Transcriptome-wide association study of risk of recurrence in Black and White breast cancer patients

Background: Continuous risk of recurrence scores (CRS) based on PAM50 gene expression are vital prognostic tools for breast cancer (BC). Studies have shown that Black women (BW) have higher CRS than White women (WW). Although systemic injustices contribute substantially to BC disparities, evidence for biological and germline contributions is also emerging. We investigated germline genetic associations with CRS and CRS disparity through a Transcriptome-Wide Association Study (TWAS). Methods: In the Carolina Breast Cancer Study, using race-specific predictive models of tumor expression from germline genetics, we performed race-stratified (N=1,043 WW, 1083 BW) linear regressions of three CRS (ROR-S: PAM50 subtype score; Proliferation Score; ROR-P: ROR-S plus Proliferation Score) on imputed Genetically-Regulated tumor eXpression (GReX). Using Bayesian multivariate regression and adaptive shrinkage, we tested TWAS-significant genes for associations with PAM50 tumor expression and subtype to elucidate patterns of germline regulation underlying TWAS-gene and CRS associations. Results: At FDR-adjusted P < 0.10, we detected 7 TWAS-genes among WW and 1 TWAS-gene among BW. Among WW, CRS showed positive associations with MCM10, FAM64A, CCNB2, and MMP1 GReX and negative associations with VAV3, PCSK6, and GNG11 GReX. Among BW, higher MMP1 GReX predicted lower Proliferation score and ROR-P. TWAS-gene and PAM50 tumor expression associations highlighted potential mechanisms for TWAS-gene to CRS associations. Conclusions: Among BC patients, we find differential germline associations with three CRS by race, underscoring the need for larger, more diverse datasets in molecular studies of BC. Our findings also suggest possible germline trans-regulation of PAM50 tumor expression, with potential implications for interpreting CRS in clinical settings.

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Geographical disparities of incidence and prevalence of triple-negative breast cancers: Multistate study data analysis.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e12599 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e12599-e12599

Author(s):

Hyein Jeon ◽

Myeong Lee ◽

Mohammed Jaloudi

Keyword(s):

Breast Cancer ◽

Black Women ◽

Significant Relationship ◽

White Women ◽

Triple Negative ◽

The State ◽

Luminal A ◽

Black Females ◽

Black And White ◽

State Effect

e12599 Background: Higher prevalence of triple negative breast cancer (TNBC) in black women with associated poor outcomes due to various disparities is well documented within a single state. We examine multiple states to better understand the state effect on such differences in incidence and prevalence of TNBC in black women. Methods: Female patients of ages 19 years old and above with breast cancer from the Surveillance, Epidemiology and End Results (SEER) Program across 13 states (608 counties) from 2015 (n = 66,444) and 2016 (n = 66,122) were examined. The relationships between the proportion of black and white women and the rate of patients with different tumor subtypes (luminal A, luminal B, HR-HER2+, and triple negative) were examined at the county level using ordinary least-square regression models. In parallel, due to consideration of various state-specific healthcare policies, socio-cultural norms, and socio-economic disparities, multi-level regression models were applied to examine the nested, random effect of each state on TNBC prevalence in each county. Bonferroni correction was applied to reduce the Type I error caused by repeated use of the same variables in multiple tests. Results: The baseline breast cancer rates between black and white women were similar in the population (0.171% for black and 0.168% for white). Consistent to previous studies, we demonstrate a significant positive correlation (p < 0.001) in TNBC in black females in both years. Surprisingly, when accounted for the random effects on states, 38.2% (2015) and 34.3% (2016) increase in incidence of TNBC in black females were seen, suggestive of state-specific disparity affecting race-specific health. In 2015, other subtypes of breast cancer in both black and white females did not result in significant relationship. Interestingly, in 2016, there was a significant relationship seen between the TNBC rate in white females and the white female population rate only after adjusting for the state effect (p = 0.026). This indicates the impact of non-biological factors such as state-wide health policies. Additionally, HR-HER2+ black females had a significant relationship against respective population rate only after adjusting for the state effect as well (p = 0.0394). For luminal A white females, a 15% decrease in incidence was seen after adjusting for state effect (p = 0.0424). Conclusions: This is the first known across-state examination of breast cancer subtypes by race with random effects on state. This study shows the role of state-specific factors affecting incidence in black and white females and potentially indicates the importance of state-level management for breast cancer on health disparities in addition to race-driven effects. Further studies are needed to elucidate comparable differences between states affecting the rates of various subtypes of breast cancer and thus health outcomes.

