Cancer statistics, 2023

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population-based cancer occurrence and outcomes using incidence data collected by central cancer registries and mortality data collected by the National Center for Health Statistics. In 2023, 1,958,310 new cancer cases and 609,820 cancer deaths are projected to occur in the United States. Cancer incidence increased for prostate cancer by 3% annually from 2014 through 2019 after two decades of decline, translating to an additional 99,000 new cases; otherwise, however, incidence trends were more favorable in men compared to women. For example, lung cancer in women decreased at one half the pace of men (1.1% vs. 2.6% annually) from 2015 through 2019, and breast and uterine corpus cancers continued to increase, as did liver cancer and melanoma, both of which stabilized in men aged 50 years and older and declined in younger men. However, a 65% drop in cervical cancer incidence during 2012 through 2019 among women in their early 20s, the first cohort to receive the human papillomavirus vaccine, foreshadows steep reductions in the burden of human papillomavirus-associated cancers, the majority of which occur in women. Despite the pandemic, and in contrast with other leading causes of death, the cancer death rate continued to decline from 2019 to 2020 (by 1.5%), contributing to a 33% overall reduction since 1991 and an estimated 3.8 million deaths averted. This progress increasingly reflects advances in treatment, which are particularly evident in the rapid declines in mortality (approximately 2% annually during 2016 through 2020) for leukemia, melanoma, and kidney cancer, despite stable/increasing incidence, and accelerated declines for lung cancer. In summary, although cancer mortality rates continue to decline, future progress may be attenuated by rising incidence for breast, prostate, and uterine corpus cancers, which also happen to have the largest racial disparities in mortality.

Annual report to the nation on the status of cancer, part 1: National cancer statistics

BACKGROUND

The American Cancer Society, the Centers for Disease Control and Prevention, the National Cancer Institute, and the North American Association of Central Cancer Registries collaborate to provide annual updates on cancer occurrence and trends in the United States.

METHODS

Data on new cancer diagnoses during 2001-2018 were obtained from the North American Association of Central Cancer Registries' Cancer in North America Incidence file, which is comprised of data from Centers for Disease Control and Prevention-funded and National Cancer Institute-funded, population-based cancer registry programs. Data on cancer deaths during 2001-2019 were obtained from the National Center for Health Statistics' National Vital Statistics System. Five-year average incidence and death rates along with trends for all cancers combined and for the leading cancer types are reported by sex, racial/ethnic group, and age.

RESULTS

Overall cancer incidence rates were 497 per 100,000 among males (ranging from 306 among Asian/Pacific Islander males to 544 among Black males) and 431 per 100,000 among females (ranging from 309 among Asian/Pacific Islander females to 473 among American Indian/Alaska Native females) during 2014-2018. The trend during the corresponding period was stable among males and increased 0.2% on average per year among females, with differing trends by sex, racial/ethnic group, and cancer type. Among males, incidence rates increased for three cancers (including pancreas and kidney), were stable for seven cancers (including prostate), and decreased for eight (including lung and larynx) of the 18 most common cancers considered in this analysis. Among females, incidence rates increased for seven cancers (including melanoma, liver, and breast), were stable for four cancers (including uterus), and decreased for seven (including thyroid and ovary) of the 18 most common cancers. Overall cancer death rates decreased by 2.3% per year among males and by 1.9% per year among females during 2015-2019, with the sex-specific declining trend reflected in every major racial/ethnic group. During 2015-2019, death rates decreased for 11 of the 19 most common cancers among males and for 14 of the 20 most common cancers among females, with the steepest declines (>4% per year) reported for lung cancer and melanoma. Five-year survival for adenocarcinoma and neuroendocrine pancreatic cancer improved between 2001 and 2018; however, overall incidence (2001-2018) and mortality (2001-2019) continued to increase for this site. Among children (younger than 15 years), recent trends were stable for incidence and decreased for mortality; and among, adolescents and young adults (aged 15-39 years), recent trends increased for incidence and declined for mortality.

CONCLUSIONS

Cancer death rates continued to decline overall, for children, and for adolescents and young adults, and treatment advances have led to accelerated declines in death rates for several sites, such as lung and melanoma. The increases in incidence rates for several common cancers in part reflect changes in risk factors, screening test use, and diagnostic practice. Racial/ethnic differences exist in cancer incidence and mortality, highlighting the need to understand and address inequities. Population-based incidence and mortality data inform prevention, early detection, and treatment efforts to help reduce the cancer burden in the United States.

Breast Cancer Statistics, 2022

This article is the American Cancer Society's update on female breast cancer statistics in the United States, including population-based data on incidence, mortality, survival, and mammography screening. Breast cancer incidence rates have risen in most of the past four decades; during the most recent data years (2010-2019), the rate increased by 0.5% annually, largely driven by localized-stage and hormone receptor-positive disease. In contrast, breast cancer mortality rates have declined steadily since their peak in 1989, albeit at a slower pace in recent years (1.3% annually from 2011 to 2020) than in the previous decade (1.9% annually from 2002 to 2011). In total, the death rate dropped by 43% during 1989-2020, translating to 460,000 fewer breast cancer deaths during that time. The death rate declined similarly for women of all racial/ethnic groups except American Indians/Alaska Natives, among whom the rates were stable. However, despite a lower incidence rate in Black versus White women (127.8 vs. 133.7 per 100,000), the racial disparity in breast cancer mortality remained unwavering, with the death rate 40% higher in Black women overall (27.6 vs. 19.7 deaths per 100,000 in 2016-2020) and two-fold higher among adult women younger than 50 years (12.1 vs. 6.5 deaths per 100,000). Black women have the lowest 5-year relative survival of any racial/ethnic group for every molecular subtype and stage of disease (except stage I), with the largest Black-White gaps in absolute terms for hormone receptor-positive/human epidermal growth factor receptor 2-negative disease (88% vs. 96%), hormone receptor-negative/human epidermal growth factor receptor 2-positive disease (78% vs. 86%), and stage III disease (64% vs. 77%). Progress against breast cancer mortality could be accelerated by mitigating racial disparities through increased access to high-quality screening and treatment via nationwide Medicaid expansion and partnerships between community stakeholders, advocacy organizations, and health systems.

Identification of Deaths Caused by Cancer and COVID-19 in the US During March to December 2020

This cross-sectional study uses 2020 mortality data in the US to analyze deaths caused by cancer and COVID-19 in terms of demographic characteristics, cancer site, and place of death.

Health insurance status and cancer stage at diagnosis and survival in the United States

Previous studies using data from the early 2000s demonstrated that patients who were uninsured were more likely to present with late-stage disease and had worse short-term survival after cancer diagnosis in the United States. In this report, the authors provide comprehensive data on the associations of health insurance coverage type with stage at diagnosis and long-term survival in individuals aged 18-64 years who were diagnosed between 2010 and 2013 with 19 common cancers from the National Cancer Database, with survival follow-up through December 31, 2019. Compared with privately insured patients, Medicaid-insured and uninsured patients were significantly more likely to be diagnosed with late-stage (III/IV) cancer for all stageable cancers combined and separately. For all stageable cancers combined and for six cancer sites-prostate, colorectal, non-Hodgkin lymphoma, oral cavity, liver, and esophagus-uninsured patients with Stage I disease had worse survival than privately insured patients with Stage II disease. Patients without private insurance coverage had worse short-term and long-term survival at each stage for all cancers combined; patients who were uninsured had worse stage-specific survival for 12 of 17 stageable cancers and had worse survival for leukemia and brain tumors. Expanding access to comprehensive health insurance coverage is crucial for improving access to cancer care and outcomes, including stage at diagnosis and survival.

Paid Sick Leave Among Working Cancer Survivors and Its Associations With Use of Preventive Services in the United States

BACKGROUND

We sought to examine the lack of paid sick leave among working cancer survivors by sociodemographic/socioeconomic and employment characteristics and its association with preventive services use in the United States.

METHODS

Working cancer survivors (ages 18-64 years; n=7,995; weighted n=3.43 million) were identified using 2001-2018 National Health Interview Survey data. Adjusted prevalence of lack of paid sick leave by sociodemographic and socioeconomic characteristics, as well as job sector, working hours, and employer size, were generated using multivariable logistic regression models. Separate analyses examined the associations of lack of paid sick leave with use of various preventive services.

RESULTS

Of all working cancer survivors, 36.4% lacked paid sick leave (n=2,925; weighted n=1.25 million), especially those working in food/agriculture/construction/personal services occupations or industries (ranging from 54.9% to 88.5%). In adjusted analyses, working cancer survivors with lower household income (<200% of the federal poverty level, 48.7%), without a high school degree (43.3%), without health insurance coverage (70.6%), and who were self-employed (89.5%), were part-time workers (68.2%), or worked in small businesses (<50 employees, 48.8%) were most likely to lack paid sick leave. Lack of paid sick leave was associated with lower use of influenza vaccine (ages 18-39 years, 21.3% vs 33.3%; ages 40-49 years, 25.8% vs 38.3%; ages 50-64 years, 46.3% vs 52.4%; P<.001 for all), cholesterol screening (ages 18-39 years, 43.1% vs 62.5%; P<.05), and blood pressure check (ages 18-39 years, 43.1% vs 62.5%; P<.05) compared with survivors having paid sick leave.

