Impact of COVID-19 pandemic on breast cancer screening in a large midwestern United States academic medical center

BACKGROUND

Access to breast screening mammogram services decreased during the COVID-19 pandemic. Our objectives were to estimate: 1) the COVID-19 affected period, 2) the proportion of pandemic-associated missed or delayed screening encounters, and 3) pandemic-associated patient attrition in screening encounters overall and by sociodemographic subgroup.

METHODS

We included screening mammogram encounter EPIC data from 1-1-2019 to 12-31-2022 for females ≥40 years old. We used Bayesian State Space models to describe weekly screening mammogram counts, modeling an interruption that phased in and out between 3-1-2020 and 9-1-2020. We used the posterior predictive distribution to model differences between a predicted, uninterrupted process and the observed screening mammogram counts. We estimated associations between race/ethnicity and age group and return screening mammogram encounters during the pandemic among those with 2019 encounters using logistic regression.

RESULTS

Our analysis modeling weekly screening mammogram counts included 231,385 encounters (n = 127,621 women). Model-estimated screening mammograms dropped by >98% between 03-15-2020 and 05-24-2020 followed by a return to pre-pandemic levels or higher with similar results by race/ethnicity and age group. Among 79,257 women, non-Hispanic (NH) Asians, NH Blacks, and Hispanics had significantly (p < .05) lower odds of screening encounter returns during 2020-2022 vs. NH Whites with odds ratios (ORs) from 0.70 to 0.91. Among 79,983 women, those 60-69 had significantly higher odds of any return screening encounter during 2020-2022 (OR = 1.28), while those ≥80 and 40-49 had significantly lower odds (ORs 0.77, 0.45) than those 50-59 years old. A sensitivity analysis suggested a possible pre-existing pattern.

CONCLUSIONS

These data suggest a short-term pandemic effect on screening mammograms of ~2 months with no evidence of disparities. However, we observed racial/ethnic disparities in screening mammogram returns during the pandemic that may be at least partially pre-existing. These results may inform future pandemic planning and continued efforts to eliminate mammogram screening disparities.

Associations between Medicaid enrollment and diagnosis stage and survival among pediatric cancer patients

BACKGROUND

Medicaid-associated disparities in childhood and adolescent (pediatric) cancer diagnosis stage and survival have been reported. However, a key limitation of prior studies is the assessment of health insurance at a single time point. To evaluate Medicaid-associated disparities more robustly, we used Surveillance, Epidemiology, and End Results (SEER)-Medicaid linked data to examine diagnosis stage and survival disparities in those (i) Medicaid-enrolled and (ii) with discontinuous and continuous Medicaid enrollment.

METHODS

SEER-Medicaid linked data from 2006 to 2013 were obtained on cases diagnosed from 0 to 19 years. Medicaid enrollment was classified as enrolled versus not enrolled, with further classifications as continuous when enrolled 6 months before through 6 months after diagnosis, and discontinuous when not enrolled continuously for this period. We used multinomial logistic and Cox proportional hazards regression models to determine associations between enrollment measures, diagnosis stage, and cancer death adjusted for covariates.

RESULTS

Among 21,502 cases, a higher odds of distant stage diagnoses were observed in association with Medicaid enrollment (odds ratio [OR] = 1.56, 95% confidence interval [CI]: 1.48-1.65), with the highest odds for discontinuous enrollment (OR = 2.0, 95% CI: 1.86-2.15). Among 30,654 cases, any Medicaid enrollment, continuous enrollment, and discontinuous enrollment were associated with 1.68 (95% CI: 1.35-2.10), 1.66 (95% CI: 1.35-2.05), and 1.89 (95% CI: 1.54-2.33) times higher hazards of cancer death versus no enrollment, respectively.

CONCLUSIONS

Medicaid enrollment, particularly discontinuous enrollment, is associated with a higher  distant stage diagnosis odds and risk of death. This study supports the critical need for consistent health insurance coverage in children and adolescents.

The impact of individual-level income predicted from the BRFSS on the association between insurance status and overall survival among adults with cancer from the SEER program

INTRODUCTION

Among patients with cancer in the United States, Medicaid insurance is associated with worse outcomes than private insurance and with similar outcomes as being uninsured. However, prior studies have not addressed the impact of individual-level socioeconomic status, which determines Medicaid eligibility, on the associations of Medicaid status and cancer outcomes. Our objective was to determine whether differences in cancer outcomes by insurance status persist after accounting for individual-level income.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried for 18-64 year-old individuals with cancer from 2014-2016. Individual-level income was imputed using a model trained on Behavioral Risk Factors Surveillance Survey participants including covariates also present in SEER. The association of 1-year overall survival and insurance status was estimated with and without adjustment for estimated individual-level income and other covariates.