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A Comparison of Clinicopathological Features and Molecular Markers in British and Nigerian Women with Breast Cancer

Clinical medicine Oncology ◽

10.4137/cmo.s474 ◽

2008 ◽

Vol 2 ◽

pp. CMO.S474

Author(s):

Isaac D. Gukas ◽

Anne C. Girling ◽

Barnabas M. Mandong ◽

Wendy Prime ◽

Barbara A. Jennings ◽

...

Keyword(s):

Breast Cancer ◽

Black Women ◽

White Women ◽

Clinical Stage ◽

Poor Response ◽

Tissue Banks ◽

Breast Cancer Patients ◽

Tumour Grade ◽

Nigerian Women ◽

Immunohistochemical Markers

Background Some studies have suggested that breast cancer in black women is more aggressive than in white women. This study's aim was to look for evidence of differences in tumour biology between the two cohorts. Methods This study compared the stage, grade and pathological expression of five immunohistochemical markers (oestrogen receptor [ER], progesterone receptor [PR], ERBB2, P53 and cyclin D1 [CCND1]) in tumour biopsies from age-matched cohorts of patients from Nigeria and England. Sixty-eight suitable samples from Nigerian (n = 34) and British (n = 34) breast cancer patients were retrieved from histology tissue banks. Results There were significant differences between the two cohorts in the expression of ER and CCND1; and stark differences in the clinical stage at presentation. But no significant differences were observed for tumour grade. Conclusion There was a significantly, low ER expression in the Nigerian cases which also predicts a poor response to hormonal therapy as well as a poorer prognosis. Differences in clinical stage at presentation will most likely influence prognosis between Nigerian and British women with breast cancer.

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Triple-Negative Breast Cancer: A Comparison of Race and Survival

The American Surgeon ◽

10.1177/000313481808400636 ◽

2018 ◽

Vol 84 (6) ◽

pp. 881-888

Author(s):

Matthew P. Doepker ◽

Scott D. Holt ◽

Martin W. Durkin ◽

Christopher H. Chu ◽

James M. Nottingham

Keyword(s):

Breast Cancer ◽

South Carolina ◽

Black Women ◽

Cancer Patients ◽

Triple Negative Breast Cancer ◽

White Women ◽

Triple Negative ◽

Early Stage ◽

Breast Cancer Patients ◽

Aggressive Subtype

Triple-negative breast cancer (TNBC) is an aggressive subtype of breast cancer with a high prevalence in blacks. South Carolina demographically has a high percentage of blacks. This study examines survival and recurrence associated with TNBC in black and white women. A retrospective review of breast cancer patients within the Palmetto Health Cancer Registry was performed from 1999 to 2015. Patient demographics and tumor characteristics were collected and correlated with outcomes. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were analyzed. The total number of breast cancer patients in the registry was 1723 (1085—white and 638—black). The median follow-up was 48.4 months. The majority of cancers diagnosed in both cohorts were early stage (I, IIA, IIB, 93.4% vs 90.4% P = NS). We identified 332 patients with TNBC. Of those 332 patients, 144 (43.4%) were whites and 188 (56.6%) were blacks. Older age (P = 0.01), high-grade (P < 0.001), and black race (P < 0.001) were significantly associated with TNBC on multivariate analysis. Five- and 10-year OS was significantly worse in blacks with TNBC (P < 0.001). There was no difference in DSS or RFS between the two cohorts. TNBC disproportionately affects black women and is an aggressive subtype of breast cancer with limited treatment options compared with receptor-positive breast cancer. Black patients with TNBC in our study had statistically worse OS. These findings are similar to what has been reported in the literature and prompts further research in newer targeted therapies.

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Outcomes for black versus white women with stage IV breast cancer enrolled on investigator-initiated clinical trials at Emory.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.1086 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. 1086-1086

Author(s):

Princess Ekpo ◽

Mylin Ann Torres ◽

Manali Rupji ◽

Jeffrey M. Switchenko ◽

Preeti Subhedar ◽

...

