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Inflammatory breast cancer ( IBC) is a relatively rare and extremely aggressive form of breast cancer that is diagnosed clinically. Standardization of clinical diagnoses is challenging, both nationally and internationally; moreover, IBC coding definitions used by registries have changed over time. This study aimed to compare diagnostic factors of IBC reported in a U.S. Surveillance, Epidemiology, and End Results ( SEER) registry to clinical criteria found in the medical records of all invasive breast cancer cases at a single institution. We conducted a medical record review of all female invasive breast cancers ( n = 915) seen at an NCI-designated comprehensive cancer center in Detroit from 2007 to 2009. IBC cases were identified based on the presence of the main clinical characteristics of the disease (erythema, edema, peau d'orange). We compared the proportion of IBC out of all breast cancers, using these clinical criteria and the standard SEER IBC codes. In the reviewed cases, the clinical criteria identified significantly more IBC cases ( n = 74, 8.1%) than the standard IBC SEER definition ( n = 19, 2.1%; p < 0.0001). No IBC cases were identified in the cancer center records using the SEER pathologic coding, which requires the diagnosis of inflammatory carcinoma on the pathology report, a notation that is rarely made. Emphasis must be placed on the documentation of clinical and pathologic characteristics of IBC in the medical record, so that analysis of putative IBC subtypes will be possible. Our results indicate the need for a consensus on the definition of IBC to be utilized in future research. [ABSTRACT FROM AUTHOR]

The long-term effect of socioeconomic status (SES) and healthcare resources availability (HCA) on breast cancer stage of presentation and mortality rates among patients in Michigan is unclear. Using data from the Michigan Department of Community Health (MDCH) between 1992 and 2009, we calculated annual proportions of late-stage diagnosis and age-adjusted breast cancer mortality rates by race and zip code in Michigan. SES and HCA were defined at the zip-code level. Joinpoint regression was used to compare the Average Annual Percent Change (AAPC) in the median zip-code level percent late stage diagnosis and mortality rate for blacks and whites and for each level of SES and HCA. Between 1992 and 2009, the proportion of late stage diagnosis increased among white women [AAPC = 1.0 (0.4, 1.6)], but was statistically unchanged among black women [AAPC = −0.5 (−1.9, 0.8)]. The breast cancer mortality rate declined among whites [AAPC = −1.3% (−1.8,−0.8)], but remained statistically unchanged among blacks [AAPC = −0.3% (−0.3, 1.0)]. In all SES and HCA area types, disparities in percent late stage between blacks and whites appeared to narrow over time, while the differences in breast cancer mortality rates between blacks and whites appeared to increase over time. [ABSTRACT FROM AUTHOR]

Background: Breast cancer screening rates have increased over time in the United States. However actual screening rates appear to be lower among black women compared with white women. Purpose: To assess determinants of breast cancer screening among women in Michigan USA, focusing on individual and neighborhood socio-economic status and healthcare access. Methods: Data from 1163 women ages 50-74 years who participated in the 2008 Michigan Special Cancer Behavioral Risk Factor Survey were analyzed. County-level SES and healthcare access were obtained from the Area Resource File. Multilevel logistic regression models were fit using SAS Proc Glimmix to account for clustering of individual observations by county. Separate models were fit for each of the two outcomes of interest; mammography screening and clinical breast examination. For each outcome, two sequential models were fit; a model including individual level covariates and a model including county level covariates. Results: After adjusting for misclassification bias, overall cancer screening rates were lower than reported by survey respondents; black women had lower mammography screening rates but higher clinical breast examination rates than white women. However, after adjusting for other individual level variables, race was not a significant predictor of screening. Having health insurance or a usual healthcare provider were the most important predictors of cancer screening. Discussion: Access to healthcare is important to ensuring appropriate cancer screening among women in Michigan. [ABSTRACT FROM AUTHOR]

