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Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. Spring 2017 2017 Epidemiology Public health Black women, Breast cancer, Longitudinal trends, Risk factors, Tumor biology, Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. Spring 2017 2017 Epidemiology Public health Black women, Breast cancer, Longitudinal trends, Risk factors, Tumor biology, Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. Spring 2017 2017 Epidemiology Public health Black women, Breast cancer, Longitudinal trends, Risk factors, Tumor biology, Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. 2017-05 2017 Epidemiology Public health Black women, Breast cancer, Longitudinal trends, Risk factors, Tumor biology, Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. 2017 Epidemiology Public health Black women, Breast cancer, Longitudinal trends, Risk factors, Tumor biology, Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text 2017-05 Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. 2017 Epidemiology Public health Black women, Breast cancer, Longitudinal trends, Risk factors, Tumor biology, Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text 2017-05 Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. 2017 Epidemiology Public health Black women, Breast cancer, Longitudinal trends, Risk factors, Tumor biology, Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text 2017-05 Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. 2017 Epidemiology Public health Black women, Breast cancer, Longitudinal trends, Risk factors, Tumor biology, Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text 2017-05 Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. 2017 Epidemiology Public health Black women, Breast cancer, Longitudinal trends, Risk factors, Tumor biology, Young age eng Doctor of Philosophy Dissertation Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text 2017-05 University of North Carolina at Chapel Hill Degree granting institution Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. 2017 Epidemiology Public health Black women, Breast cancer, Longitudinal trends, Risk factors, Tumor biology, Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text 2017-05 Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. 2017 Epidemiology Public health Black women, Breast cancer, Longitudinal trends, Risk factors, Tumor biology, Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text 2017-05 Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. 2017 Epidemiology Public health Black women; Breast cancer; Longitudinal trends; Risk factors; Tumor biology; Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text 2017-05 Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. 2017 Epidemiology Public health Black women, Breast cancer, Longitudinal trends, Risk factors, Tumor biology, Young age eng Doctor of Philosophy Dissertation Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text 2017-05 University of North Carolina at Chapel Hill Degree granting institution Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. 2017 Epidemiology Public health Black women, Breast cancer, Longitudinal trends, Risk factors, Tumor biology, Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text 2017-05 Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. 2017 Epidemiology Public health Black women; Breast cancer; Longitudinal trends; Risk factors; Tumor biology; Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text 2017-05 Lynn Chollet Hinton Creator Department of Epidemiology Gillings School of Global Public Health Epidemiology of breast cancer among young black women and the rise in young-onset distant disease in the U.S. Purpose: Rates of distant (stage IV) breast cancer have significantly increased since 1976 among young women <40 years. Young-onset breast cancers tend to be more aggressive with poorer prognosis than older-onset disease, particularly among black women. This dissertation sought to clarify the impact of shifting incidence by (1) characterizing the epidemiology of young black women’s breast cancer, and (2) investigating temporal shifts in breast cancer biology and diagnostic imaging use as contributors to rising young-onset distant disease. Methods: We examined tumor characteristics and breast cancer risk factors associated with premenopausal young (<40) vs. older (≥40) black women’s breast cancer in the African American Breast Cancer Epidemiology and Risk Consortium (2,008 cases; 5,144 controls) using unconditional logistic regression. Additionally, we examined longitudinal breast cancer incidence using joinpoint regression among young women (20-39 years) from 1992-2011 according to breast tumor characteristics in the Surveillance, Epidemiology, and End Results (SEER) program. Temporal patterns in imaging use (positron emission tomography, computed tomography, magnetic resonance imaging, bone scans) were examined separately among Medicare-eligible breast cancer cases using SEER-Medicare-linked data. Results: Premenopausal black women <40 years had higher frequency of poorer-prognostic tumor characteristics compared to older (≥40) women, including negative estrogen and progesterone receptor (ER/PR) status, triple-negative subtype, high grade, higher stage, and larger tumor size. Adiposity, family history of breast cancer, and oral contraceptive use were associated with increased risk for young women while breastfeeding was more strongly protective. In SEER, the frequency of favorable tumor characteristics significantly increased while less favorable characteristics declined among young women. Imaging use dramatically increased from 1992-2011 among SEER-Medicare cases and was significantly associated with less favorable characteristics, including ER/PR negativity, high grade, and tumor size >2cm. Conclusions: Among premenopausal black women, young age (<40 years) was associated with more aggressive breast tumor biology. Modifiable risk factors including breastfeeding, adiposity, and oral contraceptive use may be important targets for mitigating harms of young-onset breast cancer. In SEER, the frequency of aggressive disease decreased while imaging use dramatically increased from 1992-2011, suggesting that stage migration rather than shifting tumor biology has contributed to rising incidence of young-onset distant breast cancer. 2017 Epidemiology Public health Black women; Breast cancer; Longitudinal trends; Risk factors; Tumor biology; Young age eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Melissa Troester Thesis advisor Carey Anders Thesis advisor Jennifer Lund Thesis advisor Hazel Nichols Thesis advisor Andrew Olshan Thesis advisor text 2017-05 CholletHinton_unc_0153D_16797.pdf uuid:05921433-971c-400b-9210-be7ef5ffb655 2019-07-05T00:00:00 proquest 2017-04-03T20:48:22Z application/pdf 1388585 yes