Keyword(s):

Breast Cancer ◽

Overall Survival ◽

Clinical Trials ◽

Black Women ◽

White Women ◽

Metastatic Breast ◽

Stage Iv ◽

Black And White ◽

Stage Iv Breast Cancer ◽

Significant Difference

1086 Background: Black women are 40% more likely to die from their breast cancer compared to White women. Inadequate representation of Blacks in clinical trials may contribute to health care inequity. Emory’s Winship Cancer Institute (WCI) in Atlanta serves a significant Black population and has a unique opportunity to engage these underrepresented patients in clinical trials. We aimed to assess clinical outcomes in Black versus White women with metastatic breast cancer (MBC) enrolled on investigator-initiated clinical trials (IITs) at Emory. Methods: Black and White women with MBC enrolled on IITs conducted at WCI between 1/2009 and 1/2019 were retrospectively evaluated. Descriptive statistics were generated for all patient characteristics. Univariate analyses and a multiple logistic regression model were used to assess the effect of age and race on clinical response, length of time on trial, number of therapy lines prior to trial enrollment, and toxicity on trial. Overall survival was assessed using Kaplan Meier analysis. Results: Sixty-two women with MBC were included [White, n = 41 (66%), and Black, n = 21 (34%), p = 0.55]. Over 90% of women were enrolled on phase II clinical trials and received targeted therapy. Mean age at clinical trial consent was 53.2 and 55.9 years in Black and White women, respectively (p = 0.36). While the majority of women had hormone-receptor positive disease, a higher percentage of Blacks had triple negative breast cancer (29% vs. 17% in Whites, p = 0.39). Black women had fewer lines of systemic therapy prior to trial enrollment (2.86 vs. 4.3, respectively, p = 0.017) and were enrolled on trial for less time than White women (5.67 mo vs. 7.83 mo, respectively, p = 0.22). There were no differences in toxicity rates among patients enrolled on IITs based on race. Black women were more likely to have progressive disease (PD) on trial (45% in Blacks vs. 20% in Whites, p = 0.05). While there was no significant difference in overall survival (p = 0.482), there was a trend towards shorter survival in Black women (51.3 mos vs. 64 mos, respectively). Conclusions: Black women with MBC who enrolled on IIT trials at Emory had worse treatment response and a trend towards poorer survival compared to White women. More research is needed to determine whether this is due to adverse biology. These results reinforce the need for exploration of biomarkers of response by race and ethnicity and improved representation of Blacks in clinical trials to inform real world efficacy.

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Health Care Segregation, Physician Recommendation, and Racial Disparities in BRCA1/2 Testing Among Women With Breast Cancer

Journal of Clinical Oncology ◽

10.1200/jco.2015.66.0019 ◽

2016 ◽

Vol 34 (22) ◽

pp. 2610-2618 ◽

Cited By ~ 57

Author(s):

Anne Marie McCarthy ◽

Mirar Bristol ◽

Susan M. Domchek ◽

Peter W. Groeneveld ◽

Younji Kim ◽

...

Keyword(s):