RESULTS

A total of 416,784 cases in SEER were analyzed. The 1-yr OS for patients with private insurance, Medicaid insurance, and no insurance was 88.7%, 76.1%, and 73.7%, respectively. After adjusting for all covariates except individual-level income, 1-year OS differences were worse with Medicaid (-6.0%, 95% CI = -6.3 to -5.6) and no insurance (-6.7%, 95% CI = -7.3 to -6.0) versus private insurance. After also adjusting for estimated individual-level income, the survival difference for Medicaid patients was similar to privately insured (-0.4%, 95% CI = -1.9 to 1.1) and better than uninsured individuals (2.1%, 95% CI = 0.7 to 3.4).

CONCLUSIONS

Income, rather than Medicaid status, may drive poor cancer outcomes in the low-income and Medicaid-insured population. Medicaid insurance coverage may improve cancer outcomes for low-income individuals.

Impact of environment on pediatric and adult brain tumors: The 2023 Brain Tumor Epidemiology Consortium meeting report

The Brain Tumor Epidemiology Consortium (BTEC) is an international organization with membership of individuals from the scientific community with interests related to brain tumor epidemiology including surveillance, classification, methodology, etiology, and factors associated with morbidity and mortality. The 2023 annual BTEC meeting entitled "Impact of Environment on Pediatric and Adult Brain Tumors" was held in Lexington, KY, USA on May 22 - 24, 2023. The meeting gathered scientists from the United States, Canada, Australia, and Europe and included four keynote sessions covering genomic, epigenomic, and metabolomic considerations in brain tumor epidemiology, cancer clusters, environmental risk factors, and new approaches to cancer investigation. The meeting also included three abstract sessions and a brainstorming session. A summary of the meeting content is included in this report.

iHeard STL: Development and first year findings from a local surveillance and rapid response system for addressing COVID-19 and other health misinformation

BACKGROUND

The U.S. Surgeon General and others have emphasized a critical need to address COVID-19 misinformation to protect public health. In St. Louis, MO, we created iHeard STL, a community-level misinformation surveillance and response system. This paper reports methods and findings from its first year of operation.

METHODS

We assembled a panel of over 200 community members who answered brief, weekly mobile phone surveys to share information they heard in the last seven days. Based on their responses, we prioritized misinformation threats. Weekly surveillance data, misinformation priorities, and accurate responses to each misinformation threat were shared on a public dashboard and sent to community organizations in weekly alerts. We used logistic regression to estimate odds ratios (ORs) for associations between panel member characteristics and misinformation exposure and belief.

RESULTS

In the first year, 214 panel members were enrolled. Weekly survey response rates were high (mean = 88.3% ± 6%). Exposure to a sample of COVID-19 misinformation items did not differ significantly by panel member age category or gender; however, African American panel members had significantly higher reported odds of exposure and belief/uncertain belief in some misinformation items (ORs from 3.4 to 17.1) compared to white panel members.

CONCLUSIONS

Our first-year experience suggests that this systematic, community-based approach to assessing and addressing misinformation is feasible, sustainable, and a promising strategy for responding to the threat of health misinformation. In addition, further studies are needed to understand whether structural factors such as medical mistrust underly the observed racial differences in exposure and belief.

Pediatric cancer patient emergency department visits and disposition by sociodemographic and economic characteristics

BACKGROUND

Limited research has been conducted on cancer-related emergency department (ED) patterns among pediatric cancer patients, including whether there are differences in the characteristics of individuals who seek ED care for cancer complications. The objectives of this study were to determine whether rates and disposition of cancer-related ED visits and hospital admissions in childhood cancer patients differ by sociodemographic factors.

METHODS

A cross-sectional analysis of ED encounters with a cancer diagnosis code among patients aged 0-19 years from the 2019 National Emergency Department Sample (NEDS) was conducted. Weighted logistic regression models were utilized to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for a primary cancer-related encounter, and hospital admission overall and by subgroup characteristics.

RESULTS

Of the unweighted 6,801,711 ED encounters in children aged 0-19 years, 10,793 were classified as visits by cancer patients. ED encounters of Hispanic versus non-Hispanic White pediatric cancer patients had higher odds of having a cancer-related primary diagnosis (OR = 1.15, 95% CI: 1.04-1.27). ED encounters of non-Hispanic Black pediatric patients and those in the lowest zip code income quartile had higher odds of hospital admission (OR = 1.28, 95% CI: 1.08-1.53; OR = 1.30, 95% CI: 1.15-1.46), while rurality was associated with lower odds of hospital admission (OR = 0.69, 95% CI: 0.57-0.83).

CONCLUSION

These results suggest that pediatric cancer patients from certain under-resourced communities are more likely to use the ED for cancer treatment complications, and their encounters are more likely to result in admission to the hospital.

