. *MMR= Hispanic: Non-Hispanic Mortality Rate Ratio.

8. Age GroupHispanic Age- Adjusted Rate Non- Hispanic Age- Adjusted Rate Hispanic: Non-Hispanic MMR* 35-64 Years AI/AN 3.2 (2.1 – 4.5) AI/AN 17.6 (16.5 – 18.8) 0.18 AA 7.9 (6.8 – 9) AA 43.6 (16.5 – 44.1) 0.18 API 11.4 (8.9 – 14.4) API 17 (16.6 – 17.5) 0.67 W 19.7 (19.3 – 20.1) W 26.6 (26.5 – 26.8) 0.74 65-85 + Years AI/AN 9.4 (5.1 – 15.7) AI/AN 66.2 (61.3 – 71.1) 0.14 AA 29.9 (25.1 – 34.8) AA 127.1 (125.6 – 128.6) 0.26 API 51.6 (38.7 – 67.5) API 43.3 (41.7 – 44.9) 1.19 W 64.3 (62.9 – 65.7) W 110.9 (110.5 – 111.4) 0.58

9. Age group Census Region Hispanic Age Adjusted Rate Non- Hispanic Age Adjusted Rate Hispanic: Non- Hispanic MMR* 35-64 years Northeast AA7.5AA41.2 0.18 W21W27 0.78 Midwest AA8.3AA44.1 0.19 W15.8W26.2 0.60 South API9.3API13.4 0.69 AA11.7AA44.4 0.26 W19.9W26.8 0.74 West AI/AN4.6AI/AN18 0.26 API13.9API20.3 0.68 AA3.5AA43.3 0.08 W20.2W26.5 0.76 Key: AA=Black or African American; AI/AN= American Indian or Alaskan Native; API= Asian or Pacific Islander; W=White. Census Region 1: Northeast; Census Region 2: Midwest; Census Region 3: South; Census Region 4: West. Absence of racial groups reflects lack of sufficient data to meet standards of confidentiality.

10. Age group Census Region Hispanic Age Adjusted Rate Non- Hispanic Age Adjusted Rate Hispanic: Non- Hispanic MMR* 65-85+ years Northeast AA27.6AA124.9 0.22 W67.8W118.8 0.57 Midwest AA43AA138.7 0.31 W48.6W112.8 0.43 South AA36.7AA125.5 0.29 W66.9W103 0.65 West API71.7API48.7 1.47 AA23.4AA124.5 0.19 W63.9W113.9 0.56 Key: AA=Black or African American; AI/AN= American Indian or Alaska Native; API= Asian or Pacific Islander; W=White. Census Region 1: Northeast; Census Region 2: Midwest; Census Region 3: South; Census Region 4: West. Absence of racial groups reflects lack of sufficient data to meet standards of confidentiality.

11. Percent Hispanic Population Age –Adjusted Breast Cancer Deaths for 100,000 Population

12. Percent Hispanic Population

13. Hispanic White 35-64 y/o VariableParameter Estimatep value Poverty %34.71<0.0001 Education %-9.880.029 Renters %-8.980.0006 Hispanic White 65-85+ y/o VariableParameter Estimatep value Poverty %49.60.1054 Education %-69.540.0032 Renters %-20.80.1003 Poverty %= percentage of Hispanics living in poverty, Education %= percentage of Hispanics with less than a high school education Renters %= percentage of Hispanics that are renters.

14. Age Group Large Metropolitan Areas Large Metropolitan Fringe Medium Metropolitan Small Metropolitan Micropolitan Non- core 35-64 y/o N=39 0.346* p=0.031 -0.094 p=0.567 -0.101 p=0.657 -0.046 p=0.780 -0.200 p=0.223 -0.308* p=0.056 65 + y/o N=34 0.168 p=0.342 -0.447** p=0.008 0.041 p=0.818 0.173 p=0.327 0.133 p=0.452 0.208 p=0.109

15. Strengths:  Mortality data has been validated for breast cancer and Hispanic ethnic classifications on death certificates.  The use of state level data allows to detect patterns of geographical variations. Limitations:  Social and structural factors are suitable for hypothesis generation but not for hypothesis testing.  Small power for detection of ethnic variations within Hispanic population.

16.  The data showed significant geographic and racial variations among Hispanic populations.  Analytic epidemiologic studies are needed to ascertain the underlying reasons, with special reference to particularly strong protective effects among AI/AN and AA Hispanics relative to non-Hispanic AI/AN and AA groups.  The observation of relatively high rates among elderly API residents in the western region needs further exploration.  Consideration of these factors would contribute to public health planning efforts.

17.  This research was supported grant number 5 P20 MD 000516 from the National Institute of Minority Health and Health Disparities.  Contact:  mmejiadegrubb@mmc.edu