Background: African-American (AA) women have lower survival rates from cervical cancer compared with white women. The objective of this study was to examine the influence of socioeconomic status (SES) and other variables on racial disparities in overall survival among women with invasive cervical cancer.Methods: One thousand thirty-six women (705 white women and 331 AA women) who were diagnosed with primary invasive cancer of the cervix between 1988 and 1992 were identified through the Metropolitan Detroit Cancer Surveillance System (MDCSS), a registry in the Surveillance, Epidemiology, and End Results (SEER) database. Pathology, treatment, and survival data were obtained through SEER. SES was categorized by using occupation, poverty, and educational status at the census tract level. Cox proportional hazards models were used to compare overall survival between AA women and white women adjusting for sociodemographics, clinical presentation, and treatment.Results: AA women were more likely to present at an older age (P<.001), with later stage disease (P<.001), and with squamous histology (P=.01), and they were more likely to reside in a census tract categorized as Working Poor (WP) (P<.001). After multivariate adjustment, race no longer had a significant impact on survival. Women who resided in a WP census tract had a higher risk of death than women from a Professional census tract (P=.05). There was a significant interaction between disease stage and time with the effect of stage on survival attenuated after 6 years.Conclusions: In this study, factors that affected access to medical care appeared to have a more important influence than race on the long-term survival of women with invasive cervical cancer. [ABSTRACT FROM AUTHOR]

Benchmark dose (BMD) analysis is used to determine levels of exposure to environmental contaminants associated with increased public health risk. In this study we used a benchmark approach to evaluate the risks associated with prenatal exposure to polychlorinated biphenyls (PCBs). We evaluated for intellectual impairment a cohort of children whose prenatal PCB exposure had been assessed from biologic specimens. We calculated BMDs and lower-bound confidence limits (BMDLs) for four end points using four sets of risk criteria. BMDLs were estimated using three different statistical methodologies. The BMDs and BMDLs were remarkably consistent across the four end points for each set of risk criteria, but differed substantially for the different risk criteria. The proportion of the sample considered at risk ranged from 9.8% for the least protective criteria to 74.1% for the most protective. Two methodologies, likelihood ratio and bootstrapping, generated generally similar BMDLs. BMD analysis provides a straightforward, reliable method for evaluating levels of exposure associated with increased public health risk. In the analyses performed in this study, the number of individuals considered at risk depended more on the risk criterion selected than on the outcome assessed. Key words: benchmark dose analysis, dose—response, environmental contaminants, in utero exposure, organochlorine contaminants, polychlorinated biphenyls, risk analysis. Environ Health Perspect 110:393–398 (2002). [Online 8 March 2002] [ABSTRACT FROM AUTHOR]

Objectives: Cardiac surgery-associated acute kidney injury occurs commonly following congenital heart surgery and is associated with adverse outcomes. This study represents the first multicenter study of neonatal cardiac surgery-associated acute kidney injury. We aimed to describe the epidemiology, including perioperative predictors and associated outcomes of this important complication.Design: This Neonatal and Pediatric Heart and Renal Outcomes Network study is a multicenter, retrospective cohort study of consecutive neonates less than 30 days. Neonatal modification of The Kidney Disease Improving Global Outcomes criteria was used. Associations between cardiac surgery-associated acute kidney injury stage and outcomes (mortality, length of stay, and duration of mechanical ventilation) were assessed through multivariable regression.Setting: Twenty-two hospitals participating in Pediatric Cardiac Critical Care Consortium.Patients: Twenty-two-thousand forty neonates who underwent major cardiac surgery from September 2015 to January 2018.Interventions: None.Measurements and Main Results: Cardiac surgery-associated acute kidney injury occurred in 1,207 patients (53.8%); 983 of 1,657 in cardiopulmonary bypass patients (59.3%) and 224 of 583 in noncardiopulmonary bypass patients (38.4%). Seven-hundred two (31.3%) had maximum stage 1, 302 (13.5%) stage 2, 203 (9.1%) stage 3; prevalence of cardiac surgery-associated acute kidney injury peaked on postoperative day 1. Cardiac surgery-associated acute kidney injury rates varied greatly (27-86%) across institutions. Preoperative enteral feeding (odds ratio = 0.68; 0.52-0.9) and open sternum (odds ratio = 0.76; 0.61-0.96) were associated with less cardiac surgery-associated acute kidney injury; cardiopulmonary bypass was associated with increased cardiac surgery-associated acute kidney injury (odds ratio = 1.53; 1.01-2.32). Duration of cardiopulmonary bypass was not associated with cardiac surgery-associated acute kidney injury in the cardiopulmonary bypass cohort. Stage 3 cardiac surgery-associated acute kidney injury was independently associated with hospital mortality (odds ratio = 2.44; 1.3-4.61). No cardiac surgery-associated acute kidney injury stage was associated with duration of mechanical ventilation or length of stay.Conclusions: Cardiac surgery-associated acute kidney injury occurs frequently after neonatal cardiac surgery in both cardiopulmonary bypass and noncardiopulmonary bypass patients. Rates vary significantly across hospitals. Only stage 3 cardiac surgery-associated acute kidney injury is associated with mortality. Cardiac surgery-associated acute kidney injury was not associated with any other outcomes. Kidney Disease Improving Global Outcomes criteria may not precisely define a clinically meaningful renal injury phenotype in this population. [ABSTRACT FROM AUTHOR]