Perinatal folate levels do not influence tumor latency or multiplicity in a model of NF1 associated plexiform-like neurofibromas

OBJECTIVE

In epidemiological and experimental research, high folic acid intake has been demonstrated to accelerate tumor development among populations with genetic and/or molecular susceptibility to cancer. Neurofibromatosis type 1 (NF1) is a common autosomal dominant disorder predisposing affected individuals to tumorigenesis, including benign plexiform neurofibromas; however, understanding of factors associated with tumor risk in NF1 patients is limited. Therefore, we investigated whether pregestational folic acid intake modified plexiform-like peripheral nerve sheath tumor risk in a transgenic NF1 murine model.

RESULTS

We observed no significant differences in overall survival according to folate group. Relative to controls (180 days), median survival did not statistically differ in deficient (174 days, P = 0.56) or supplemented (177 days, P = 0.13) folate groups. Dietary folate intake was positively associated with RBC folate levels at weaning, (P = 0.023, 0.0096, and 0.0006 for deficient vs. control, control vs. supplemented, and deficient vs. supplemented groups, respectively). Dorsal root ganglia (DRG), brachial plexi, and sciatic nerves were assessed according to folate group. Mice in the folate deficient group had significantly more enlarged DRG relative to controls (P = 0.044), but no other groups statistically differed. No significant differences for brachial plexi or sciatic nerve enlargement were observed according to folate status.

State Public Assistance Spending and Survival Among Adults With Cancer

Importance

Social determinants of health contribute to disparities in cancer outcomes. State public assistance spending, including Medicaid and cash assistance programs for socioeconomically disadvantaged individuals, may improve access to care; address barriers, such as food and housing insecurity; and lead to improved cancer outcomes for marginalized populations.

Objective

To determine whether state-level public assistance spending is associated with overall survival (OS) among individuals with cancer, overall and by race and ethnicity.

Design, Setting, and Participants

This cohort study included US adults aged at least 18 years with a new cancer diagnosis from 2007 to 2013, with follow-up through 2019. Data were obtained from the Surveillance, Epidemiology, and End Results program. Data were analyzed from November 18, 2021, to July 6, 2023.

Exposure

Differential state-level public assistance spending.

Main Outcome and Measure

The main outcome was 6-year OS. Analyses were adjusted for age, race, ethnicity, sex, metropolitan residence, county-level income, state fixed effects, state-level percentages of residents living in poverty and aged 65 years or older, cancer type, and cancer stage.

Results

A total 2 035 977 individuals with cancer were identified and included in analysis, with 1 005 702 individuals (49.4%) aged 65 years or older and 1 026 309 (50.4%) male. By tertile of public assistance spending, 6-year OS was 55.9% for the lowest tertile, 55.9% for the middle tertile, and 56.6% for the highest tertile. In adjusted analyses, public assistance spending at the state-level was significantly associated with higher 6-year OS (0.09% [95% CI, 0.04%-0.13%] per $100 per capita; P < .001), particularly for non-Hispanic Black individuals (0.29% [95% CI, 0.07%-0.52%] per $100 per capita; P = .01) and non-Hispanic White individuals (0.12% [95% CI, 0.08%-0.16%] per $100 per capita; P < .001). In sensitivity analyses examining the roles of Medicaid spending and Medicaid expansion including additional years of data, non-Medicaid spending was associated with higher 3-year OS among non-Hispanic Black individuals (0.49% [95% CI, 0.26%-0.72%] per $100 per capita when accounting for Medicaid spending; 0.17% [95% CI, 0.02%-0.31%] per $100 per capita Medicaid expansion effects).

Conclusions and Relevance

This cohort study found that state public assistance expenditures, including cash assistance programs and Medicaid, were associated with improved survival for individuals with cancer. State investment in public assistance programs may represent an important avenue to improve cancer outcomes through addressing social determinants of health and should be a topic of further investigation.

Changes in cancer mortality after Medicaid expansion and the role of stage at diagnosis

BACKGROUND

Medicaid expansion is associated with improved survival following cancer diagnosis. However, little research has assessed how changes in cancer stage may mediate improved cancer mortality or how expansion may have decreased population-level cancer mortality rates.

METHODS

Nationwide state-level cancer data from 2001 to 2019 for individuals ages 20-64 years were obtained from the combined Surveillance, Epidemiology, and End Results National Program of Cancer Registries (incidence) and the National Center for Health Statistics (mortality) databases. We estimated changes in distant stage cancer incidence and cancer mortality rates from pre- to post-2014 in expansion vs nonexpansion states using generalized estimating equations with robust standard errors. Mediation analyses were used to assess whether distant stage cancer incidence mediated changes in cancer mortality.

RESULTS

There were 17 370 state-level observations. For all cancers combined, there were Medicaid expansion-associated decreases in distant stage cancer incidence (adjusted odds ratio = 0.967, 95% confidence interval  = 0.943 to 0.992; P = .01) and cancer mortality (adjusted odds ratio = 0.965, 95% confidence interval = 0.936 to 0.995; P = .022). This translates to 2591 averted distant stage cancer diagnoses and 1616 averted cancer deaths in the Medicaid expansion states. Distant stage cancer incidence mediated 58.4% of expansion-associated changes in cancer mortality overall (P = .008). By cancer site subgroups, there were expansion-associated decreases in breast, cervix, and liver cancer mortality.