CONCLUSIONS

In the United States, more than one-third of all working cancer survivors and more than half of survivors working for small employers and in certain occupations/industries lack paid sick leave. Survivors with lower household income or educational attainment are particularly vulnerable. Moreover, lack of paid sick leave is associated with lower use of some recommended preventive services, suggesting that ensuring working cancer survivors have access to paid sick leave may be an important mechanism for reducing health disparities.

Association Between Smoking, Smoking Cessation, and Mortality by Race, Ethnicity, and Sex Among US Adults

Importance

Patterns of cigarette smoking and smoking cessation vary considerably across demographic groups in the US, but there is limited evidence on whether the hazards of smoking and benefits of quitting vary across these groups. Population-specific evidence on the benefits of quitting smoking may motivate cessation among groups historically underrepresented in medical research.

Objective

To quantify the association between smoking, smoking cessation, and mortality by race, ethnicity, and sex.

Design, Setting, and Participants

This nationally representative, prospective cohort study used data from the US National Health Interview Survey collected via questionnaire between January 1997 and December 2018 among adults aged 25 to 84 years at recruitment. Participants were followed up for cause-specific mortality through December 31, 2019.

Exposures

Self-reported smoking status at recruitment, age at quitting smoking, and years since quitting smoking.

Main Outcomes and Measures

The main outcomes were all-cause mortality and mortality from cancer, cardiovascular disease, and lower respiratory disease. Adjusted mortality rate ratios comparing never, former, and current smokers were calculated using Cox proportional hazards regression. Weighted analyses were conducted by race, ethnicity, and sex as reported by participants.

Results

Among the 551 388 participants in the main analyses, the mean (SD) age at recruitment was 48.9 (15.3) years; 307 601 (55.8%) were women, 87 207 (15.8%) were Hispanic, 75 545 (13.7%) were non-Hispanic Black, 355 782 (64.5%) were non-Hispanic White, and 32 854 (6.0%) identified as other non-Hispanic race and ethnicity. There were 74 870 deaths among participants aged 25 to 89 years during follow-up (36 792 [49.1%] among men; 38 078 [50.9%] among women). The all-cause mortality rate ratio (RR) for current vs never smoking was 2.80 (95% CI, 2.73-2.88) overall. The RRs were similar by sex but varied by race and ethnicity: Hispanic, 2.01 (95% CI, 1.84-2.18); non-Hispanic Black, 2.19 (95% CI, 2.06-2.33); non-Hispanic White, 3.00 (95% CI, 2.91-3.10); and other non-Hispanic race and ethnicity, 2.16 (95% CI, 1.88-2.47). When comparing those who quit smoking before age 45 years with never smokers, all-cause mortality RRs were 1.15 (95% CI, 1.03-1.28) among Hispanic individuals, 1.16 (95% CI, 1.07-1.25) among non-Hispanic Black individuals, 1.11 (95% CI, 1.08-1.15) among non-Hispanic White individuals, and 1.17 (95% CI, 0.99-1.39) among other non-Hispanic individuals.

Conclusions and Relevance

In this prospective cohort study, among men and women from diverse racial and ethnic groups, current smoking was associated with at least twice the all-cause mortality rate of never smoking. Quitting smoking, particularly at younger ages, was associated with substantial reductions in the relative excess mortality associated with continued smoking.

Association of the Affordable Care Act Medicaid expansion and receipt of palliative care among individuals newly diagnosed with advanced stage cancers

73

Background: Receipt of palliative care is a guideline-based practice but is low among patients with advanced cancer is low in the U.S. Lack of insurance is a major barrier to accessing palliative care. It is unknown, however, whether Medicaid expansion under the Affordable Care Act (ACA) and the associated increase in insurance coverage among individuals diagnosed with cancer has led to increased palliative care. We use a nationwide dataset to examine the association between Medicaid expansion and receipt of palliative care among individuals newly diagnosed with advanced stage cancers. Methods: Individuals aged 18-64 years with newly diagnosed stage-IV solid cancers pre- (2010-2013) and post- (2014-2019) ACA Medicaid expansion were identified from the National Cancer Database. We used difference-in-differences (DD) analyses to estimate the association between Medicaid expansion and changes in receipt of palliative care as part of first-line therapy, adjusting for age group, sex, race/ethnicity, area-level poverty, metropolitan status, comorbidity, facility type, palliative care specialist availability, diagnosis year and state of residence. Stratified analyses were conducted by cancer type and sociodemographic factors. Results: A total of 685,781 individuals diagnosed with stage IV cancers were included from Medicaid expansion (N = 439,142) and non-expansion (N = 246,639) states. The percentage of eligible patients who received palliative care as part of first-line therapy increased from 17.0% pre-ACA to 18.9% post-ACA in Medicaid expansion states and from 15.7% to 16.7% in non-expansion states, resulting in a net increase (DD) of 1.4 (95%CI = 1.0-1.8) percentage points in expansion states after adjusting for sociodemographic and clinical factors. The increase in receipt of palliative care in expansion states compared to non-expansion states was greater for patients with advanced pancreatic (DD = 2.5; 95%CI = 0.8-4.3), colorectal (DD = 2.2; 95%CI = 1.1-3.3), female breast (DD = 1.9; 95%CI = 0.1-3.7), lung (DD = 1.6; 95%CI = 0.7-2.5), oral cavity and pharynx (DD = 1.1;95%CI = 0.5-1.6) cancers, and non-Hodgkin lymphoma (DD = 0.9; 95%CI = 0.2-1.5). The improvement in receipt of palliative care was larger among individuals aged 55-64 years, non-Hispanic White patients, and patients residing in middle-income areas and nonmetropolitan areas. Conclusions: Among individuals newly diagnosed with stage-IV cancer, Medicaid expansion was associated with increases in receipt of palliative care, although overall use was low. Furthermore, the increase varied by cancer type and sociodemographic factors. Improving access to insurance can facilitate access to guideline-based palliative care.

Cancer treatment and survivorship statistics, 2022

The number of cancer survivors continues to increase in the United States due to the growth and aging of the population as well as advances in early detection and treatment. To assist the public health community in better serving these individuals, the American Cancer Society and the National Cancer Institute collaborate triennially to estimate cancer prevalence in the United States using incidence and survival data from the Surveillance, Epidemiology, and End Results cancer registries, vital statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics, and population projections from the US Census Bureau. Current treatment patterns based on information in the National Cancer Database are presented for the most prevalent cancer types by race, and cancer-related and treatment-related side-effects are also briefly described. More than 18 million Americans (8.3 million males and 9.7 million females) with a history of cancer were alive on January 1, 2022. The 3 most prevalent cancers are prostate (3,523,230), melanoma of the skin (760,640), and colon and rectum (726,450) among males and breast (4,055,770), uterine corpus (891,560), and thyroid (823,800) among females. More than one-half (53%) of survivors were diagnosed within the past 10 years, and two-thirds (67%) were aged 65 years or older. One of the largest racial disparities in treatment is for rectal cancer, for which 41% of Black patients with stage I disease receive proctectomy or proctocolectomy compared to 66% of White patients. Surgical receipt is also substantially lower among Black patients with non-small cell lung cancer, 49% for stages I-II and 16% for stage III versus 55% and 22% for White patients, respectively. These treatment disparities are exacerbated by the fact that Black patients continue to be less likely to be diagnosed with stage I disease than White patients for most cancers, with some of the largest disparities for female breast (53% vs 68%) and endometrial (59% vs 73%). Although there are a growing number of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based strategies and equitable access to available resources are needed to mitigate disparities for communities of color and optimize care for people with a history of cancer. CA Cancer J Clin. 2022;72:409-436.

Spatial Analysis of Changes in Cigarette Sales in Massachusetts and Bordering States Following the Massachusetts Menthol Flavor Ban

This cohort study examines changes in cigarette sales in Massachusetts and its bordering states following a comprehensive ban on menthol flavor in Massachusetts in 2020.

Progress in Reducing Disparities in Premature Mortality in the USA: a Descriptive Study

BACKGROUND

Eliminating health disparities among different segments of the US population is an overarching goal of the US Healthy People 2020 objectives.

OBJECTIVE

Examine changes in educational, rural-urban, and racial disparities in premature mortality during the past 10 years.

DESIGN AND PARTICIPANTS

Descriptive analysis of US mortality data from 2007 to 2017.

MAIN MEASURES

Relative and absolute rural-urban, educational attainment, and Black-White disparities in premature mortality for all-cause and top 10 causes of death among persons ages 25-74 years, estimated as rate ratios and rate differences between ≤12 and ≥16 years of education, rural versus urban, and non-Hispanic Black (Black) versus non-Hispanic White (White), respectively, in 2007 and 2017.