Breast Cancer ◽

Black Women ◽

Racial Disparities ◽

Racial Differences ◽

White Women ◽

Physician Recommendation ◽

Study Objective ◽

Black And White ◽

Physician Characteristics ◽

White Patients

Purpose Racial disparities in BRCA1/2 testing have been documented, but causes of these disparities are poorly understood. The study objective was to investigate whether the distribution of black and white patients across cancer providers contributes to disparities in BRCA1/2 testing. Patients and Methods We conducted a population-based study of women in Pennsylvania and Florida who were 18 to 64 years old and diagnosed with invasive breast cancer between 2007 and 2009, linking cancer registry data, the American Medical Association Physician Masterfile, and patient and physician surveys. The study included 3,016 women (69% white, 31% black), 808 medical oncologists, and 732 surgeons. Results Black women were less likely to undergo BRCA1/2 testing than white women (odds ratio [OR], 0.40; 95% CI, 0.34 to 0.48; P < .001). This difference was attenuated but not eliminated by adjustment for mutation risk, clinical factors, sociodemographic characteristics, and attitudes about testing (OR, 0.66; 95% CI, 0.53 to 0.81; P < .001). The care of black and white women was highly segregated across surgeons and oncologists (index of dissimilarity 64.1 and 61.9, respectively), but adjusting for clustering within physician or physician characteristics did not change the size of the testing disparity. Black women were less likely to report that they had received physician recommendation for BRCA1/2 testing even after adjusting for mutation risk (OR, 0.66; 95% CI, 0.54 to 0.82; P < .001). Adjusting for physician recommendation further attenuated the testing disparity (OR, 0.76; 95% CI, 0.57 to 1.02; P = .06). Conclusion Although black and white patients with breast cancer tend to see different surgeons and oncologists, this distribution does not contribute to disparities in BRCA1/2 testing. Instead, residual racial differences in testing after accounting for patient and physician characteristics are largely attributable to differences in physician recommendations. Efforts to address these disparities should focus on ensuring equity in testing recommendations.

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Searching beyond the Lamppost to Reduce Breast Cancer Disparities

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18031186 ◽

2021 ◽

Vol 18 (3) ◽

pp. 1186

Author(s):

Sarah Gehlert ◽

Marion Kavanaugh-Lynch ◽

Senaida Fernandez Poole

Keyword(s):

Breast Cancer ◽

Black Women ◽

White Women ◽

The United States ◽

Cancer Disparities ◽

Black And White ◽

Asian Pacific Islander ◽

Asian Pacific ◽

Pacific Islander Women ◽

Breast Cancer Disparities

Racial and ethnic differences in breast cancer occur by race/ethnicity in both incidence and mortality rates. Women of lower socioeconomic status likewise have poorer outcomes. When race alone is considered, incidence rates in the United States are highest among White women (130.8 per 100,000), with Black women close behind (126.7 per 100,000). Incidence is lowest among Asian/Pacific Islander women, at 93.2 per 100,000. Mortality differences are more pronounced, with Black women 40% more likely to die from breast cancer than White women (28.4 per 100,000 and 20.3 per 100,000, respectively). Mortality rates for Asian/Pacific Islander women (11.5 per 100,000) are far lower than for Black and White women. When age is considered, additional differences between Black and White women appear, in part accounted for by types of breast cancer experienced. Women of other racial/ethnic groups and socioeconomic status have received less scientific attention. In this article, we provide a brief overview of the evidence for social determinants of breast cancer and argue that the current reliance on race over racism and ethnicity contributes to our inability to eliminate breast cancer disparities in the United States and elsewhere in the world. We suggest alternatives to the current approach to research in breast cancer disparities.

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Outcomes of hormone-receptor positive, HER2-negative breast cancers by race and tumor biological features

JNCI Cancer Spectrum ◽

10.1093/jncics/pkaa072 ◽

2020 ◽

Author(s):

Halei C Benefield ◽

Katherine E Reeder-Hayes ◽

Hazel B Nichols ◽

Benjamin C Calhoun ◽

Michael I Love ◽

...

Keyword(s):