CONCLUSIONS

Medicaid expansion was associated with decreased distant stage cancer incidence and cancer mortality. Approximately 60% of the expansion-associated changes in cancer mortality overall were mediated by distant stage diagnoses.

When do people increase COVID-19 protective behaviors? A longitudinal analysis of the impact of infections among close contacts and in the community

Studies examining individual-level changes in protective behaviors over time in association with community-level infection and self or close-contact infection with SARS-CoV-2 are limited. We analyzed overall and demographic specific week-to-week changes in COVID-19 protective behaviors and their association with COVID-19 infections (regional case counts and self or close contacts). Data were collected through 37 consecutive weekly surveys from 10/17/2021 - 6/26/2022. Our survey panel included 212 individuals living or working in St. Louis City and County, Missouri, U.S.A. Frequency of mask-wearing, handwashing, physical distancing, and avoiding large gatherings was self-reported (more/the same/less than the prior week). Close contact with COVID-19 was reported if the panel member, their household member, or their close contact tested positive, got sick, or was hospitalized for COVID-19 in the prior week. Regional weekly COVID-19 case counts were matched to the closest survey administration date. We used generalized linear mixed models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations. Evidence for effect modification was assessed using the likelihood ratio test. Increased protective behaviors were positively associated with COVID-19 case counts (OR_{highest vs. lowest case count category} = 4.39, 95% CI 3.35-5.74) and with participant-reported self or close contacts with COVID-19 (OR = 5.10, 95% CI 3.88-6.70). Stronger associations were found for White vs. Black panel members (p <.0001). Individuals modulated their protective behaviors in association with regional COVID-19 case counts and self or close contact infection. Rapid reporting and widespread public awareness of infectious disease rates may help reduce transmission during a pandemic by increasing protective behaviors.

The association of Medicaid expansion and pediatric cancer overall survival

Medicaid eligibility expansion, though not directly applicable to children, has been associated with improved access to care in children with cancer, but associations with overall survival are unknown. Data for children ages 0 to 14 years diagnosed with cancer from 2011 to 2018 were queried from central cancer registries data covering cancer diagnoses from 40 states as part of the Centers for Disease Control and Prevention's National Program of Cancer Registries. Difference-in-differences analyses were used to compare changes in 2-year survival from 2011-2013 to 2015-2018 in Medicaid expansion relative to nonexpansion states. In adjusted analyses, there was a 1.50 percentage point (95% confidence interval = 0.37 to 2.64) increase in 2-year overall survival after 2014 in expansion relative to nonexpansion states, particularly for those living in the lowest county income quartile (difference-in-differences  = 5.12 percentage point, 95% confidence interval = 2.59 to 7.65). Medicaid expansion may improve cancer outcomes for children with cancer.

Disparities in survival improvement for U.S. childhood and adolescent cancer between 1995 and 2019: An analysis of population-based data

BACKGROUND

Although treatment advances have increased childhood and adolescent cancer survival, whether patient subgroups have benefited equally from these improvements is unclear.

METHODS

Data on 42,865 malignant primary cancers diagnosed between 1995 and 2019 in individuals ≤ 19 years were obtained from 12 Surveillance, Epidemiology, and End Results registries. Hazard ratios (HRs) and 95 % confidence intervals (CIs) for cancer-specific mortality by age group (0-14 and 15-19 years), sex, and race/ethnicity were estimated using flexible parametric models with a restricted cubic spline function in each of the periods: 2000-2004, 2005-2009, 2010-2014 and 2015-2019, versus 1995-1999. Interactions between diagnosis period and age group (children 0-14 and adolescents 15-19 years at diagnosis), sex, and race/ethnicity were assessed using likelihood ratio tests. Five-year cancer-specific survival rates for each diagnosis period were further predicted.

RESULTS

Compared with the 1995-1999 cohort, the risk of dying from all cancers combined decreased in subgroups defined by age, sex and race/ethnicity with HRs ranging from 0.50 to 0.68 for the 2015-2019 comparison. HRs were more variable by cancer subtype. There were no statistically significant interactions by age group (P_interaction=0.05) or sex (P_interaction=0.71). Despite non-significant differences in cancer-specific survival improvement across different races and ethnicities (P_interaction=0.33) over the study period, minorities consistently experienced inferior survival compared with non-Hispanic Whites.

CONCLUSIONS

The substantial improvements in cancer-specific survival for childhood and adolescent cancer did not differ significantly by different age, sex, and race/ethnicity groups. However, persistent gaps in survival between minorities and non-Hispanic Whites are noteworthy.

Health Insurance Coverage and Racial/Ethnic Disparities in U.S. Childhood and Adolescent Cancer Survival

OBJECTIVE

To evaluate potential effect modification by health insurance coverage on racial and ethnic disparities in cancer survival among U.S. children and adolescents.