KEY RESULTS

During 2007-2017, mortality rates in persons aged 25-74 years in the USA increased for several leading causes of death, especially in persons with <16 years of education, rural residents, and White people. As a result, disparity in mortality between 2007 and 2017 widened on both relative and absolute scales for all-cause and for 6 of the top 10 causes of death by education and for all-cause and for 9 of the top 10 causes by rural/urban residence. In contrast, Black-White disparities narrowed for all-cause and for all 7 causes that Black people had a higher rate than White people. For all-cause mortality for example, absolute disparities in the number of deaths per 100,000 person-years between 2007 and 2017 increased from 454.0 (95%CI, 446.0-462.1) to 542.7 (535.6-549.7) for educational attainment and from 85.8 (82.8-88.8) to 140.5 (137.6-143.4) for rural versus urban; in contrast, absolute Black-White disparity decreased from 315.3 (311.0-319.7) to 221.7 (218.1-225.3).

CONCLUSIONS

Educational and rural-urban disparities in premature mortality widened, whereas Black-White disparities narrowed in the USA between 2007 and 2017, though overall rates remained considerably higher in Black people.

The first year of the COVID-19 pandemic and health among cancer survivors in the United States

Background

Cancer survivors represent a population with high health care needs. If and how cancer survivors were affected by the first year of the coronavirus disease 2019 (COVID‐19) pandemic are largely unknown.

Methods

Using data from the nationwide, population‐based Behavioral Risk Factor Surveillance System (2017–2020), the authors investigated changes in health‐related measures during the COVID‐19 pandemic among cancer survivors and compared them with changes among adults without a cancer history in the United States. Sociodemographic and health‐related measures such as insurance coverage, employment status, health behaviors, and health status were self‐reported. Adjusted prevalence ratios of health‐related measures in 2020 versus 2017–2019 were calculated with multivariable logistic regressions and stratified by age group (18–64 vs. ≥65 years).

Results

Among adults aged 18–64 years, the uninsured rate did not change significantly in 2020 despite increases in unemployment. The prevalence of unhealthy behaviors, such as insufficient sleep and smoking, decreased in 2020, and self‐rated health improved, regardless of cancer history. Notably, declines in smoking were larger among cancer survivors than nonelderly adults without a cancer history. Few changes were observed for adults aged ≥65 years.

Conclusions

Further research is needed to confirm the observed positive health behavior and health changes and to investigate the role of potential mechanisms, such as the national and regional policy responses to the pandemic regarding insurance coverage, unemployment benefits, and financial assistance. As polices related to the public health emergency expire, ongoing monitoring of longer term effects of the pandemic on cancer survivorship is warranted.

Among cancer survivors aged 18–64 years, the uninsured rate did not change significantly in 2020 despite increases in unemployment. The prevalence of unhealthy behaviors, such as insufficient sleep and smoking, decreased in 2020, and self‐rated health improved, regardless of cancer history.

Person-years of life lost and lost earnings from cigarette smoking-attributable cancer deaths, United States, 2019

State-specific information on lost earnings due to smoking-attributable cancer deaths to inform and advocate for tobacco control policies is lacking. We estimated person-years of life lost (PYLL) and lost earnings due to cigarette smoking-attributable cancer deaths in the United States nationally and by state. Proportions and numbers of cigarette smoking-attributable cancer deaths and associated PYLL among individuals aged 25 to 79 years in 2019 were calculated and combined with annual median earnings to estimate lost earnings attributable to cigarette smoking. In 2019, estimated total PYLL and lost earnings associated with cigarette smoking-attributable cancer deaths in ages 25 to 79 years in the United States were 2 188 195 (95% CI, 2 148 707-2 231 538) PYLL and $20.9 billion ($20.0 billion-$21.7 billion), respectively. States with the highest overall age-standardized PYLL and lost earning rates generally were in the South and Midwest. The estimated rate per 100 000 population ranged from 352 (339-366) in Utah to 1337 (1310-1367) in West Virginia for PYLL and from $4.3 million ($3.5 million-$5.2 million) in Idaho to $14.8 million ($10.6 million-$20.7 million) in Missouri for lost earnings. If age-specific PYLL and lost earning rates in Utah had been achieved by all states, 58.2% (57.0%-59.5%) of the estimated total PYLL (1 274 178; 1 242 218-1 306 685 PYLL) and 50.5% (34.2%-62.4%) of lost earnings ($10.5 billion; $7.1 billion-$13.1 billion) in 2019 nationally would have been avoided. Lost earnings due to smoking-attributable cancer deaths are substantial in the United States and are highest in states with weaker tobacco control policies.

Changes in Smoking Cessation-Related Behaviors Among US Adults During the COVID-19 Pandemic

IMPORTANCE

Smoking cessation is an urgent public health priority given that smoking is associated with increased risk of severe COVID-19 outcomes and other diseases. It is unknown how smoking cessation changed nationally during the COVID-19 pandemic.

OBJECTIVE

To investigate changes in smoking cessation-related behaviors in the US during the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted using 2011 to 2020 data on 788 008 individuals who had smoked in the past year from the nationally representative Behavioral Risk Factor Surveillance System (BRFSS) survey. Representative retail scanner sales data between January 2017 and July 2021 for 1004 unique nicotine replacement therapy (NRT) universal product codes in 31 US states from NielsenIQ were also used.

EXPOSURES

Calendar year and 4-week sales periods.

MAIN OUTCOMES AND MEASURES

Changes in annual self-reported prevalence of past-year quit attempts and recent successful cessation before (ie, 2011-2019) and during (ie, 2020) the COVID-19 pandemic and changes in sales volumes in millions of pieces of nicotine gum, lozenge, and patch brands before (1271 four-week sales periods between January 2017 and February 2020) and during (558 four-week sales periods between March 2020 and July 2021) the COVID-19 pandemic were calculated.

RESULTS

The 2011 to 2020 pooled BRFSS sample (response rate range, 45.2%-49.9%) included 788 008 respondents (243 061 individuals ages 25-44 years [weighted percentage, 42.5%]; 374 519 men [weighted percentage, 55.7%]). For the first time since 2011, annual past-year quit attempt prevalence decreased between 2019 and 2020, from 65.2% (95% CI, 64.5% to 65.9%) to 63.2% (95% CI, 62.3% to 64.0%), with the largest relative decreases among individuals ages 45 to 64 years (61.4% [95% CI, 60.3% to 62.5%] vs 57.7% [95% CI, 56.3% to 59.2%]), those with 2 or more comorbidities (67.1% [95% CI, 66.0% to 68.2%] to 63.0% [95% CI, 61.6% to 64.4%]), and Black individuals (72.5% [95% CI, 70.3 to 74.6] vs 68.4% [95% CI, 65.3% to 71.3%]). Recent successful cessation remained unchanged during 2019 to 2020. Observed mean (SD) 4-week NRT sales volume in the prepandemic period was 105.6 (66.2) million gum pieces, 51.9 (31.6) million lozenges, and 2.0 (1.1) million patches. Compared with expected sales, observed sales during the COVID-19 pandemic were lower by 13.0% (95% CI, -13.7% to -12.3%) for lozenges, 6.4% (95% CI, -7.3% to -5.5%) for patches, and 1.2% (95% CI, -1.7% to -0.7%) for gum.

CONCLUSIONS AND RELEVANCE

This study found that serious smoking cessation activity among US adults decreased immediately and remained depressed for more than a year during the COVID-19 pandemic. These findings suggest that smokers experiencing disproportionately negative outcomes during the pandemic should be reengaged and assisted in quit attempts.

Clinicopathology and Treatment Patterns of Head and Neck Cancers in Ethiopia

Head and neck cancers are the third most common cancers treated with radiation in Ethiopia. There is, however, a lack of published data on clinical and pathological characteristics and treatment patterns of head and neck cancers in the country. The objective of the study was to assess clinical and pathological characteristics and treatment patterns of head and neck cancers at Tikur Anbessa Specialized Hospital, which housed the only radiotherapy facility in Ethiopia during the study period.

Curative radiation dosing for #headandneck #cancer in #Ethiopia is challenged by the limitations of 2D radiation and long wait times. @JCOGO_ASCO

Relative Harm Perceptions of E-Cigarettes Versus Cigarettes, U.S. Adults, 2018-2020

INTRODUCTION

It is unknown how U.S. adults' relative harm perceptions of E-cigarettes versus cigarettes and associated behaviors changed during the E-cigarette or vaping product use‒associated lung injury epidemic (late 2019) and COVID-19 pandemic (since early 2020).

METHODS

Data from cross-sectional nationally representative Health Information National Trends Survey collected in 2018 (n=3,360), 2019 (n=3,217), and 2020 (n=3,677) (analyzed in 2021) were used to estimate changes in relative harm perceptions of E-cigarettes versus cigarettes (less harmful, as harmful, more harmful, don't know as a measure of uncertainty). In addition, changes in exclusive cigarette smoking, exclusive E-cigarette use, and dual use were estimated for each relative harm perception level.