Background and Objectives: Distal symmetric polyneuropathy (DSP) is a disabling, often painful condition associated with falls and reduced quality of life. Non-Hispanic Black people and people with low income are underrepresented in existing DSP studies; therefore, it is unknown whether data accurately reflect the prevalence, risk factors, and burden of disease in these populations., Methods: Patients older than 40 years presenting to an outpatient internal medicine clinic predominantly serving Medicaid patients in Flint, Michigan, were enrolled in a cross-sectional study. Demographics, clinical characteristics, including medication use, anthropomorphic measurements, fasting lipids, and hemoglobin A1c were collected. DSP was defined using the modified Toronto Clinical Neuropathy Score (mTCNS). Multivariable logistic regression was performed to model DSP and undiagnosed DSP as a function of potential risk factors age, metabolic syndrome, and race. DSP burden was measured using Peripheral Neuropathy Quality of Life Instrument-97., Results: Two hundred participants were enrolled, and 169 (85%) completed all data collection. The population was 55% female of mean age (SD) 58.2 years (10.4) and 69% non-Hispanic Black. Among the population, 50% had diabetes, 67% had metabolic syndrome, and 47% had a household income <$20,000. DSP was present in 73% of the population, of which 75% were previously undiagnosed. Neuropathic pain was documented in 57% of participants with DSP. DSP based on mTCNS criteria was associated with older age (odds ratio [OR] 1.1 [95% confidence interval (CI) 1.03-1.2]) and metabolic syndrome (OR 4.4 [1.1-18.1]). Non-Hispanic Black participants had lower odds of DSP (OR 0.1 [0.01-0.4]) than non-Hispanic White and Hispanic participants. DSP burden was high, including increased pain, health-related worry, and poorer quality of life (all p < 0.001)., Discussion: DSP is extremely common and often underrecognized in this predominantly non-Hispanic Black, low-income population and leads to substantial disease burden. Metabolic syndrome is a highly prevalent, modifiable risk factor in this population that should be managed to lower DSP prevalence.

Background: Despite improved survival with chemotherapy for stage III colorectal cancer (CRC), patients may suffer substantial economic hardship during treatment. Methods for quantifying financial burden in CRC patients are lacking., Objective: To derive and validate a novel patient-reported measure of personal financial burden during CRC treatment., Data Collection: Within a population-based survey of patients in the Detroit and Georgia Surveillance, Epidemiology and End Results regions diagnosed with stage III CRC between 2011 and 2013, we asked 7 binary questions assessing effects of disease and treatment on personal finances., Data Analysis: We used factor analysis to compute a composite measure of financial burden. We used χ tests to evaluate relationships between individual components of financial burden and chemotherapy use with χ analyses. We used Mantel-Haenszel χ trend tests to examine relationships between the composite financial burden metric and chemotherapy use., Results: Among 956 patient surveys (66% response rate), factor analysis of 7 burden items yielded a single-factor solution. Factor loadings of 6 items were >0.4; these were included in the composite score. Internal consistency was high (Cronbach α=0.79). The mean financial burden score among all respondents was 1.72 (range, 0-6). The 812 (85%) who reported chemotherapy use had significantly higher financial burden scores than those who did not (mean burden score 1.88 vs. 0.88, P<0.001)., Conclusions: Financial burden is high among CRC patients, particularly those who use adjuvant chemotherapy. We encourage use of our instrument to validate our measure in the identification of patients in need of additional financial support during treatment.

