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Neighborhood Adversity Associated With Increased Risk of ER- Breast Cancer, TNBC for Black Women in the United States

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Data showed that Black women, regardless of education level or income, are more likely to reside in disadvantaged neighborhoods, which may contribute to racial disparities in breast cancer.

In the United States, Black women have a 40% higher mortality rate from breast cancer than White women, explained Julie R. Palmer, ScD, MPH, Karen Grunebaum professor in cancer research at the Boston University School of Medicine, during a presentation at the 15th American Association for Cancer Research Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved. Palmer explained further that this is the worst disparity present in breast cancer data and this disparity has not improved in more than 20 years.

“We know that’s a big part of the reason [for this disparity] is access to care. And by that I mean true access, which takes into account everything from economics, being able to get there, to how physicians and other providers treat a person and communicate,” Palmer said. “But it’s not only that, there are other differences too.”

Palmer explained that the data show differences in the occurrence of tumor subtypes between White and Black women as well.

“We’re all aware that triple-negative breast cancer (TNBC)—which is the most aggressive, occurs at younger ages, and is more difficult to treat—occurs at least twice as often on average among Black women as in any other group in the United States,” Palmer said. “Twenty-two percent of the tumors in Black women are triple-negative versus 10% to 12% in the other [population] groups. So having more of these aggressive tumors will necessarily lead to more mortality, which then brings me to the question: Why is there more [TNBC]?”

This is a question many in the field have been working to answer for some time, Palmer explained. She noted that the answer is likely multifactorial, with some causes that are biological and perhaps even genetically derived.

There are several investigators assessing the issue from varying lenses. For example, Lisa A. Newman, MD, MPH, FACS, FASCO, FSSO, chief of the Section of Breast Surgery at the New York-Presbyterian/Weill Cornell Medical Center and leader of the Multidisciplinary Breast Oncology Programs at the New York-Presbyterian David H. Koch Center in Weill Cornell Medicine, is an investigator working to assess patterns of breast cancer subtypes in different regions of Africa.

Additionally, looking at data within the United States, Melissa Davis has been investigating evolutionarily conserved genetic variants that play a role on the immune system. Based on the data Newman and Davis have presented, Palmer explained that biology does seem to be a part of the picture in terms of risk factors.

Palmer noted there are also behavioral differences across culturally defined groups in the United States that may be contributing to the disparity in rates of breast cancer among Black women versus other population groups. In particular, a diet high in fruits and vegetables has been shown to reduce the risk of estrogen receptor-negative (ER-) breast cancer and TNBC. Because diets and access to healthy food can differ across populations, diet may be another contributing factor, Palmer said.

Additionally, breastfeeding has been found to be an important protector against TNBC, Palmer noted. For a multitude of reasons that date back through the history of Black women in the United States, Black women are often less likely to breastfeed, according to Palmer.

“So my team and others have been doing work on these factors. But then I also feel we need to go beyond just these individual factors, which leads us to some social factors, neighborhood level factors, and in particular stress,” Palmer said. “Stress is another factor that, in some ways, disproportionately affects Black individuals in this country, because of the anti-Black racism that exists, which has shown to have one of the most powerful effects on people. That was the reason for this work that we began doing.”

Although the experience of stress can be a good thing in certain situations for which it may positively impact behavior, chronic stress has significant negative impacts on the body.

“Things get overburdened in both the sympathetic nervous system and the hypothalamic pituitary adrenal system. Then different biomarkers that are involved in inflammation, depression, and the immune system come into play more,” Palmer said. “That leads to a cascade of events with possible epigenetic modifications playing a role, [as well as] telomere shortening, and all of that can lead to cancer development, including possibly breast cancer.”

Additionally, the characteristics of a neighborhood can be a contributing factor to chronic stress, including low neighborhood socioeconomic status (NSES), concentrations of disadvantaged individuals, neighborhood violence, lack of green spaces, and lack of social cohesion, as well as loud noises and associated difficulties with sleeping.