STUDY DESIGN

Data from 54,558 individuals diagnosed with cancer at ≤ 19 years between 2004 and 2010 were obtained from the National Cancer Database. Cox proportional hazards regression was used for analyses. An interaction term between race/ethnicity and health insurance type was included to examine racial/ethnic disparities in survival by each insurance status category.

RESULTS

Racial/ethnic minorities experienced a 14-42% higher hazard of death compared with non-Hispanic Whites with magnitudes varying by health insurance type (P_interaction < 0.001). Specifically, among those reported as privately insured, the hazard of death was higher for non-Hispanic Blacks (hazard ratio [HR]=1.48, 95% confidence interval [CI]: 1.36-1.62), non-Hispanic American Indian/Alaskan Natives (HR=1.30, 95%CI: 1.13-1.50), non-Hispanic Asians or Pacific Islanders (HR=1.99, 95%CI: 1.36-2.90) and Hispanics (HR=1.28, 95%CI: 1.17-1.40) vs. non-Hispanic Whites. Racial/ethnic disparities in survival among those reported as covered by Medicaid were present for non-Hispanic Blacks (HR=1.30, 95%CI: 1.19-1.43) but no other racial/ethnic minorities (HR ranges: 0.98∼1.00) vs. non-Hispanic Whites. In the uninsured group, the hazard of death for non-Hispanic Blacks (HR=1.68, 95%CI: 1.26-2.23) and Hispanics (HR=1.27, 95%CI: 1.01-1.61) was higher vs. non-Hispanic Whites.

CONCLUSIONS

Disparities in survival exist across insurance types, particularly for non-Hispanic Black childhood and adolescent cancer patients vs. non-Hispanic Whites with private insurance. These findings provide insights for research and policy and point to the need for more efforts on promoting health equity while improving health insurance coverage.

Pediatric brain tumors: Origins, epidemiology, and classification - The 2022 Brain Tumor Epidemiology Consortium meeting report

The Brain Tumor Epidemiology Consortium (BTEC) is an international organization that fosters collaboration among scientists focused on understanding the epidemiology of brain tumors with interests ranging from the etiology of brain tumor development and outcomes to the control of morbidity and mortality. The 2022 annual BTEC meeting with the theme "Pediatric Brain Tumors: Origins, Epidemiology, and Classification" was held in Lyon, France on June 20 - 22, 2022. Scientists from North America and Europe presented recent research and progress in the field. The meeting content is summarized in this report.

Pf7: an open dataset of Plasmodium falciparum genome variation in 20,000 worldwide samples

We describe the MalariaGEN Pf7 data resource, the seventh release of Plasmodium falciparum genome variation data from the MalariaGEN network.  It comprises over 20,000 samples from 82 partner studies in 33 countries, including several malaria endemic regions that were previously underrepresented.  For the first time we include dried blood spot samples that were sequenced after selective whole genome amplification, necessitating new methods to genotype copy number variations.  We identify a large number of newly emerging crt mutations in parts of Southeast Asia, and show examples of heterogeneities in patterns of drug resistance within Africa and within the Indian subcontinent.  We describe the profile of variations in the C-terminal of the csp gene and relate this to the sequence used in the RTS,S and R21 malaria vaccines.  Pf7 provides high-quality data on genotype calls for 6 million SNPs and short indels, analysis of large deletions that cause failure of rapid diagnostic tests, and systematic characterisation of six major drug resistance loci, all of which can be freely downloaded from the MalariaGEN website.

Facility patient volume and survival among individuals diagnosed with malignant central nervous system tumors

PURPOSE

Prior research indicates that the volume of central nervous system (CNS) tumor patients seen by a facility is associated with outcomes. However, most studies have focused on short-term survival and specific CNS tumor subtypes. Our objective was to examine whether facility CNS tumor patient volume is associated with longer-term CNS tumor survival overall and by subtype.

METHODS

We obtained National Cancer Database (NCDB) data including individuals diagnosed with CNS tumors from 2004 to 2016. Analyses were stratified by age group (0-14, 15-39, 40-64, and ≥ 65 years) and tumor type. We used Cox Proportional Hazards (PH) regression and restricted mean survival time (RMST) analyses to examine associations between survival and facility patient volume percentile category adjusting for potential confounding factors.

RESULTS

Our analytic dataset included data from 130,830 individuals diagnosed with malignant first primary CNS tumors. We found a consistently reduced hazard rate of death across age groups for individuals reported by higher vs. lower (> 95th vs. ≤ 70th percentile) volume facilities (hazard ratio (HR)_0-14 = 0.78, 95% confidence interval (CI) 0.64-0.95; HR_15-39 = 0.87, 95% CI 0.78-0.96; HR_40-64 = 0.82, 95% CI 0.76-0.88; HR_≥65 = 0.80, 95% CI 0.75-0.86). Significantly longer survival times within 5 years for higher vs. lower volume facilities were observed ranging from 1.20 months (15-39) to 3.08 months (40-64) higher. Associations varied by CNS tumor subtype for all age groups.