Background: Surgical site infection (SSI) remains a costly and morbid complication after colectomy. The primary objective of this study was to investigate whether a group of perioperative care measures previously shown to be associated with reduced SSI would have an additive effect in SSI reduction. If so, this would support the use of an "SSI prevention bundle" as a quality improvement intervention., Methods: Data from 24 hospitals participating in the Michigan Surgical Quality Collaborative were included in the study. The main outcome measure was SSI. Hierarchical logistic regression was used to account for clustering of patients within hospitals., Results: In total, 4,085 operations fulfilled inclusion criteria for the study (Current Procedural Terminology codes 44140, 44160, 44204, and 44205). A "bundle score" was assigned to each operation, based on the number of perioperative care measures followed (appropriate Surgical Care Improvement Project-2 antibiotics, postoperative normothermia, oral antibiotics with bowel preparation, perioperative glycemic control, minimally invasive surgery, and short operative duration). There was a strong stepwise inverse association between bundle score and incidence of SSI. Patients who received all 6 bundle elements had risk-adjusted SSI rates of 2.0% (95% confidence interval [CI], 7.9-0.5%), whereas patients who received only 1 bundle measure had SSI rates of 17.5% (95% CI, 27.1-10.8%)., Conclusion: This multi-institutional study shows that patients who received all 6 perioperative care measures attained a very low, risk-adjusted SSI rate of 2.0%. These results suggest the promise of an SSI reduction intervention for quality improvement; however, prospective research are required to confirm this finding., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Objective: To determine which perioperative care practices are associated with decreased risk of surgical site infection (SSI) after colectomy surgery., Background: Optimization of perioperative care has been a common strategy for improving surgical safety, but the relationship between process measure compliance and surgical complication rates is controversial., Methods: This is a retrospective cohort study performed within the Michigan Surgical Quality Collaborative (MSQC), an organization of hospitals that prospectively collects patient data, processes of care, and 30-day outcomes. Patients undergoing colectomy surgery (n = 4331) were studied. Factors potentially associated with SSI were tested using univariate statistical tests, and a hierarchical generalized linear model was created to test for independent associations between processes of care and SSI, while adjusting for patient risk factors and clustering of patients within hospitals., Results: Several perioperative care practices were independently associated with lower risk of SSI after adjustment for patient risk, procedure type/duration, and clustering of patients by hospital site. Best practices include selection of a Surgical Care Improvement Project (SCIP-2)-compliant prophylactic intravenous antibiotic, postoperative normothermia, postoperative day 1 glucose control, and oral antibiotics given when bowel prep used (SCIP-1 was not significant). Further, several specific prophylactic antibiotic choices were independently associated with lower SSI rates, including cefazolin/metronidazole, ciprofloxacin/metronidazole, and ertapenem., Conclusions: In Michigan, several perioperative care practices are independently associated with decreased risk of SSI after colectomy, including SCIP-2-compliant prophylactic antibiotics, postoperative normothermia, glucose control, and oral antibiotics. Furthermore, specific prophylactic antibiotic choices are associated with lower risk of SSI. These results account for patient factors and unmeasured hospital effects, suggesting that dissemination of these perioperative care practices may decrease SSI rates.

Objective: We sought to identify risk factors for venous thromboembolism (VTE) among patients undergoing bariatric surgery in Michigan., Background: VTE remains a major source of morbidity and mortality after bariatric surgery. It is unclear which factors should be used to identify patients at high risk for VTE., Methods: The Michigan Bariatric Surgery Collaborative maintains a prospective clinical registry of bariatric surgery patients. For this study, we identified all patients undergoing primary bariatric surgery between June 2006 and April 2011 and determined rates of VTE. Potential risk factors for VTE were analyzed using a hierarchical logistic regression model, accounting for clustering of patients within hospitals. Significant risk factors were used to develop a risk calculator for development of VTE after bariatric surgery., Results: Among 27,818 patients who underwent bariatric surgery during the study period, 93 patients (0.33%) experienced a VTE complication, including 51 patents with pulmonary embolism. There were 8 associated deaths. Significant risk factors included previous history of VTE (OR 4.15, CI 2.42-7.08); male gender (OR 2.08, CI 1.36-3.19); operative time more than 3 hours (OR 1.86, CI 1.07-3.24); BMI category (per 10 units) (OR 1.37, CI 1.06-1.75); age category (per 10 years) (OR 1.25, CI 1.03-1.51); and procedure type (reference adjustable gastric band): duodenal switch (OR 9.45, CI 2.50-35.97); open gastric bypass (OR 6.48, CI 2.17-19.41); laparoscopic gastric bypass (OR 3.97, CI 1.77-8.91); and sleeve gastrectomy (OR 3.50, CI 1.30-9.34). Nearly 97% of patients had a predicted VTE risk less than 1%., Conclusions: In this population-based study, overall VTE rates were low among patients undergoing bariatric surgery. The use of an empirically based risk calculator will allow for the development of a risk-stratified approach to VTE prophylaxis.