“A neighborhood that lacks safety can be a more stressful place to live. Also, randomized trials of different communities that changed the environment of similar housing so that one sees a lot of greenery and the other doesn’t have shown that [greenery] has a real impact on mental health and wellbeing. So a lack of green space can have an effect,” Palmer said. “Then simply the noise that is more likely to be a problem in disadvantaged neighborhoods can lead to sleep problems, which also leads to more stress.”

To evaluate the impact of these neighborhood factors that may contribute to chronic stress, Palmer explained it was necessary to geocode addresses, which required that the investigators place a number on every address associated with a patient included for assessment that locates the address in space. That number, which corresponds to either a house or housing unit, can then be linked to other databases that provide information about the characteristics of the people who live in a certain area in which that number exists.

“The best sources of data for these types of neighborhood variables I’m interested in are the ones that relate to social and economic conditions come from the US Census Bureau—the long form ones which most of us have probably never filled out,” Palmer said.

With these data, Palmer and her colleagues worked to develop scores representing either neighborhood disadvantage or NSES based on different variables. For example, Palmer explained that when looking at the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program data, the investigators identified where those included in the SEER data set were living, which is the score the investigators used for their assessment .

“So the analysis we did was in the Black women’s health study. This study has been going on now for over 27 years, with the same 59,000 women who enrolled back in 1995. Not everyone is still filling out the questionnaires, but a very large proportion is,” Palmer said. “So there’s a lot of data in there on individual level factors. We also have geocoded addresses for every 2 years throughout the time [period] and then linked to those 2 databases.”

When the study began, the median age of the participants was 38 years, with residence throughout the country, Palmer explained. They investigators then learned of new breast cancer cases through self-reporting in these biannual questionnaires, but also through linkage with 24 state cancer registries for states in which most participants lived. Palmer noted for patients who are lost to follow-up, they would also link to a national death index to assess rates of mortality.

When breaking up the compiled data for analysis, the investigators first looked at the variable of concentrated neighborhood disadvantage. They then used a continuous score for each person, and then divided it into quartiles.

“So we were comparing women who lived in the highest quartile disadvantaged, so those are the ones in the most disadvantaged neighborhood, versus those in the lowest quartile,” Palmer said.

Palmer explained that the data showed a statistically significant increase in incidence of ER-breast cancer in the most disadvantaged neighborhoods. Specifically, high levels of neighborhood adversity were associated with a 25% increased risk of both ER- breast cancer and TNBC.

“Given that US Black women, regardless of their own education or income, are more likely to reside in disadvantaged neighborhoods, this factor may contribute to racial disparities in incidence of ER-breast cancer and TNBC,” Palmer said.

Reference

Palmer Jr. Neighborhood-level and individual-level psychosocial stressors and risk of breast cancer incidence among Black women. Philadelphia, PA: 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; September 18, 2022.

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Women’s Health

Why I Invested: Whitney Port on investing in prenatal vitamin brand Perelel

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Perelel, touting himself to be the first OBGYN-founded prenatal vitamin supplement brand to offer targeted nutrition at each stage of pregnancy, recently announced the completion of a $4.7 million seed fundraise with notable participation from celebrities in business, fashion, and wellness.

The company’s subscription-based business model spans a number of product offerings targeted for the particular life stage the customer is in, including a conception support pack; prenatal packs for first, second, and third trimesters; packs for postpartum and early motherhood; and daily vitamins for women of all reproductive ages. Perelel also has offerings for men, including a multi-support pack and additional supplemental products for iron, libido, and probiotic support.

The Hills star and Cozeco founder Whitney Port recently shared more with Fortune about her own prenatal experiences and subsequent interest to invest in the company.

