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Ben Schwartz is Associate Editor, Contemporary OB/GYN.
A new report from The American Cancer Society shows that in every US state, breast cancer incidence rates are higher in non-Hispanic white (NHW) women than in non-Hispanic black (NHB) women, but rates of death from the disease, however, are higher in NHB women than in NHW women. Also: Is second-stage labor longer with epidural analgesia? Plus, a study finds that ovarian reserve biomarkers are not associated with fertility.
A new report from The American Cancer Society shows that in every US state, breast cancer incidence rates are higher in non-Hispanic white (NHW) women than in non-Hispanic black (NHB) women. Rates of death from the disease, however, are higher in NHB women than in NHW women in every state, indicating that social and structural factors, along with biologic factors, may contribute to discrepancies in outcomes.
Using the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results (SEER) program and the Centers for Disease Control and Prevention’s National Program of Cancer Registries, the researchers predicted that there will be approximately 252,710 new cases of breast cancer and 40,610 breast cancer deaths in 2017. According to the research, overall breast cancer incidence from 2005-2014 increased among Asian/Pacific Islander (API) (1.7% per year), non-Hispanic black (0.4% per year), and Hispanic (0.3% per year) women. Non-Hispanic white and American Indian/Alaska native women saw breast cancer incidence rates remain stable.
The authors note that racial and ethnic difference in breast cancer subtypes may reflect variation in the prevalence of risk factors for the disease. Hormone receptor (HR)-positive/HER2-negative breast cancer is the most common subtype in each racial/ethnic group, with incidence rates ranging from 53 cases per 100,000 in Hispanics to 82 cases per 100,000 in NHW. The authors note that lower overall rates of breast cancer in AI/AN, Hispanic, and API women are a result of lower rates of the HR-positive/HER2-negative subtype. However, incidence of triple-negative breast cancer, which is typically of the basal subtype, is twice as high in NHB women (24 per 100000) as in NHW women (12 per 100000).
From 1989 to 2015, breast cancer mortality rates decreased by 39% (322,600 deaths averted) in the United States. From 2006 to 2015, all racial/ethnic groups experienced decreased breast cancer death rates. When looking closer at the data, though, it is evident that not all women benefited equally from this decline. In 2015, breast cancer death rates were 39% higher in black women than in white women. Excess death rates in black women ranged from 20% in Nevada to 66% in Louisiana. From 2011 through 2015, breast cancer mortality rates were 42% higher among NHB women (29.5 per 100,000) than NHW women (20.8 per 100000). However, breast cancer incidence rates were slightly lower among NHB women (125.5 per 100000) than among NHW women (128.5 per 100000).
The mortality gap between white and black patients with breast cancer, which, according to the authors, emerged in the early 1980s and continued to widen, may have stabilized. The authors attribute this stabilization to improvements in treatment and earlier detection by mammography. However, the authors suggest that improving access to care for all populations could help to eliminate the racial disparity in breast cancer mortality rates.
Is second-stage labor longer with epidural analgesia?
Results of new research show that the duration of second-stage labor is no different with epidural analgesia versus a placebo. The findings, published in Obstetrics & Gynecology, are from a double-blind, randomized trial in nulliparous women with term cephalic singletons.
For the research, 400 women who had received 0.08% ropivacaine with 0.4 mcg/mL sufentanil during first-stage labor were randomized at the onset of second-stage labor to a blinded infusion of either the same epidural solution or a placebo saline infusion. The primary outcome was duration of second-stage labor and the trial was powered to identify at least a 15% difference in duration.
An intent-to-treat analysis showed that the duration of second-stage labor was similar between the two groups of women (52±27 minutes for epidural vs 51±25 minutes for saline; P = .52). Rates of spontaneous vaginal delivery also were similar (193 [96.5%] for epidural vs 198 [99%] for saline, P = .17). At each measurement during the second stage, pain scores were similar but more women in the placebo group reported satisfaction scores of 8 or less (saline 62 [30.5% vs epidural 32 [16%]; P = .001.
Their data, the authors said, demonstrate that maintaining an epidural infusion has no effect on the duration of second-stage labor compared with placebo.
According to a prospective study published online in JAMA, biomarkers used to estimate ovarian reserve are not linked to fertility in women aged 30 to 44 years who have no history of infertility and have tried to conceive for 3 months or less. The findings call into question the use of serum and urinary follicle-stimulating hormone (FSH) tests or antimüllerian hormone (AMH) levels to assess natural fertility levels in these women.
The researchers examined the association of early-follicular-phase serum AMH, serum FSH, serum inhibin B, and urinary FSH with reproductive potential as measured by the probability of conceiving naturally. Using a prospective time-to-pregnancy model, between 2008 and 2016, 750 women were enrolled in the study and provided a blood and urine sample. The researchers adjusted for age, body mass index, race, current smoking status, and hormonal contraceptive use. Subgroup analyses were also conducted using age and parity.
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The researchers found no association between low AMH (0.7 ng/mL) or high FSH (> 10mIU/mL) and reduced fecundability or decreased cumulative probability of conceiving with 6 or 12 cycles of attempting pregnancy. Among women with low AMH numbers, the probability of conceiving by 6 cycles of attempt was 65% vs. 62% among women with normal values. No difference was found between the groups after 12 cycles either (84% vs. 75%, respectively). Women with high serum FSH did not have a significant difference in predicted probability of conceiving after 6 cycles of attempt compared with women who had normal values (63% vs 62%, respectively) or after 12 cycles (82% vs. 75%, respectively). Women with high urinary FSH values (> 11.5mlU/mg creatine) did not have significantly different predicted probability of conceiving after 6 cycles (61% vs 62% for women with normal values) or after 12 cycles (70% vs. 76% for women with normal values).
The researchers concluded that because their findings do not support an association between biomarkers and fertility, clinicians should not use urinary or blood follicle-stimulating tests or antimüllerian hormone levels to predict natural infertility in healthy women without a history of infertility. However, they noted several limitations to the study. Because the only pregnancy outcome available was a positive pregnancy test, it is possible that more pregnancy losses and lower live birth rates occurred among women with low ovarian reserve. Women with known fertility problems or who had partners affected by fertility problems were excluded from the study, so more research is necessary to determine the effectiveness of biomarker prediction in this population.