RESULTS

Perceptions of E-cigarettes as more harmful than cigarettes doubled year on year, increasing most between 2019 and 2020 (2018: 6.8%, 2019: 12.8%, 2020: 28.3%), whereas uncertainty in relative harm declined (2018: 38.2%, 2019: 34.2%, 2020: 24.7%). Less harmful relative perceptions declined (2018:17.6%, 2019:15.3%, 2020:11.4%), whereas as harmful perceptions remained steady (2018: 37.4%, 2019: 37.7%, 2020: 35.6%). Exclusive cigarette smoking increased between 2019 and 2020 among those who perceived E-cigarettes as relatively more harmful (2018: 18.5%; 2019: 8.4%; 2020: 16.3%), exclusive E-cigarette use increased linearly among those who perceived them as relatively less harmful (7.9%, 15.3%, 26.7%), and dual use increased linearly in those who perceived them relatively as harmful (0.1%, 1.4%, 2.9%).

CONCLUSIONS

Perceptions of E-cigarettes as more harmful than cigarettes increased sharply between 2019 and 2020. Increases in tobacco product use were potentially guided by product-specific relative harm perceptions because changes occurred primarily in individuals who perceived their preferred product as relatively less harmful, suggesting the need for accurate messaging of relative and absolute product risks.

Racial differences in cardiovascular disease mortality among cancer survivors

12075

Background: Cancer survivors have an elevated risk of death from cardiovascular disease (CVD). Whether the risk differs by race/ethnicity and cancer type has not been fully explored in the U.S. Methods: Data from survivors of top 23 cancers diagnosed at ages 20 to 64 years during 2000-2018 were obtained from 17 Surveillance, Epidemiology, and End Results registries. Risks for CVD death among survivors relative to the general population were calculated using standardized mortality ratios (SMRs) in each racial/ethnic group: Non-Hispanic White (NHW), Non-Hispanic Black (NHB), Hispanic, Non-Hispanic Asian or Pacific Islander (API), and Non-Hispanic American Indian (AI). Among survivors, the risks were compared by race/ethnicity using cause-specific proportional hazards models for competing risks, controlling for year of diagnosis, age at diagnosis, sex, stage (when appropriate), and the first course of treatment receipt (surgery, radiotherapy, chemotherapy). Results: Among 2,806,515 survivors (NHW, 68%; NHB, 13%; Hispanic, 12%; API, 7%; AI, 0.5%), 57,883 CVD deaths occurred during 6.4 person-years of mean follow-up (32 per 10,000). Cancer survivors overall were at increased risk of CVD death compared to their general population counterpart with an SMR of 1.76 among API (95% CI = 1.69-1.84; 8.7 excess deaths per 10,000), 1.49 among AI (95% CI = 1.33-1.68; 11.9 excess deaths per 10,000), 1.46 among Hispanic (95% CI = 1.41-1.50; 7.4 excess deaths per 10,000), 1.30 among NHB (95% CI = 1281-1.33; 14.9 excess deaths per 10,000), and 1.13 among NHW (95% CI = 1.12-1.14; 3.4 excess deaths per 10,000) survivors. Compared with NHW survivors, the adjusted hazard of CVD death was statistically significantly higher among NHB survivors for 23/23 cancers and among AI survivors for 9/18 cancers but was statistically significantly lower among Hispanic survivors for 5/23 cancers and among API survivors for 10/23 cancers, with no significant difference otherwise. The highest hazards ratios (HRs) were among NHB survivors of melanoma (HR = 3.19, 95% CI = 2.11-4.83); breast (HR = 2.73, 95% CI = 2.57-2.89); pancreatic (HR = 2.63, 95% CI = 2.19-3.16); and testicular (HR = 2.59, 95% CI = 1.62-4.14) cancers, whereas the lowest HRs were among API survivors of head and neck (HR = 0.53, 95% CI = 0.44-0.63) and cervical (HR = 0.57, 95% CI = 0.41-0.80) cancers and Hispanic survivors of cervical cancer (HR = 0.59, 95% CI = 0.46-0.75). Conclusions: The risk of CVD death differs considerably among cancer survivors by race/ethnicity and cancer types, highlighting the need for targeted prevention and surveillance in primary care. Future studies are needed to identify factors that contribute to this variation in order to inform efforts towards mitigating risk.

Suicide risk among patients with cancer in the United States, 2000-2016

12119

Background: Individuals diagnosed with cancer have elevated suicide risk in the US, although little is known about risk associated with state of residence, health insurance coverage, or time since diagnosis by cancer types. This study used a recent national dataset to examine a wide range of patients’ sociodemographic and clinical factors that may be associated with suicide risks. Methods: We identified patients diagnosed with cancer from 43 population-based state cancer registries in 2000-2016 with follow-up through Dec 31, 2016. Standardized Mortality Ratios (SMR) and 95% confidence intervals (95CI) were calculated by state of residence, attained age group, sex, and race/ethnicity to compare suicide risks in the cohort vs. the general US population. Hazard Ratios (HR) and 95CI from multivariable Cox proportional hazard models were derived to identify cancer-specific risk factors of suicide among the cohort, controlling for competing risks from other causes of death. Results: Among 16,771,397 patients, 7,972,782 (47.5%) died during the study period, and 20,792 (0.3%) from suicide. The overall SMR for suicide was 1.26 (95CI = 1.24-1.28), decreasing from 1.67 (95CI 1.47-1.88) in 2000 to 1.16 (95CI 1.11-1.21) in 2016. Patients from Alaska, Colorado and Idaho, those aged 65-69 years (SMR = 1.44, 95CI = 1.39-1.50), Hispanic patients (SMR = 1.48, 95CI = 1.38-1.58), those uninsured (SMR = 1.66, 95CI = 1.53-1.80) or insured with Medicaid (SMR = 1.72, 95CI = 1.61-1.84) or ≤64 years of age with Medicare (SMR = 1.94, 95CI = 1.80-2.07) had the highest suicide risks compared to the general population. Moreover, the highest suicide risk occurred within two years of diagnosis (SMR [95CI] = 7.19 [6.97-7.41], 5.60 [5.35-5.84] and 4.18 [4.03-4.33] for ≤5 months, 6-11 months, and 12-23 months after cancer diagnosis, respectively). In the first two years following diagnosis, the risk of suicide was higher in patients diagnosed with distant-stage than early-stage diseases (HR = 1.29, 95CI = 1.21-1.37), and in patients with more cancer types with poor prognoses and high symptom burdens, such as cancers of oral cavity & pharynx, esophagus, stomach, brain, lung and pancreas (HRs ranged 1.23-2.10 vs. colorectal cancer, all P≤0.001). After two years, patients diagnosed with cancers subject to long-term quality of life impairment, such as cancers of oral cavity & pharynx, female breast, bladder, and leukemia (HRs ranged 1.17-1.54 vs. colorectal cancer, all P≤0.01), had higher suicide risks. Conclusions: Suicide risk among patients diagnosed with cancer decreased during the past two decades but remained elevated compared to the general population. Different geographic, racial/ethnic, socioeconomic, and clinical factors, some of which are modifiable, contribute to increased suicide risk among patients diagnosed with cancer. Tailored social and psych-oncological interventions are warranted for suicide prevention in this vulnerable population.

Changes in Cancer Screening in the US During the COVID-19 Pandemic

IMPORTANCE

Health care was disrupted in the US during the first quarter of 2020 with the emergence of the COVID-19 pandemic. Early reports in selected samples suggested that cancer screening services decreased greatly, but population-based estimates of cancer screening prevalence during 2020 have not yet been reported.

OBJECTIVE

To examine changes in breast cancer (BC), cervical cancer (CC), and colorectal cancer (CRC) screening prevalence with contemporary national, population-based Behavioral Risk Factor Surveillance System (BRFSS) data.

DESIGN, SETTING, AND PARTICIPANTS

This survey study included respondents from the 2014, 2016, 2018, and 2020 BRFSS surveys who were eligible for BC (women aged 50-74 years), CC (women aged 25-64 years), and CRC (women and men aged 50-75 years) screening. Data analysis was performed from September 2021 to February 2022.

EXPOSURES

Calendar year.

MAIN OUTCOMES AND MEASURES

Self-reported receipt of a recent (defined as in the past year) BC, CC, and CRC screening test. Adjusted prevalence ratios (aPRs) comparing 2020 vs 2018 prevalence and 95% CIs were computed.

RESULTS

In total, 479 248 individuals were included in the analyses of BC screening, 301 453 individuals were included in CC screening, and 854 210 individuals were included in CRC screening, In 2020, among respondents aged 50 to 75 years, 14 815 (11.4%) were Black, 12 081 (12.6%) were Hispanic, 156 198 (67.3%) were White, and 79 234 (29.9%) graduated from college (all percentages are weighted). After 4 years (2014-2018) of nearly steady prevalence, past-year BC screening decreased by 6% between 2018 and 2020 (from 61.6% in 2018 to 57.8% in 2020; aPR, 0.94; 95% CI, 0.92-0.96), and CC screening decreased by 11% (from 58.3% in 2018 to 51.9% in 2020; aPR, 0.89; 95% CI, 0.87-0.91). The magnitude of these decreases was greater in people with lower educational attainment and Hispanic persons. CRC screening prevalence remained steady; past-year stool testing increased by 7% (aPR, 1.07; 95% CI, 1.02-1.12), offsetting a 16% decrease in colonoscopy (aPR, 0.84; 95% CI, 0.82-0.88) between 2018 and 2020.