  • Startup: Perelel
  • Location: Santa Monica, Calif.
  • Year founded: 2018
  • valuation: Declined to disclose
  • investment level: Seed
  • Number of employees: Nine
  • Other major investors: The seed round was led by Unilever Ventures with additional investors including Willow Growth Partners; Gaby Dalkin, CEO of What’s Gaby Cooking; Marissa Hermer, restaurateur and owner of the Draycott, Olivetta, and Issima; Rocky Barnes, founder of The Bright Side; Julia Hunter, dermatologist and founder of Wholistic Dermatology; Joan Nyugen, co-founder and CEO of Bumo; Aimee Song, founder of Song of Style and Two Songs; and Ali Weiss, chief marketing officer of Glossier

Why she invested, in her own words

Since striving for child number two, I’ve become much more conscious about the ingredients I put into my body. In my research on prenatal vitamins, I learned that most supplement brands on the market offer a one-size-fits-all approach to nutrition, which neglects essential dosages and nutrients during the different stages of pregnancy and postpartum. After multiple miscarriages, I learned there isn’t just one answer or one solution to fertility problems. Each miscarriage I’ve had occurred for a different reason.

So, as someone who can intimately relate to these multileveled issues that Perelel is tackling head-on in women’s healthcare, I was immediately drawn to the brand’s innovation and mission-driven business model. After the birth of my son, postpartum presented additional problem areas for me and I needed a boost; Perelel checked all the boxes I needed. Now I know countless women who are struggling similarly and would truly benefit from the product.

Perelel is much more than a business venture for me, and the value proposition goes further than a dollar sign. Its products are intentionally formulated for each stage of womanhood by a team of top women’s health doctors, including my reproductive endocrinologist, Dr. Andy Huang (who formulated their Conception Support vitamin packs).

Also, the intentionality behind building the brand community moved me. It’s much more than a customer base; it’s an intimately supportive network of women where we can lean on each other for emotional support and tap Perelel’s panel of doctors and experts for insight. Finally, for every subscription Perelel donates a supply of their own prenatal vitamins to underserved women in the US who lack access to high-quality prenatal care.

This is an installation of Why I Invested, a series featuring famous investors from all different backgrounds and industries, revealing what inspired them to invest their own money in a new business.

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​​While UI faculty are warned against even talking about emergency contraception, WSU will offer emergency contraceptives in vending machine

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Separated by just 8 miles, Washington State University and the University of Idaho remain vastly different places. Now in the post Roe v. Wade era, the differences are more apparent than ever.

This week, the University of Idaho warned faculty and staff that counseling students about abortion or contraception could lead to termination or result in a felony charge. The warning was delivered in a controversial memo that prompted a response from the White House. Meanwhile, across the state line, WSU’s student government announced funding for a contraceptive vending machine that will dispense pregnancy tests, condoms and Plan B, the so-called “morning-after” pill.

“WSU is part of a state system in (Washington) and Idaho is part of a state system in a state that is much more conservative,” said Mike Satz, former law professor and associate dean at the University of Idaho. “The workplace environment is very different for both schools and what it’s like to be a student is very different for both schools.”

The differences have led to confusion and frustration among students and faculty, according to multiple interviews and media coverage.

“It feels awful that my body is having to be used in a political fight,” said Alexandria Miller, a student at the University of Idaho.

Miller worries that the women’s health center on the UI campus will be restricted in the help they can offer students in need of contraceptives and counsel around pregnancy. The Idaho law mentioned in the memo also states that the university cannot dispense any emergency contraception except in the case of rape.

As of now, it is safe for Idahoans to travel to Washington to use resources, but that could change, Satz said.

“There are certain members of the legislature that have clearly shown their intent to want to control women’s choices, no matter where they are,” Satz said. “That is something that advocates for women’s health are looking at in Idaho because we’re very concerned about that.”

At WSU, a different political landscape

WSU’s Director of University Affairs Nikolai Sublett has been spearheading a way to bring an emergency contraceptive vending machine to WSU at a reasonable price. His inspiration came from an Instagram post.