Breast Cancer ◽

Black Women ◽

Hormone Receptor ◽

White Women ◽

Recurrence Score ◽

Recurrence Risk ◽

Early Recurrence ◽

High Grade ◽

Risk Of Recurrence ◽

Hormone Receptor Positive

Abstract Background Black women have higher hormone receptor positive (HR+) breast cancer mortality than White women. Early recurrence rates differ by race, but little is known about genomic predictors of early recurrence among HR+ women. Methods Using data from the Carolina Breast Cancer Study (phase III, 2008-2013), we estimated associations between race and recurrence among nonmetastatic HR+/HER2 negative tumors, overall and by PAM50 Risk of Recurrence score, PAM50 intrinsic subtype, and tumor grade using survival curves and Cox models standardized for age and stage. Relative frequency differences (RFD) were estimated using multivariable linear regression. To assess intervention opportunities, we evaluated treatment patterns by race among patients with high-risk disease. Results Black women had higher recurrence risk relative to White women (crude hazard ratio = 1.81, 95% confidence interval [CI] = 1.34 to 2.46), which remained elevated after standardizing for clinical covariates (hazard ratio = 1.42, 95% CI = 1.05 to 1.93). Racial disparities were most pronounced among those with high PAM50 Risk of Recurrence score (5-year standardized recurrence risk = 18.9%, 95% CI = 8.6% to 29% in Black women vs 12.5%, 95% CI = 2.0% to 23.0% in White women) and high grade (5-year standardized recurrence risk = 16.6%, 95% CI = 11.7% to 21.5% in Black women vs 12.0%, 95% CI = 7.3% to 16.7% in White women). However, Black women with high-grade tumors were statistically significantly less likely to initiate endocrine therapy (RFD = −8.3%, 95% CI = −15.9% to − 0.6%) and experienced treatment delay more often than White women (RFD = +9.0%, 95% CI = 0.3% to 17.8%). Conclusions Differences in recurrence by race appear greatest among women with aggressive tumors and may be influenced by treatment differences. Efforts to identify causes of variation in cancer treatment are critical to reducing outcome disparities.

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Racial differences in treatment for breast cancer among black and white women in Atlanta

Journal of Clinical Oncology ◽

10.1200/jco.2006.24.18_suppl.603 ◽

2006 ◽

Vol 24 (18_suppl) ◽

pp. 603-603

Author(s):

M. J. Lund ◽

O. W. Brawley ◽

J. W. Eley ◽

K. C. Ward ◽

J. L. Young ◽

...

Keyword(s):

Breast Cancer ◽

Black Women ◽

Racial Differences ◽

Hormonal Therapy ◽

White Women ◽

Treatment Guidelines ◽

Teaching Hospitals ◽

Treatment Standards ◽

Black And White ◽

Treatment Type

603 Background: Among women with breast cancer, Black women experience a disproportionate excess in mortality, a reflection of their marked poorer survival, which persists even within stage and age groups. Adherence to first course treatment guidelines for breast cancer may not be uniform across racial/ethnic groups and could be a major contributing factor to racial disparities in outcome. In this population-based study, we assessed racial differences in initial treatment of primary invasive breast cancer. Methods: All data were obtained from the Surveillance, Epidemiology, and End Results (SEER) program. The study population included all invasive breast cancers diagnosed during 2000–2001 among Black (n=877) and White (n=2437) female residents of the five Atlanta SEER counties, an area whose population is 36% Black and where several large teaching hospitals are located. Outcome factors included delay in first course treatment, type of treatment, performance of cancer directed surgery, type of surgery, and receipt of chemotherapy, radiotherapy, or hormonal therapy. Racial differences in treatment were analyzed according to their basis for treatment; stage or age at diagnosis and tumor factors. Analyses utilized frequency distributions, χ2 tests of independence, and Cochran-Mantel-Haenszel statistics in and across strata. Results: Black women were more likely to experience delays in treatment, regardless of stage at diagnosis, and 4–5 fold more likely to experience delays greater than 60 days (p<0.001). For local-regional disease, more Black women did not receive cancer directed surgery (14.2% vs. 2.9% of white women, p<0.001), but did receive breast conserving surgery (BCS) equivalently. However, only 61% of Black vs. 72% of White women received radiation with BCS (p<0.001). Black women eligible for hormonal therapy were less likely to receive it (p<0.001). Conclusions: Our findings suggest treatment standards are not adequately or equivalently implemented among Black and White women, even in a metropolitan area where teaching hospitals provide a substantial portion of breast cancer care. Treatment differences can adversely affect outcome and reasons for the differences need to be addressed. No significant financial relationships to disclose.