CONCLUSIONS AND RELEVANCE

In this survey study, stool testing increased and counterbalanced a decrease in colonoscopy during 2020, and BC and CC screening modestly decreased. How these findings might be associated with outcomes is not yet known, but they will be important to monitor, especially in populations with lower socioeconomic status, who experienced greater screening decreases during the COVID-19 pandemic.

Changes in cancer-related mortality during the COVID-19 pandemic in the United States

6581

Background: The coronavirus disease 2019 (COVID-19) pandemic resulted in delayed medical care that may have led to increased death rates in 2020 among people with medical conditions such as cancer. This study examined changes in cancer-related mortality between 2019 and 2020. Methods: We used the US 2019-2020 Multiple Cause of Death database from the CDC WONDER to identify cancer-related deaths, defined as decedents with invasive or noninvasive cancer as a contributing cause of death (ICD-10 codes: C00-C97 and D00-D09). We compared age-standardized cancer-related annual and monthly mortality rates (per 100,000 person-years and person-months, respectively) in January-December 2020 (pandemic) versus January-December 2019 (pre-pandemic) overall and stratified by rurality and place of death. We calculated the 2020 excess death by comparing the numbers of observed death with the projected death based on age-specific cancer-related death rate from 2015 to 2019. Results: The number of cancer-related deaths was 686 054 in 2020, up from 664 888 in 2019, with an annual increase of 3.2%. Compared to the number of projected deaths for 2020 (666 286), the number of cancer-related excess deaths was 19 768 in 2020. Annual age-standardized cancer-related mortality rate (per 100,000 person-years) continuously decreased from 173.7 in 2015 to 162.1 in 2019, while it increased to 164.1 in 2020 (2020 vs 2019 rate ratio (RR): 1.013, 95% confidence interval (CI): 1.009 - 1.016). The cancer-related monthly mortality rate was higher in April 2020 (RR: 1.032, 95% CI: 1.020 – 1.044) when healthcare capacity was most challenged by the pandemic, subsequently declined in May and June 2020, and higher mortality rates were again observed each month from July to December 2020 compared to 2019. In large metropolitan areas, the largest increase in cancer-related mortality was observed in April 2020, while in non-metropolitan areas, the largest increases occurred from July to December 2020, coinciding with the time-spatial pattern of COVID-19 incidence in the country. Compared to 2019, cancer-related mortality rates were lower from March to December 2020 in medical facilities, hospice facilities, and nursing homes or long-term care settings but higher in decedent's homes. Conclusions: The COVID-19 pandemic led to significant increases in cancer-related deaths in 2020 versus 2019. Ongoing evaluation of the spatial-temporal effects of the pandemic on cancer care and outcomes is warranted, especially in relation to patterns in vaccine uptake and COVID-19 hospitalization rates.[Table: see text]

Association of parental cancer and minor child’s unmet economic needs in food, housing, and transportation

12014

Background: A cancer diagnosis is associated with substantial economic burden among cancer survivors and their families. Some families make sacrifices that adversely affect food, housing, and transportation to offset high out-of-pocket medical expenses. Cancer survivors with minor children may be particularly vulnerable to financial hardship, even years after diagnosis. However, little is known about the extent to which parental cancer affects minor children’s food insecurity, unmet housing needs, and delayed medical care due to transportation barriers. Methods: The 2013 to 2018 National Health Interview Survey was used to identify minor children (ages 5-17 years) living in families with a parental cancer history (n = 812, representing 860,488 children) and children without a parental cancer history (n = 22,129, representing about 24.5 million children). Multivariable logistic regressions were used to compare family-level food insecurity, parent’s worry about ability to pay monthly bills and housing costs, and delayed medical care for the child because of no transportation between minor children with and without a parental cancer history. All analyses adjusted for child-, parent-, and family-related characteristics, including child’s age group, sex, and race/ethnicity; parent’s age group, sex, race/ethnicity, health insurance coverage, number of comorbid conditions, and obesity status; family’s structure (married/cohabiting parents versus single parent families), highest educational attainment in the family, and family income as a percentage of the federal poverty level. Results: About 3.4% of minor children were living in families with a parental cancer history. In adjusted analyses and compared to children whose parents did not report a history of cancer, children of cancer survivors were more likely to live in families that experience shortages in basic economic needs, such as food bought did not last 26.0% (95% confidence intervals[CI]: 22.3%-29.7%) vs 16.7% (95CI: 16.1%-17.3%), inability to afford balanced meals 16.9% (95CI: 13.8%-20.0%) vs 13.3% (95CI: 12.8%-13.8%), worry about paying monthly bills 44.8% (95CI: 40.6%-48.9%) vs 37.9% (95CI: 37.1%-38.7%), and worry about housing costs 35.7% (95CI: 31.9%-39.5%) vs 30.7% (95CI: 30.0%-31.5%). Moreover, children with a parental cancer history were more likely to experience delayed medical care due to lack of transportation than children without a parental cancer history 3.6% (95CI: 2.2%-4.9%) vs 1.6% (95CI: 1.4%-1.9%), all p <.05. Conclusions: Parental cancer is associated with greater likelihood of food insecurity, worse housing and other living conditions, and transportation barriers to medical care for minor children. Efforts to identify minor children with a parental cancer history and develop strategies to attenuate their unmet economic needs are warranted.

Association Between Medicaid Expansion Under the Affordable Care Act and Survival Among Newly Diagnosed Cancer Patients

BACKGROUND

Medicaid expansion under the Affordable Care Act (ACA) is associated with increased insurance coverage among patients with cancer. Whether these gains translate to improved survival is largely unknown. This study examines changes in 2-year survival among patients newly diagnosed with cancer following the ACA Medicaid expansion.

METHODS

Patients aged 18-62 years from 42 states' population-based cancer registries diagnosed pre (2010-2012) and post (2014-2016) ACA Medicaid expansion were followed through September 30, 2013, and December 31, 2017, respectively. Difference-in-differences (DD) analysis of 2-year overall survival was stratified by sex, race and ethnicity, census tract-level poverty, and rurality.

RESULTS

A total of 2 555 302 patients diagnosed with cancer were included from Medicaid expansion (n = 1 523 585) and nonexpansion (n = 1 031 717) states. The 2-year overall survival increased from 80.58% pre-ACA to 82.23% post-ACA in expansion states and from 78.71% to 80.04% in nonexpansion states, resulting in a net increase of 0.44 percentage points (ppt) (95% confidence interval [CI] = 0.24ppt to 0.64ppt) in expansion states after adjusting for sociodemographic factors. By cancer site, the net increase was greater for colorectal cancer (DD = 0.90ppt, 95% CI = 0.19ppt to 1.60ppt), lung cancer (DD = 1.29ppt, 95% CI = 0.50ppt to 2.08ppt), non-Hodgkin lymphoma (DD = 1.07ppt, 95% CI = 0.14ppt to 1.99ppt), pancreatic cancer (DD = 1.80ppt, 95% CI = 0.40ppt to 3.21ppt), and liver cancer (DD = 2.57ppt, 95% CI = 1.00ppt to 4.15ppt). The improvement in 2-year overall survival was larger among non-Hispanic Black patients (DD = 0.72ppt, 95% CI = 0.12ppt to 1.31ppt) and patients residing in rural areas (DD = 1.48ppt, 95% CI= -0.26ppt to 3.23ppt), leading to narrowing survival disparities by race and rurality.

CONCLUSIONS

Medicaid expansion was associated with greater increase in 2-year overall survival, and the increase was prominent among non-Hispanic Blacks and in rural areas, highlighting the role of Medicaid expansion in reducing health disparities. Future studies should monitor changes in longer-term health outcomes following the ACA.

Subsequent primary cancer risk among five-year survivors of adolescent and young adult cancers

BACKGROUND

A comprehensive examination of the incidence and mortality of subsequent primary cancers (SPCs) among adolescent and young adult (AYA) cancer survivors in the US is lacking.

METHODS

Cancer incidence and mortality among 170,404 ≥ 5-year cancer survivors aged 15-39 years at first primary cancer diagnosis during 1975-2013 in 9 Surveillance, Epidemiology, and End Results registries were compared to those in the general population using standardized incidence ratio (SIR), absolute excess incidence (AEI), standardized mortality ratio (SMR), and absolute excess mortality (AEM).