Students were asking where to get Plan B and responses poured in saying that even though Plan B is accessible at places like Safeway, Walmart and Planned Parenthood, they are either sold out or are too far away from campus to be readily available, Sublett said.

Funding for the machine itself, which costs about $4,000, is coming from the budget of the Associated Students of WSU, while funding for the actual products will come from the student government’s Coug Health Fund, he said.

Sublett said emergency contraceptives will be priced at $15 a pill, $35 less than the usual name-brand price.

Excluding the $15 fee for the pill, bringing the vending machine to WSU will be no additional cost to students, he said. Sublett made a purchase request for the emergency contraceptives vending machine on Sept. 19 and hopes to get it ordered within the next two weeks, he said.

At least 22 universities around the country have vending machines for emergency contraceptives on their campuses, with at least 12 more in the works, according to an article from Bloomberg.

Safe sex supplies such as condoms, dental dams and lube are easily accessible on campus at WSU’s Women’s Center and the university’s Gender Identity/Expression and Sexual Orientation Resource Center, according to Amy Sharp, director of WSU Women’s Center.

Sharp said the only option for emergency contraception on campus costs $25 from the Cougar Health Services pharmacy, Sharp said.

“It just adds more accessibility for our students,” Sharp said.

Idaho employees unwilling to speak

Until recently, condoms have been made available on campus to prevent sexually transmitted diseases and pregnancy. Now, they are only advertised to prevent sexually transmitted diseases, Miller said.

“It’s almost considered offensive to talk about the facts of what a condom is used for,” she said.

In media reports, University of Idaho faculty and staff are requesting anonymity when they discuss the topic. The memo urged staff and faculty to refrain from speaking on these issues until they know more.

The fact that professors are asking for anonymity in interviews speaks to a toxic environment in which faculty and staff are afraid to speak, Satz said. He worries the memo could also damage faculty-student conversations for students seeking resources.

“I cannot tell you how many times as a faculty member I’ve had students come with really serious personal problems, and they came to me in my case, because I was one of the few faculty members of color on campus and they knew that they could trust me,” he said. “In this case, I think it’s going to be very damaging to those kinds of situations.”

Satz, who left the University of Idaho in 2020 and has co-founded the Idaho 97 Project, which advocates for sensitive public health measures and an end to hate, intimidation and disinformation, has been outspoken on the issue. This week, he posted a tweet noting the university memo and the Idaho law cite language that was originally written in 1887 – when Idaho was still a territory.

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Women’s Health

ER Goddess: Low-Income Women and Women of Color Will Bear th… : Emergency Medicine News

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figures:

abortion, bias

FU2-7figures

Half of American women seeking abortions live on incomes below the federal poverty level. (N Engl J Med. 2022;386[22]:2061; https://bit.ly/3zYFcRy.) It will be these women—women who are least able to support a pregnancy and a child—who will disproportionately bear the brunt of post-Roe abortion bans.

In anti-abortion states, only women with the financial resources, ability to take time off work, and pay for child care will be able to seek abortions elsewhere. What was formerly a right for all women is now in too many states a privilege for those with money and connections.

My patients generally don’t have money or connections. I work in an urban inner-city ED where the surrounding neighborhood has a lower per capita income, more single-mother households, and a child poverty rate higher than 99.9 percent of the neighborhoods in America. (Neighborhood Scout. http://bit.ly/2Oc37XD.) I recently saw a 12-year-old who is sexually active. Her mother, who had just learned her preteen was having sex, brought her in concerned that she could be pregnant. What will happen to this 12-year-old and other girls and women who come to my ED when they can’t access abortion?

The Turnaway study offers some unsettling insights into what life will be like for women after they are denied an abortion. (Foster, Diana Greene. The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having—or Being Denied—an Abortion. New York: Scribner, 2021; https://bit.ly/3JsHBHz.) The prospective longitudinal study compared the trajectories of women who were turned away by abortion clinics because they were too far along to the trajectories of women who received abortions at the same clinic.