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Changes in black-white disparity in receipt of guideline concordant treatment for women with early-stage breast tumors.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e19089 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e19089-e19089

Author(s):

Hasan Nadeem ◽

John Romley ◽

Shaneda Warren-Andersen

Keyword(s):

Breast Cancer ◽

Radiation Therapy ◽

Black Women ◽

White Women ◽

Treatment Guidelines ◽

Early Stage ◽

Breast Tumors ◽

Breast Conserving Surgery ◽

Black And White ◽

Period 2

e19089 Background: Racial disparities are well documented in the treatment of women with breast cancer. Whereas clinical treatment guidelines are established for early stage breast tumors, disparities in guideline-concordant (GC) treatment may influence variation in breast cancer outcomes. As such, we investigated differences in the receipt of GC treatment for black and white women with early-stage breast cancer between 2008 and 2016. Methods: We evaluated the Surveillance, Epidemiology, and End Results Registry (SEER) Incidence database for black and white women aged 20-64 years with stage I / stage II breast tumors. Primary analyses investigated associations between race and receipt of GC treatment in three chronological periods. Potential driving factors for trends in receipt of guideline-concordant treatment were also assessed. Results: Among 145,561 women diagnosed with early stage breast tumors, overall receipt of GC care decreased from 84.58% in 2008 to 83.89% in 2016. In period 1 (2008-2010), there was a prominent disparity between black and white women (81.89% black vs 86.24% white; p < 0.001). By period 3 (2014-2016), GC care increased for black women (84.29%) but decreased for white women (84.82%), eliminating the disparity (p = 0.276). Multivariate logistic regression on changes in the black-white disparity across the study period showed increased receipt of GC treatment for black women relative to white women in period 2 (2011-2013, odds ratio [OR], 1.202; 95% confidence interval [CI], 1.075 – 1.344) and period 3 (OR, 1.376; 95% CI, 1.212 – 1.505). For black women undergoing breast conserving surgery, administration of radiation therapy increased from 44.01% in period 1 to 50.64% in period 3 (p < 0.001) and was a prominent driver for increased GC care. Conclusions: Overall receipt of guideline-concordant treatment decreased from 2008-2016. Black women experienced a substantial increase in receipt of guideline-concordant care in period 2 (2011-2013) and period 3 (2014-2016) relative to white women. Delivery and completion of radiation therapy with breast conserving surgery increased the likelihood of receipt of guideline-concordant treatment.

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Racial disparities in obesity and comorbidities among women with early breast cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e19061 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e19061-e19061

Author(s):

Kirsten A. Nyrop ◽

Allison Mary Deal ◽

Hyman B. Muss ◽

Emily Damone ◽

Michael Lorentsen ◽

...

Keyword(s):

Breast Cancer ◽

Black Women ◽

Early Breast Cancer ◽

White Women ◽

Retrospective Chart Review ◽

Future Research ◽

Black And White ◽

Black Patients ◽

Potential Impact ◽

White Patients

e19061 Background: Both comorbidities and obesity (body mass index/BMI 30 or higher) are observed in women at the time of early breast cancer (EBC) diagnosis. This study investigates age and obesity and their association with disparities in comorbidities between black and white women at EBC diagnosis. Methods: This is a retrospective chart review of women with EBC (Stage I-III) treated at a single institution. Relative risk (RR) with 95% Confidence Interval (CI) for individual comorbidities are calculated for black compared to white patients, adjusted for age and BMI. Results: In a sample of 548 women, 26% are black and 74% are white. 18% of black patients vs 28% of white patients were age 65 or older (p = .01). 62% of black vs 33% of white patients had obesity (p < .0001). 63% of black vs 47% of white patients had 2 or more total comorbidities at diagnosis (p = .003). 33% of black vs 10% of white patients had 2 or more obesity-related comorbidities (p < .0001). 60% of black vs 32% of white patients had hypertension (p < .0001); 23% of black vs 6% of white patients had diabetes (p < .0001); and 28% of black vs 18% of white patients had high cholesterol (p = .02). In multivariable (MV) analysis adjusted for age and BMI, black women had 45% higher risk for hypertension [RR 1.45 (1.19-1.75), p = .0002)] and 44% higher risk for diabetes [RR 1.44 (1.02-5.86), p < .0001)] at EBC diagnosis. However, after adjustment, differences by race were no longer seen for > = 2 total comorbidities, > = 2 obesity-related comorbidities, heart disease, or thyroid disease. Conclusions: This study documents significant disparities between black and white women with EBC with regard to high rates of obesity, overall comorbidities and obesity-related comorbidities. Future research should assess the potential impact of weight management (avoiding weight gain) interventions in the first 2 years post diagnosis on improving OS and BCSS among patients with obesity and in reducing OS and BCSS disparities between black and white women.

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