RESULTS

During a mean follow-up of 14.6 years, 13,420 SPC cases and 5,008 SPC deaths occurred among survivors (excluding the same-site as index cancer), corresponding to 25% higher incidence (95%CI = 1.23-1.27; AEI = 10.8 per 10,000) and 84% higher mortality (95%CI = 1.79-1.89; AEM = 9.2 per 10,000) than that in the general population. Overall SPC risk was statistically significantly higher for 20 of 29 index cancers for incidence and 26 for mortality, with the highest SIR among female Hodgkin lymphoma survivors (SIR = 3.05, 95%CI = 2.88-3.24; AEI = 73.0 per 10,000) and the highest SMR among small intestine cancer survivors (SMR = 6.97, 95%CI = 4.80-9.79; AEM = 64.1 per 10,000). Type-specific SPC risks varied substantially by index cancers; however, SPCs of the female breast, lung, and colorectum combined constituted 36% of all SPC cases and 39% of all SPC deaths, with lung cancer alone representing 11% and 24% of all cases and deaths, respectively.

CONCLUSION

AYA cancer survivors are almost twice as likely to die from a new primary cancer as the general population, highlighting the need for primary care clinicians to prioritize cancer prevention and targeted surveillance strategies in these individuals.

Cancer statistics for African American/Black People 2022

African American/Black individuals have a disproportionate cancer burden, including the highest mortality and the lowest survival of any racial/ethnic group for most cancers. Every 3 years, the American Cancer Society estimates the number of new cancer cases and deaths for Black people in the United States and compiles the most recent data on cancer incidence (herein through 2018), mortality (through 2019), survival, screening, and risk factors using population-based data from the National Cancer Institute and the Centers for Disease Control and Prevention. In 2022, there will be approximately 224,080 new cancer cases and 73,680 cancer deaths among Black people in the United States. During the most recent 5-year period, Black men had a 6% higher incidence rate but 19% higher mortality than White men overall, including an approximately 2-fold higher risk of death from myeloma, stomach cancer, and prostate cancer. The overall cancer mortality disparity is narrowing between Black and White men because of a steeper drop in Black men for lung and prostate cancers. However, the decline in prostate cancer mortality in Black men slowed from 5% annually during 2010 through 2014 to 1.3% during 2015 through 2019, likely reflecting the 5% annual increase in advanced-stage diagnoses since 2012. Black women have an 8% lower incidence rate than White women but a 12% higher mortality; further, mortality rates are 2-fold higher for endometrial cancer and 41% higher for breast cancer despite similar or lower incidence rates. The wide breast cancer disparity reflects both later stage diagnosis (57% localized stage vs 67% in White women) and lower 5-year survival overall (82% vs 92%, respectively) and for every stage of disease (eg, 20% vs 30%, respectively, for distant stage). Breast cancer surpassed lung cancer as the leading cause of cancer death among Black women in 2019. Targeted interventions are needed to reduce stark cancer inequalities in the Black community.

Association of Medical Financial Hardship and Mortality Among Cancer Survivors in the United States

BACKGROUND

Cancer survivors frequently experience medical financial hardship in the United States. Little is known, however, about long-term health consequences. This study examines the associations of financial hardship and mortality in a large nationally representative sample of cancer survivors.

METHODS

We identified cancer survivors aged 18-64 years (n = 14 917) and 65-79 years (n = 10 391) from the 1997-2014 National Health Interview Survey and its linked mortality files with vital status through December 31, 2015. Medical financial hardship was measured as problems affording care or delaying or forgoing any care because of cost in the past 12 months. Risk of mortality was estimated with separate weighted Cox proportional hazards models by age group with age as the timescale, controlling for the effects of sociodemographic characteristics. Health insurance coverage was added sequentially to multivariable models.

RESULTS

Among cancer survivors aged 18-64 years and 65-79 years, 29.6% and 11.0%, respectively, reported financial hardship in the past 12 months. Survivors with hardship had higher adjusted mortality risk than their counterparts in both age groups: 18-64 years (hazard ratio [HR] = 1.17, 95% confidence interval [CI] = 1.04 to 1.30) and 65-79 years (HR = 1.14, 95% CI = 1.02 to 1.28). Further adjustment for health insurance reduced the magnitude of association of hardship and mortality among survivors aged 18-64 years (HR = 1.09, 95% CI = 0.97 to 1.24). Adjustment for supplemental Medicare coverage had little effect among survivors aged 65-79 years (HR = 1.15, 95% CI = 1.02 to 1.29).

CONCLUSION

Medical financial hardship was associated with mortality risk among cancer survivors in the United States.

Association of Race With Receipt of Proton Beam Therapy for Patients With Newly Diagnosed Cancer in the US, 2004-2018

IMPORTANCE

Black patients are less likely than White patients to receive guideline-concordant cancer care in the US. Proton beam therapy (PBT) is a potentially superior technology to photon radiotherapy for tumors with complex anatomy, tumors surrounded by sensitive tissues, and childhood cancers.

OBJECTIVE

To evaluate whether there are racial disparities in the receipt of PBT among Black and White individuals diagnosed with all PBT-eligible cancers in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study evaluated Black and White individuals diagnosed with PBT-eligible cancers between January 1, 2004, and December 31, 2018, in the National Cancer Database, a nationwide hospital-based cancer registry that collects data on radiation treatment, even when it is received outside the reporting facility. American Society of Radiation Oncology model policies were used to classify patients into those for whom PBT is the recommended radiation therapy modality (group 1) and those for whom evidence of PBT efficacy is still under investigation (group 2). Propensity score matching was used to ensure comparability of Black and White patients' clinical characteristics and regional availability of PBT according to the National Academy of Medicine's definition of disparities. Data analysis was performed from October 4, 2021, to February 22, 2022.

EXPOSURE

Patients' self-identified race was ascertained from medical records.

MAIN OUTCOMES AND MEASURES

The main outcome was receipt of PBT, with disparities in this therapy's use evaluated with logistic regression analysis.

RESULTS

Of the 5 225 929 patients who were eligible to receive PBT and included in the study, 13.6% were Black, 86.4% were White, and 54.3% were female. The mean (SD) age at diagnosis was 63.2 (12.4) years. Black patients were less likely to be treated with PBT than their White counterparts (0.3% vs 0.5%; odds ratio [OR], 0.67; 95% CI, 0.64-0.71). Racial disparities were greater for group 1 cancers (0.4% vs 0.8%; OR, 0.49; 95% CI, 0.44-0.55) than group 2 cancers (0.3% vs 0.4%; OR, 0.75; 95% CI, 0.70-0.80). Racial disparities in PBT receipt among group 1 cancers increased over time (annual percent change = 0.09, P < .001) and were greatest in 2018, the most recent year of available data.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, Black patients were less likely to receive PBT than their White counterparts, and disparities were greatest for cancers for which PBT was the recommended radiation therapy modality. These findings suggest that efforts other than increasing the number of facilities that provide PBT will be needed to eliminate disparities.

Assessment of Proton Beam Therapy Use Among Patients With Newly Diagnosed Cancer in the US, 2004-2018

IMPORTANCE

Proton beam therapy (PBT) is a potentially superior technology to photon radiotherapy for tumors with complex anatomy, those surrounded by sensitive tissues, and childhood cancers.

OBJECTIVE

To assess patterns of use of PBT according to the present American Society of Radiation Oncology (ASTRO) clinical indications in the US.

DESIGN, SETTING, AND PARTICIPANTS

Individuals newly diagnosed with cancer between 2004 and 2018 were selected from the National Cancer Database. Data analysis was performed from October 4, 2021, to February 22, 2022. ASTRO's Model Policies (2017) were used to classify patients into group 1, for which health insurance coverage for PBT treatment is recommended, and group 2, for which coverage is recommended only if additional requirements are met.

MAIN OUTCOMES AND MEASURES

Use of PBT.

RESULTS

Of the 5 919 368 patients eligible to receive PBT included in the study, 3 206 902 were female (54.2%), and mean (SD) age at diagnosis was 62.6 (12.3) years. Use of PBT in the US increased from 0.4% in 2004 to 1.2% in 2018 (annual percent change [APC], 8.12%; P < .001) due to increases in group 1 from 0.4% in 2010 to 2.2% in 2018 (APC, 21.97; P < .001) and increases in group 2 from 0.03% in 2014 to 0.1% in 2018 (APC, 30.57; P < .001). From 2010 to 2018, among patients in group 2, PBT targeted to the breast increased from 0.0% to 0.9% (APC, 51.95%), and PBT targeted to the lung increased from 0.1% to 0.7% (APC, 28.06%) (P < .001 for both). Use of PBT targeted to the prostate decreased from 1.4% in 2011 to 0.8% in 2014 (APC, -16.48%; P = .03) then increased to 1.3% in 2018 (APC, 12.45; P < .001). Most patients in group 1 treated with PBT had private insurance coverage in 2018 (1039 [55.4%]); Medicare was the most common insurance type among those in group 2 (1973 [52.5%]).

CONCLUSIONS AND RELEVANCE

The findings of this study show an increase in the use of PBT in the US between 2004 to 2018; prostate was the only cancer site for which PBT use decreased temporarily between 2011 and 2014, increasing again between 2014 and 2018. These findings may be especially relevant for Medicare radiation oncology coverage policies.