Still stigmatized

The two groups were similar in demographics and socioeconomics; what separated them was who got to the clinic in time and who didn’t. Interviews with the women every six months during the five years following their pregnancies revealed that receiving an abortion did not harm women’s health and well-being. On the contrary, carrying an unwanted pregnancy to term harmed their finances, health, and families.

The Turnaway study showed that women who were denied an abortion were more likely to end up living in poverty, be unemployed, and go through bankruptcy or eviction and less likely to have money for food, gas, or other basic necessities. Women denied an abortion were more likely to be with a partner who abused them and to end up as a single parent. They were less likely to agree with the statement, “I feel happy when my child laughs or smiles” and more likely to say they felt trapped as a mother.

Even teens could be criminalized for pregnancy if we continue on our current path of stripping women of their reproductive health rights. It sounds like a dystopian novel, but women have already been jailed for miscarrying, something that happens naturally in 12 to 15 percent of pregnancies of women in their 20s, a number that rises to about 25 percent by age 40. (Cleveland Clinic. July 19, 2022; https://cle.clinic/3oUNfIV.)

Brittney Poolaw was 19 when she presented to an Oklahoma ED having a miscarriage at about 16 weeks gestational age. She was asked about illicit drug use, and she answered honestly that she had used methamphetamine. The fetus tested positive for methamphetamine at autopsy. No conclusive evidence proved that methamphetamine caused her miscarriage, but she was sentenced to four years in prison for first-degree manslaughter. She was all of 21 by then. The autopsy reported that the miscarriage could have been caused by congenital abnormality or placental abruption, but this was apparently ignored. (BBC. Nov. 12, 2021; https://bbc.in/3Q3lKJ2.)

Brittney, a Native American, faced the same type of prosecution that many low-income women, drug-using women, and women of color will face if the current legal climate surrounding pregnancy and abortion persists. The majority of women with unplanned pregnancies reported to the Turnaway researchers that they had used contraception, but these women are still stigmatized, as if forgoing abstinence is a moral shortcoming and birth control doesn’t have a significant failure rate.

Supporting Women in the ED

Contrary to what lawmakers may assume, decisions to have an abortion are not casual but serious and agonizing, often made in order to take care of family. The Turnaway interviews showed that most women seeking abortion were already mothers, and their children were more likely to hit developmental milestones and less likely to live in poverty in the years after they terminated a pregnancy. Many who had abortions went on to have more children; their subsequent pregnancies were more likely to be planned and those children had better outcomes too.

Women who seek abortion after their state’s gestational age cutoff often don’t even realize they are pregnant until it’s too late, due to factors like irregular menses and lack of morning sickness, the Turnaway study found. Nonetheless, strangers will impose their morality on these women’s private reproductive health decisions.

At best, our low-income, marginalized patients left with no option but to carry an unwanted pregnancy will face the loss of life they had envisioned for themselves. At worst, they will face their own death from complications of pregnancy. None of the women in the Turnaway study who received an abortion died from it, but two women who were turned away died from complications of pregnancy. The risk of dying from childbirth is 50 to 130 times greater than the risk of dying from abortion, according to the Centers for Disease Control and Prevention. (N Engl J Med. 2022;386[22]:2061; https://bit.ly/3zYFcRy.)

Are we willing to sacrifice the people who gestate fetuses on the altar of fetal rights?

No matter our political or religious beliefs, we EPs need to be empathetic to patients who feel frightened and trapped by the disturbing trend of forced birth and criminal sentences for pregnancy outcomes. Our patients may not seek health care during a miscarriage or after an illegal abortion because they are too scared. We need to be ready to support them with whatever resources we can when they end up in our EDs. Sadly, we also need to be ready for more of them to come experiencing the medical emergencies that will inevitably occur when a common health care procedure becomes illegal and inaccessible.

dr Simonsis a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter@ERGoddessMDand read her past columns athttp://bit.ly/EMN-ERGoddess.

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