Objectives: To develop a risk prediction model for serious complications after bariatric surgery., Background: Despite evidence for improved safety with bariatric surgery, serious complications remain a concern for patients, providers and payers. There is little population-level data on which risk factors can be used to identify patients at high risk for major morbidity., Methods: The Michigan Bariatric Surgery Collaborative is a statewide consortium of hospitals and surgeons, which maintains an externally-audited prospective clinical registry. We analyzed data from 25,469 patients undergoing bariatric surgery between June 2006 and December 2010. Significant risk factors on univariable analysis were entered into a multivariable logistic regression model to identify factors associated with serious complications (life threatening and/or associated with lasting disability) within 30 days of surgery. Bootstrap resampling was performed to obtain bias-corrected confidence intervals and c-statistic., Results: Overall, 644 patients (2.5%) experienced a serious complication. Significant risk factors (P < 0.05) included: prior VTE (odds ratio [OR] 1.90, confidence interval [CI] 1.41-2.54); mobility limitations (OR 1.61, CI 1.23-2.13); coronary artery disease (OR 1.53, CI 1.17-2.02); age over 50 (OR 1.38, CI 1.18-1.61); pulmonary disease (OR 1.37, CI 1.15-1.64); male gender (OR 1.26, CI 1.06-1.50); smoking history (OR 1.20, CI 1.02-1.40); and procedure type (reference lap band): duodenal switch (OR 9.68, CI 6.05-15.49); laparoscopic gastric bypass (OR 3.58, CI 2.79-4.64); open gastric bypass (OR 3.51, CI 2.38-5.22); sleeve gastrectomy (OR 2.46, CI 1.73-3.50). The c-statistic was 0.68 (bias-corrected to 0.66) and the model was well-calibrated across deciles of predicted risk., Conclusions: We have developed and validated a population-based risk scoring system for serious complications after bariatric surgery. We expect that this scoring system will improve the process of informed consent, facilitate the selection of procedures for high-risk patients, and allow for better risk stratification across studies of bariatric surgery.

Background: Mechanical bowel preparation before colectomy is controversial for several reasons, including a theoretically increased risk of Clostridium difficile infection., Objective: The primary aim of this study was to compare the incidence of C difficile infection among patients who underwent mechanical bowel preparation and those who did not. A secondary objective was to assess the association between C difficile infection and the use of oral antibiotics., Design: This was an observational cohort study., Setting: The Michigan Surgical Quality Collaborative Colectomy Project (n = 24 hospitals) participates in the American College of Surgeons-National Surgical Quality Improvement Program with additional targeted data specific to patients undergoing colectomies., Patients: Included were adult patients (21 years and older) admitted to participating hospitals for elective colectomy between August 2007 and June 2009., Main Outcome Measure: The main outcome measure was laboratory detection of a positive C difficile toxin assay or stool culture., Results: Two thousand two hundred sixty-three patients underwent colectomy and fulfilled inclusion criteria. Fifty-four patients developed a C difficile infection, for a hospital median rate of 2.8% (range, 0-14.7%). Use of mechanical bowel preparation was not associated with an increased incidence of C difficile infection (P = .95). Among 1685 patients that received mechanical bowel preparation, 684 (41%) received oral antibiotics. The proportion of patients in whom C difficile infection was diagnosed after the use of preoperative oral antibiotics was smaller than the proportion of patients with C difficile infection who did not receive oral antibiotics (1.6% vs 2.9%, P = .09)., Limitations: The potential exists for underestimation of C difficile infection because of the study's strict data collection criteria and risk of undetected infection after postoperative day 30., Conclusions: In contrast to previous single-center data, this multicenter study showed that the preoperative use of mechanical bowel preparation was not associated with increased risk of C difficile infection after colectomy. Moreover, the addition of oral antibiotics with mechanical bowel preparation did not confer any additional risk of infection.

Cause-specific analyses under a competing risks framework have received considerable attention in the statistical literature. Such analyses are useful for comparing mortality patterns across racial and/or age groups. Earlier work in the statistical literature focused on the situation when the cause of death is known. A challenging twist to the problem arises when the cause of death is not known exactly, but can be narrowed down to a set of potential causes that do not necessarily act independently. This phenomenon, referred to as masking, is often the result of incomplete or partial information on death certificates and/or lack of routine autopsy on every patient. In this article we propose a semiparametric Bayesian approach for analyzing competing risks survival data with masked cause of death. The models proposed do not assume independence among the causes, and are valid for an arbitrary number of causes. Further, the Bayesian approach is flexible in allowing a general pattern of missingness for the cause of death. We illustrate our methodology using breast cancer data from the Detroit Surveillance, Epidemiology, and End Results registry., (Copyright (c) 2010 John Wiley & Sons, Ltd.)