American Cancer Society's report on the status of cancer disparities in the United States, 2021

In this report, the authors provide comprehensive and up-to-date US data on disparities in cancer occurrence, major risk factors, and access to and utilization of preventive measures and screening by sociodemographic characteristics. They also review programs and resources that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. The overall cancer death rate is 19% higher among Black males than among White males. Black females also have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. There are also substantial variations in death rates for specific cancer types and in stage at diagnosis, survival, exposure to risk factors, and receipt of preventive measures and screening by race/ethnicity, socioeconomic status, and geographic location. For example, kidney cancer death rates by sex among American Indian/Alaska Native people are ≥64% higher than the corresponding rates in each of the other racial/ethnic groups, and the 5-year relative survival for all cancers combined is 14% lower among residents of poorer counties than among residents of more affluent counties. Broad and equitable implementation of evidence-based interventions, such as increasing health insurance coverage through Medicaid expansion or other initiatives, could substantially reduce cancer disparities. However, progress will require not only equitable local, state, and federal policies but also broad interdisciplinary engagement to elevate and address fundamental social inequities and longstanding systemic racism.

Association of Cigarette Sales With Comprehensive Menthol Flavor Ban in Massachusetts

This cohort study examines whether cigarette sales changed after Massachusetts banned menthol-flavored tobacco products.

Global, regional, and national burden of cancers attributable to excess body weight in 204 countries and territories, 1990 to 2019

OBJECTIVE

The aim of this study was to report the level and trends of 13 cancers that are attributable to excess body weight (EBW) for 204 countries and territories from 1990 to 2019.

METHODS

Using publicly available data, the burden of cancers attributable to EBW was reported from 1990 to 2019 based on the comparative risk assessment approach used in the Global Burden of Disease study 2019. [Correction added on 27 January 2022, after first online publication: 'Using publicly available data,' has been added before the first sentence and 'estimated' was corrected to 'reported'.] RESULTS: In 2019, EBW caused 11.2 million disability-adjusted life-years (DALYs), or 4.4% of all cancer-related DALYs. Between 1990 and 2019, the global EBW-attributable age-standardized cancer DALY rates (per 100,000) increased from 109.9 to 133.9, a relative increase of 21.9%. The age-standardized DALY rates (per 100,000) of cancers attributable to EBW in 2019 were highest and lowest in Mongolia (611.8) and Bangladesh (30.2), respectively. The 60- to 64-year age group had the highest number of DALYs attributable to EBW, whereas there were no large sex differences in the cancer-related burden attributable to EBW. Furthermore, the association between the age-standardized DALY rates and the sociodemographic index was generally positive.

CONCLUSIONS

Overall, the EBW-attributable burden of cancers has increased in the past three decades. Public health efforts should focus on identifying appropriate preventive interventions at the population and individual levels, especially in the regions and countries with the highest burden.

Association of State Medicaid Income Eligibility Limits and Long-Term Survival After Cancer Diagnosis in the United States

PURPOSE

To examine the association between historic state Medicaid income eligibility limits and long-term survival among patients with cancer.

METHODS

1,449,144 adults age 18-64 years newly diagnosed with 19 common cancers between 2010 and 2013 were identified from the National Cancer Database. States' Medicaid income eligibility limits were categorized as ≤ 50%, 51%-137%, and ≥ 138% of federal poverty level (FPL). Survival time was measured from diagnosis date through December 31, 2017, for up to an 8-year follow-up. Multivariable Cox proportional hazards models with age as time scale were used to assess associations of eligibility limits and stage-specific survival, adjusting for the effects of sex, metropolitan statistical area, comorbidities, year of diagnosis, facility type and volume, and state.

RESULTS

Among patients with newly diagnosed cancer age 18-64 years, patients living in states with lower Medicaid income eligibility limits had worse survival for most cancers in both early and late stages, compared with those living in states with Medicaid income eligibility limits ≥ 138% FPL. A dose-response relationship was observed for most cancers with lower income limits associated with worse survival (13 of 17 cancers evaluated for early-stage cancers, and 11 of 17 cancers evaluated for late-stage cancers, and leukemia and brain tumors with P-trend < .05).

CONCLUSION

Lower Medicaid income eligibility limits were associated with worse long-term survival within stage; increasing Medicaid income eligibility may improve survival after cancer diagnosis.

Abstract PR-01: Association of Affordable Care Act Medicaid expansions with healthcare access and utilization among people who smoke

Background: People who smoke have a higher risk of developing cancer and disproportionately lower incomes which worsens healthcare access and health outcomes. The Affordable Care Act expanded Medicaid eligibility to adults with income up to 138% of the federal poverty line. It is unknown if and how Medicaid expansions changed healthcare access, preventive service use, and health behaviors. Also, it is unknown whether expansions impacted income or racial/ethnic disparities in these measures, given historically lower healthcare access and utilization in lower income people and people of color. Methods: Data were from the nationally representative Behavioral Risk Factor Surveillance System surveys between 2011-2019 of adults ages 18-64 years who currently smoked cigarettes and former smokers who had quit in the past year (n=580,858). Generalized difference-in-differences (DID) analyses using logistic regression models examined the association of Medicaid expansions (staggered time-varying exposure, 34 states expanded as of December 2019) with healthcare access (insurance coverage, care affordability, usual source of care), preventive service use (routine checkup, flu shot, HIV test, breast and colorectal cancer screening, cholesterol check, dentist visit), and health/risk behaviors (heavy alcohol drinking, obesity), including cessation behaviors (past-year quit attempt, successful cessation for &gt;3 months). Income and race/ethnicity differences were also tested. Results: Among people who smoke, Medicaid expansions were associated with healthcare access and preventive care utilization improvements, but not health behaviors, including cessation. Expansions resulted in narrowing of disparities in several measures across income levels and Black vs. White people in expansion states. For example, expansion associated gains in insurance coverage were significantly larger in low-income (expansion: 74.6% vs. nonexpansion: 60.8%; DID: 13.8% 95% CI: 12.8, 14.8%) than high-income (insurance: 87.5% vs. 93.7%, DID: -6.2% points 95% CI: -7.2, -5.2%); and in Black people (82.6% vs. 74.6%, DID: 7.9% points 95% CI: 6.3, 9.5%) than White people (79.5% vs. 75.7%; DID: 3.8%, 95% CI: 3, 4.6%). Medicaid expansions gains were also larger among lower than higher income people for all in preventive care utilization measures studied; and uptake of flu shots, mammograms, and HIV tests were larger in Black than White people. Significant gains in multiple measures were also observed for Hispanic and American Indian/Alaska Native people who smoke, but changes were generally no different than White people. Conclusions: Among people who smoke, Medicaid expansions improved healthcare access and preventive services use. Expansions were also associated with a reduction, but not elimination, of income and Black-White disparities in healthcare access and utilization. Despite insurance and preventive service gains, expansions were not associated with cessation behaviors, signaling the need for improving comprehensive cessation treatments in Medicaid expansion programs.

Citation Format: Priti Bandi, Samuel Asare, J. Lee Westmaas, Nigar Nargis, Robin Yabroff, Ahmedin Jemal, Xuesong Han, Stacey Fedewa. Association of Affordable Care Act Medicaid expansions with healthcare access and utilization among people who smoke [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PR-01.

Abstract PO-215: Racial disparities in proton beam therapy use for newly diagnosed cancer patients in the United States

Background: Black patients are less likely than White patients in the US to receive guideline-concordant cancer care, including radiation therapy. Proton Beam Therapy (PBT) is a potentially superior technology to photon radiotherapy for the treatment of pediatric cancers, where decreasing late effects of radiation treatment is a main concern, and in cancers where pituitary, visual, auditory, and intellectual functions might be disrupted because of radiation therapy. The aim of this study was to conduct a comprehensive evaluation of racial disparities in PBT use in the US. Methods: We identified 4,919,975 Black and White patients diagnosed between 2004 and 2018 in the National Cancer Database (NCDB) based on data collected from Commission on Cancer (CoC) accredited hospitals. Once a patient is diagnosed and/or treated at a CoC accredited facility, the patient is followed and all treatment is reported (including treatment received outside of the reporting facility). Therefore, NCDB captures PBT received both at CoC-accredited hospitals (59.5% of patients who received PBT in this study) and PBT received at hospitals not accredited by CoCs (40.5% of PBT patients in this study). American Society of Radiation Oncology (ASTRO) Model Policies were used to classify patients into Group 1, for which PBT is the recommended radiation therapy modality, and Group 2, for which evidence of PBT efficacy is still under investigation. Propensity score matching was used to ensure comparability of Black and White patients' clinical characteristics and regional availability of PBT. Results: Black cancer patients were less likely to be treated with PBT than White cancer patients with similar characteristics (Odds Ratios [OR]: 0.72; 95% Confidence Interval [CI]: 0.68, 0.76). Racial disparities were greater for Group 1 cancers (OR = 0.61; CI: 0.54, 0.69) than for Group 2 cancers (OR: 0.75; CI: 0.70, 0.81). Disparities were greatest for Group 1 cancers commonly diagnosed in children, such as central nervous system (OR: 0.54; CI: 0.46, 0.63) and rhabdomyosarcoma (OR: 0.47; CI: 0.31, 0.70). Racial disparities in PBT receipt among Group 1 cancers increased during the study period and were greatest in 2018 despite the increase in the number of facilities offering PBT from 4 to 28 during the corresponding period, Conclusion and Relevance: Racial disparities in PBT receipt are greatest for cancers for which PBT is the recommended radiation therapy modality. The racial disparities identified in our study suggest undertreatment of Black patients with the greatest need (e.g. children diagnosed with central nervous system cancers). Future studies are needed to identify modifiable factors contributing to the racial disparity in receipt of PBT as efforts other than increasing the number of facilities providing PBT will be needed to eliminate disparities.