CONCLUSIONS

These results suggest facility factors influence CNS tumor survival with longer survival for patients reported by higher volume facilities. Understanding these factors will be critical to developing strategies that eliminate modifiable differences in survival times.

Changes in cancer mortality rates after Medicaid expansion under the Affordable Care Act and the role of changes in stage at diagnosis

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Background: Medicaid expansion is associated with earlier cancer diagnoses and improved cancer survival. However, it is unclear if the expansion-associated survival benefits are driven primarily by early detection leading to improved prognosis and/or increased access to appropriate cancer care. A nationwide analysis was performed to determine the degree to which expansion-associated changes in cancer mortality rates can be explained by changes in stage at diagnosis. Methods: State-level cancer incidence and mortality data from 2001-2019 for individuals ages 20-64 years were obtained from the combined Surveillance, Epidemiology, and End Results and National Program of Cancer Registries databases (incidence) and the National Center for Health Statistics (mortality), which cover the 50 US States and Washington DC. Difference-in-differences analyses were conducted to compare changes in localized and distant stage cancer incidence rates and cancer mortality rates from pre- vs. post-2014 in expansion vs. non-expansion states. We utilized generalized estimating equations to account for autocorrelation within states and adjusted for age, race, sex, year, state, early Medicaid expansion effects, and state-level covariates (unemployment, education, poverty, race/ethnicity, and insurance). Analyses were conducted overall and by cancer site subtype. Mediation analyses were utilized to assess whether local and/or distant stage diagnosis rates were mediators of the changes in cancer mortality rates. Results: The data consisted of 16,470 state-year observations stratified by age, sex and race. In our adjusted analyses with all cancer sites combined, there were decreases in the distant stage cancer incidence rate (OR: 0.966, 95% CI = 0.942 - 0.991, P=.009) and cancer mortality rate (OR: 0.974, 95% CI = 0.950 - 0.999, P=.041) after Medicaid expansion in expansion relative to non-expansion states. There were no expansion-associated changes in localized cancer incidence rates (OR: 0.989, P=.45). Changes in distant stage cancer incidence mediated 26% of the expansion-associated change in cancer mortality ( P=.013). By cancer site, there were Medicaid expansion-associated decreases in cancer mortality rates for breast (OR: 0.954, P<.001), cervical (OR: 0.934, P=.020), and colorectal (OR: 0.945, P=.045) cancers, though local or distant stage incidence rates were not found to be statistically significant mediators. Conclusions: Medicaid expansion was associated with decreased metastatic stage cancer incidence and decreased overall cancer mortality. Approximately 25% of the improvements in cancer mortality can be attributed to decreases in metastatic diagnoses suggesting increased rates of curative-intent treatment, amongst other factors. Remaining survival benefits may reflect access to timely, quality cancer care not captured in this analysis.

Pediatric, adolescent, and young adult cancer in an HIV-infected rural sub-Saharan African population

Youth living with HIV (YLWHIV) have an increased cancer risk. Our objective is to describe the prevalence of medical record (MR) reported suspected cancers in a contemporary cohort of YLWHIV in Uganda that was assembled through MR reviews of patients 10 to 24 years old across 35 Ugandan HIV care health facilities. Clinical data were abstracted to identify suspected cancer cases and information about HIV care. Among 3728 YLWHIV, we identified eight suspected cancer cases. The most common suspected types were Kaposi sarcoma (n=4) followed by lymphoma (n=3). Challenges encountered in data abstraction were missing data for several variables and confirmatory cancer diagnostic information. In follow-up of suspected cases referred for diagnosis at the Uganda Cancer Institute (UCI), none had diagnosis records in UCI files. In addition, ∼18% of patients (n=686) were lost-to-follow-up (LTF) defined as not having returned to the clinic in ≥183 days and three patients died from presumed Kaposi sarcoma. Although our results suggest that cancer is rare in YLWHIV, the possibility that the cancer burden is higher cannot be excluded due to incomplete information in MRs and high LTF rates. Further, our study raises concern that patients referred for diagnosis are not accessing potential life-saving care.

Employment Loss and Food Insecurity - Race and Sex Disparities in the Context of COVID-19

Introduction

Applying an intersectional framework, we examined sex and racial inequality in COVID-19–related employment loss (ie, job furlough, layoff, and reduced pay) and food insecurity (ie, quality and quantity of food eaten, food worry, and receipt of free meals or groceries) among residents in Saint Louis County, Missouri.

Methods

We used cross-sectional data from adults aged 18 or older (N = 2,146), surveyed by using landlines or cellular phones between August 12, 2020, and October 27, 2020. We calculated survey-weighted prevalence of employment loss and food insecurity for each group (Black female, Black male, White female, White male). Odds ratios for each group were estimated by using survey-weighted binary and multinomial logistic regression models.