Background: Racial misclassification of American Indian and Alaska Native (AI/AN) individuals as non-AI/AN in cancer registries presents problems for cancer surveillance, research, and public health practice. The aim of this study was to investigate the efficiency of tribal linkages in enhancing the quality of racial information in state cancer registries., Methods: Registry Plus Link Plus 2.0 probabilistic record linkage software was used to link the Michigan state cancer registry data (1985-2004; 1,031,168 cancer cases) to the tribal membership roster (40,340 individuals) in July of 2007. A data set was created containing AI/AN cancer cases identified by the state registry, Indian Health Service (IHS) linkages, and tribal linkage. The differences between these three groups of individuals were compared by distribution of demographic, diagnostic, and county-level characteristics using multilevel analysis (conducted in 2007-2008)., Results: From 1995 to 2004, the tribal enrollment file showed linkages to 670 cancer cases (583 individuals) and the tribal linkage led to the identification of 190 AI/AN cancer cases (168 individuals) that were classified as non-AI/AN in the registry. More than 80% of tribal members were reported as non-AI/AN to the registry. Individuals identified by IHS or tribal linkages were different from those reported to be AI/AN in terms of stage at diagnosis, tumor confirmation, and characteristics of the county of diagnosis, including contract health services availability, tribal health services availability, and proportion of AI/AN residents., Conclusions: The data linkage between tribal and state cancer registry data sets improved racial classification validity of AI/AN Michigan cancer cases. Assessing tribal linkages is a simple, noninvasive way to improve the accuracy of state cancer data for AI/AN populations and to generate tribe-specific cancer information.

Objectives: To assess the association between Staphylococcus aureus (S. aureus) blood stream infections (BSIs) and morbidity and mortality in older adults., Design: Retrospective review., Setting: Veterans Affairs Ann Arbor Healthcare System., Participants: All patients with S. aureus BSI during 2004/05., Measurements: Outcomes included in-hospital and 6-month mortality, as well as need for subacute care., Results: Sixty-eight patients with S. aureus BSI were identified (mean age 63.5+/-13.0). Outcomes of interest included in-hospital mortality (19.1%), 6-month mortality (33.8%), and need for subacute care (65.4%). Univariate analysis identified several predictors of death, including older age, chronic renal insufficiency, catheter-related infection, Charlson weighted index of comorbidity score, and infection with methicillin-resistant S. aureus (MRSA). Multivariable analysis demonstrated that older age (odds ratio (OR)=1.1, P<.01), chronic renal insufficiency (OR=16.6, P=.01), and MRSA infection (OR=5.1, P=.03) were independently associated with 6-month mortality. These results suggest that, for every decade increase in age, the odds of death within 6 months of S. aureus BSI doubles (OR=1.1). Chronic renal insufficiency was also independently associated with in-hospital mortality. Of the previously community-dwelling patients (n=50), 41 survived hospitalization, of whom 22 (53.7%) required subacute care after discharge., Conclusion: Better understanding of the epidemiology of S. aureus BSI in older patients and validation of risk factors for poor functional outcomes and death should be the focus of future prospective studies.

African American (AA) women have poorer breast cancer survival compared to Caucasian American (CA) women. The purpose of this analysis was to determine whether socioeconomic status (SES) and treatment differences influence racial differences in breast cancer survival. The study population included 9,321 women (82% CA, 18% AA) diagnosed with local (63%) or regional (37%) stage disease between 1988 and 1992, identified through the Metropolitan Detroit SEER registry. Data on SES were obtained through linkage with the 1990 Census of Population and Housing Summary Tape and cases were geocoded to census block groups. Pathology, treatment and survival data were obtained through SEER. Cox proportional hazards models were used to compare survival for AA versus CA women after adjusting for age, SES, tumor size, number of involved lymph nodes, and treatment. AA women were more likely to live in a geographic area classified as working poor than were CA women (p<0.001). AA women were less likely to have lumpectomy and radiation and more likely to have mastectomy with radiation (p<0.001). After multivariable adjusted analysis, there were no significant racial differences in survival among women with local stage disease, although AA women with regional stage disease had persistent but attenuated poorer survival compared to CA women. After adjusting for known clinical and SES predictors of survival, AA and CA women who are diagnosed with local disease demonstrate similar overall and breast cancer-specific survival, while race continues to have an independent effect among women presenting at a later stage of disease.