Results

Black female residents had higher odds of being laid off, as compared with White male residents (OR = 2.61, 95% CI, 1.24–5.46). Both Black female residents (OR = 4.13, 95% CI, 2.29–7.45) and Black male residents (OR = 2.41, 95% CI, 1.15–5.07) were more likely to receive free groceries, compared with White male residents. Black female (OR = 4.25, 95% CI, 2.28–7.94) and White female residents (OR = 1.93, 95% CI, 1.04–3.60) had higher odds of sometimes worrying about food compared with White male residents. Black women also had higher odds of always or nearly always worrying about food, compared with White men (OR = 2.99, 95% CI, 1.52–5.87).

Conclusion

Black women faced the highest odds of employment loss and food insecurity, highlighting the disproportionate impact of COVID-19 among people with intersectional disadvantages of being both Black and female. Interventions to reduce employment loss and food insecurity can help reduce the disproportionately negative social effects among Black women.

The impact of health insurance coverage on racial/ethnic disparities in US childhood and adolescent cancer stage at diagnosis

BACKGROUND

Racial/ethnic minority children and adolescents are more likely to have an advanced cancer diagnosis compared with non-Hispanic Whites, which may relate to the lack of consistent health care access. This study aims to describe racial/ethnic disparities in cancer diagnosis stage among children and adolescents and assess whether health insurance mediates these disparities.

METHODS

Data on individuals ≤19 years of age diagnosed with primary cancers from 2007 to 2016 were obtained from the Surveillance, Epidemiology, and End Results 18 database. Prevalence ratios (PRs) and 95% confidence intervals (CIs) for the association between race/ethnicity and cancer diagnosis stage were calculated using Poisson regression. Analyses addressing health insurance as a potential mediator were also performed.

RESULTS

Compared with non-Hispanic Whites, racial/ethnic minorities had a higher prevalence of a distant cancer diagnosis, with PRs of 1.31 (95% CI, 1.23-1.40) for non-Hispanic Blacks, 1.14 (95% CI, 1.04-1.24) for non-Hispanic Asian/Pacific Islanders, and 1.15 (95% CI, 1.09-1.21) for Hispanics. These associations were attenuated when adjusting for health insurance, with PRs of 1.24 (95% CI, 1.16-1.33) for non-Hispanic Blacks, 1.11 (95% CI, 1.02-1.21) for non-Hispanic Asian/Pacific Islanders, and 1.07 (95% CI, 1.01-1.13) for Hispanics. Any Medicaid or no insurance at diagnosis mediated 49%, 22%, and 9% of the observed association with distant stage in Hispanics, non-Hispanic Blacks, and non-Hispanic Asian/Pacific Islanders, respectively.

CONCLUSIONS

Disparities in cancer diagnosis stage in racial/ethnic minority children and adolescents may be partially explained by health insurance coverage. Further research is needed to understand the mechanisms.

Association of Medicaid expansion under the Affordable Care Act and overall survival among children with cancer

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Background: State Medicaid expansions under the Affordable Care Act are associated with increased Medicaid coverage among children, including those with cancer. Since the expansions did not directly affect Medicaid eligibility criteria for children, these changes suggest “welcome mat” effects, where previously uninsured children become enrolled in Medicaid after their parents gain coverage. Insurance improvements from the expansions have been associated with improved cancer outcomes for non-elderly adults. However, it is unclear whether the expansions also impacted childhood cancer outcomes. Methods: Data for children ages 0-14 years diagnosed with cancer from 2011-2017 were queried from central cancer registries covering cancer diagnoses from 43 states as part of the Centers for Disease Control’s National Program of Cancer Registries. The primary outcome was 2-year overall survival. We utilized difference-in-differences analyses to compare changes in 2-year survival from 2011-2013 to 2014-2017 between children who resided in states expanding Medicaid by 2014 vs. states not expanding Medicaid within the study period. Analyses were adjusted for covariates including age, race/ethnicity, sex, metropolitan residence, cancer type, and stage at diagnosis. Results: A total of 42,970 children with cancer were included. Overall, there were increases in 2-year survival among children in expansion states (90.5% in 2011-2013 to 91.4% in 2014-2017) but no change among children in non-expansion states (90.0% in 2011-2013 to 90.0% in 2014-2017). In adjusted difference-in-differences analyses, there was no significant change in survival after Medicaid expansion for children in expansion vs. non-expansion states (1.01 percentage points, 95% CI = -0.23 to 2.25, p = 0.11). In difference-in-differences analyses by race/ethnicity, there was a significant expansion-associated improvement in survival in Black children (3.97 percentage points, 95% CI = 0.02 to 7.93, p = 0.049) but not in White children (0.4 percentage points, 95% CI = -1.07 to 2.04, p = 0.54). There were also expansion-associated improvements in survival among children residing in counties with the lowest quartile of county income (5.88 percentage points, 95% CI = 0.38 to 11.38, p = 0.036) but not for those in higher income counties (1.15, 1.23, and 0.12 percentage points for 2nd, 3rd, and 4th quartiles, respectively). Conclusions: Medicaid expansion, through presumed increases in Medicaid coverage via welcome mat effects, was associated with increased 2-year survival for Black children and children residing in low-income counties. However, the concentration of Black children in states that have not expanded Medicaid highlights the need for further advocacy to more fully achieve improved outcomes. Future data are needed to clarify potential long-term impacts of Medicaid expansion on childhood cancer outcomes.

An open dataset of Plasmodium vivax genome variation in 1,895 worldwide samples

This report describes the MalariaGEN Pv4 dataset, a new release of curated genome variation data on 1,895 samples of Plasmodium vivax collected at 88 worldwide locations between 2001 and 2017. It includes 1,370 new samples contributed by MalariaGEN and VivaxGEN partner studies in addition to previously published samples from these and other sources. We provide genotype calls at over 4.5 million variable positions including over 3 million single nucleotide polymorphisms (SNPs), as well as short indels and tandem duplications. This enlarged dataset highlights major compartments of parasite population structure, with clear differentiation between Africa, Latin America, Oceania, Western Asia and different parts of Southeast Asia. Each sample has been classified for drug resistance to sulfadoxine, pyrimethamine and mefloquine based on known markers at the dhfr, dhps and mdr1 loci. The prevalence of all of these resistance markers was much higher in Southeast Asia and Oceania than elsewhere. This open resource of analysis-ready genome variation data from the MalariaGEN and VivaxGEN networks is driven by our collective goal to advance research into the complex biology of P. vivax and to accelerate genomic surveillance for malaria control and elimination.

Assessment of the impact of the COVID-19 pandemic on health services use

Objectives

The coronavirus disease of 2019 (COVID-19) pandemic declared by the World Health Organization on March 11, 2020 impacted healthcare services with provider and patient cancellations, delays, and patient avoidance or delay of emergency department or urgent care. Limited data exist on the population proportion affected by delayed healthcare, which is important for future healthcare planning efforts. Our objective was to evaluate the impact of the COVID-19 pandemic on healthcare service cancellations or delays and delays/avoidance of emergency/urgent care overall and by population characteristics.

Study design

This was a cross-sectional study.

Methods

Our sample (n = 2314) was assembled through a phone survey from 8/12/2020–10/27/2020 among non-institutionalized St. Louis County, Missouri, USA residents ≥18 years. We asked about provider and patient-initiated cancellations or delays of appointments and pandemic-associated delays/avoidance of emergency/urgent care overall and by participant characteristics. We calculated weighted prevalence estimates by select resident characteristics.

Results

Healthcare services cancellations or delays affected ∼54% (95% CI 50.6%–57.1%) of residents with dental (31.1%, 95% CI 28.1%–34.0%) and primary care (22.1%, 95% CI 19.5%–24.6%) being most common. The highest prevalences were among those who were White, ≥65 years old, female, in fair/poor health, who had health insurance, and who had ≥1 medical condition. Delayed or avoided emergency/urgent care impacted ∼23% (95% CI 19.9%–25.4%) of residents with a higher prevalence in females than males.

Conclusions

Healthcare use disruptions impacted a substantial proportion of residents. Future healthcare planning efforts should consider these data to minimize potential morbidity and mortality from delayed care.

SARS-CoV-2 active infection prevalence and seroprevalence in the adult population of St. Louis County

BACKGROUND

The true prevalence of COVID-19 is difficult to estimate due to the absence of random population-based testing. To estimate current and past COVID-19 infection prevalence in a large urban area, we conducted a population-based survey in St. Louis County, Missouri.

METHODS

The population-based survey of active infection (PCR) and seroprevalence (IgG antibodies) of adults (≥ 18 years) was conducted through random-digit dialing and targeted sampling of St. Louis County residents with oversampling of Black residents. Infection prevalence of residents was estimated using design-based and raking weighting.

RESULTS

Between August 17 and October 24, 2020, 1,245 residents completed a survey and underwent PCR testing; 1,073 residents completed a survey and underwent PCR and IgG testing or self-reported results. Weighted prevalence estimates of residents with active infection was 1.9% (95% CI, 0.4% to 3.3%) and 5.6% were ever infected (95% CI, 3.3% to 8.0%). Overall infection hospitalization and fatality ratios were 4.9% and 1.4%, respectively.

CONCLUSIONS

Through October 2020, the percentage of residents that had ever been infected was relatively low. A markedly higher percentage of Black and other minorities compared to White residents were infected with COVID-19. The St. Louis region remained highly vulnerable to widespread infection in late 2020.

Human Papillomavirus Vaccination and Trends in Cervical Cancer Incidence and Mortality in the US

This cohort study examines the association of human papillomvirus vaccination with cervical cancer incidence and mortality rates in the US, comparing age groups understood to have differing levels of vaccination.