Citation Format: Leticia M. Nogueira, Ahmedin Jemal, Jason A. Efstathiou, K. Robin Yabroff. Racial disparities in proton beam therapy use for newly diagnosed cancer patients in the United States [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-215.

Cancer statistics, 2022

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population-based cancer occurrence and outcomes. Incidence data (through 2018) were collected by the Surveillance, Epidemiology, and End Results program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data (through 2019) were collected by the National Center for Health Statistics. In 2022, 1,918,030 new cancer cases and 609,360 cancer deaths are projected to occur in the United States, including approximately 350 deaths per day from lung cancer, the leading cause of cancer death. Incidence during 2014 through 2018 continued a slow increase for female breast cancer (by 0.5% annually) and remained stable for prostate cancer, despite a 4% to 6% annual increase for advanced disease since 2011. Consequently, the proportion of prostate cancer diagnosed at a distant stage increased from 3.9% to 8.2% over the past decade. In contrast, lung cancer incidence continued to decline steeply for advanced disease while rates for localized-stage increased suddenly by 4.5% annually, contributing to gains both in the proportion of localized-stage diagnoses (from 17% in 2004 to 28% in 2018) and 3-year relative survival (from 21% to 31%). Mortality patterns reflect incidence trends, with declines accelerating for lung cancer, slowing for breast cancer, and stabilizing for prostate cancer. In summary, progress has stagnated for breast and prostate cancers but strengthened for lung cancer, coinciding with changes in medical practice related to cancer screening and/or treatment. More targeted cancer control interventions and investment in improved early detection and treatment would facilitate reductions in cancer mortality.

Cancer statistics, 2022

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population-based cancer occurrence and outcomes. Incidence data (through 2018) were collected by the Surveillance, Epidemiology, and End Results program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data (through 2019) were collected by the National Center for Health Statistics. In 2022, 1,918,030 new cancer cases and 609,360 cancer deaths are projected to occur in the United States, including approximately 350 deaths per day from lung cancer, the leading cause of cancer death. Incidence during 2014 through 2018 continued a slow increase for female breast cancer (by 0.5% annually) and remained stable for prostate cancer, despite a 4% to 6% annual increase for advanced disease since 2011. Consequently, the proportion of prostate cancer diagnosed at a distant stage increased from 3.9% to 8.2% over the past decade. In contrast, lung cancer incidence continued to decline steeply for advanced disease while rates for localized-stage increased suddenly by 4.5% annually, contributing to gains both in the proportion of localized-stage diagnoses (from 17% in 2004 to 28% in 2018) and 3-year relative survival (from 21% to 31%). Mortality patterns reflect incidence trends, with declines accelerating for lung cancer, slowing for breast cancer, and stabilizing for prostate cancer. In summary, progress has stagnated for breast and prostate cancers but strengthened for lung cancer, coinciding with changes in medical practice related to cancer screening and/or treatment. More targeted cancer control interventions and investment in improved early detection and treatment would facilitate reductions in cancer mortality.

OUP accepted manuscript

Introduction

Many women in rural Ethiopia do not receive adjuvant therapy following breast cancer surgery despite the majority being diagnosed with estrogen-receptor-positive breast cancer and tamoxifen being available in the country. We aimed to compare a breast nurse intervention to improve adherence to tamoxifen therapy for breast cancer patients.

Methods and Materials

The 8 hospitals were randomized to intervention and control sites. Between February 2018 and December 2019, patients with breast cancer were recruited after their initial surgery. The primary outcome of the study was adherence to tamoxifen therapy by evaluating 12-month medication-refill data with medication possession ratio (MPR) and using a simplified medication adherence scale (SMAQ) in a subjective assessment.

Results

A total of 162 patients were recruited (87 intervention and 75 control). Trained nurses delivered education and provided literacy material, gave additional empathetic counselling, phone call reminders, and monitoring of medication refill at the intervention hospitals. Adherence according to MPR at 12 months was high in both the intervention (90%) and control sites (79.3%) (P = .302). The SMAQ revealed that adherence at intervention sites was 70% compared with 44.8% in the control sites (P = .036) at 12 months. Persistence to therapy was found to be 91.2% in the intervention and 77.8% in the control sites during the one-year period (P = .010).

Conclusion

Breast nurses can improve cost-effective endocrine therapy adherence at peripheral hospitals in low-resource settings. We recommend such task sharing to overcome the shortage of oncologists and distances to central cancer centers.

Breast Cancer Diagnostics, Therapy, and Outcomes in Sub-Saharan Africa: A Population-Based Registry Study

BACKGROUND

Breast cancer (BC) is the most common cancer in sub-Saharan Africa (SSA). However, little is known about the actual therapy received by women with BC and their survival outcome at the population level in SSA. This study aims to describe the cancer-directed therapy received by patients with BC at the population level in SSA, compare these results with the NCCN Harmonized Guidelines for SSA (NCCN Harmonized Guidelines), and evaluate the impact on survival.

METHODS

Random samples of patients with BC (≥40 patients per registry), diagnosed from 2009 through 2015, were drawn from 11 urban population-based cancer registries from 10 countries (Benin, Congo, Cote d'Ivoire, Ethiopia, Kenya, Mali, Mozambique, Namibia, Uganda, and Zimbabwe). Active methods were used to update the therapy and outcome data of diagnosed patients ("traced patients"). Excess hazards of death by therapy use were modeled in a relative survival context.

RESULTS

A total of 809 patients were included. Additional information was traced for 517 patients (63.8%), and this proportion varied by registry. One in 5 traced patients met the minimum diagnostic criteria (cancer stage and hormone receptor status known) for use of the NCCN Harmonized Guidelines. The hormone receptor status was unknown for 72.5% of patients. Of the traced patients with stage I-III BC (n=320), 50.9% received inadequate or no cancer-directed therapy. Access to therapy differed by registry area. Initiation of adequate therapy and early-stage diagnosis were the most important determinants of survival.

CONCLUSIONS

Downstaging BC and improving access to diagnostics and care are necessary steps to increase guideline adherence and improve survival for women in SSA. It will also be important to strengthen health systems and facilities for data management in SSA to facilitate patient follow-up and disease surveillance.

Association of obesity and annual health care utilization and spending among long-term cancer survivors

BACKGROUND

Obesity is associated with a substantial health and economic burden in the general population in the United States. This study estimates the excess health care utilization and medical spending associated with overweight and obesity among long-term cancer survivors.

METHODS

Long-term cancer survivors (≥2 years after their diagnosis) aged ≥18 years (N = 12,547) were identified from the nationally representative 2008-2016 Medical Expenditure Panel Survey. A 2-part modeling approach was used to calculate the average annual care utilization and spending by service type. Excess care utilization and spending associated with overweight (25 kg/m² ≤ body mass index [BMI] < 30 kg/m² ), obesity (BMI ≥ 30 kg/m² ), and severe obesity (BMI ≥ 40 kg/m² ), in comparison with normal weight (18.5 kg/m² ≤ BMI < 25 kg/m² ), were estimated.

RESULTS

Compared with normal-weight cancer survivors, overweight survivors had comparable care utilization and medical spending; survivors with obesity had an additional $3216 (95% CI, $1940-$4492) of medical spending, including $1243 (95% CI, $417-$2070) on hospital inpatient services and $1130 (95% CI, $756-$1504) on prescriptions per person per year. The excess annual medical spending associated with obesity among long-term cancer survivors translated to $19.7 billion in 2016 in the United States. The excess medical spending was magnified in cancer survivors with severe obesity ($5317 [95% CI, $2849-$7785], which translated to $6.7 billion in 2016). Excess care utilization and medical spending were mostly explained by comorbid conditions related to obesity.

CONCLUSIONS

For long-term cancer survivors, obesity was associated with increased health care utilization and substantial excess medical spending. This suggests that policies and practices promoting a healthy lifestyle and achieving and maintaining a healthy body weight for cancer survivors may reduce their health care utilization and economic burden.

Annual Report to the Nation on the Status of Cancer, Part 1: National Cancer Statistics

BACKGROUND

The American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, and North American Association of Central Cancer Registries collaborate to provide annual updates on cancer incidence and mortality and trends by cancer type, sex, age group, and racial/ethnic group in the United States. In this report, we also examine trends in stage-specific survival for melanoma of the skin (melanoma).

METHODS

Incidence data for all cancers from 2001 through 2017 and survival data for melanoma cases diagnosed during 2001-2014 and followed-up through 2016 were obtained from the Centers for Disease Control and Prevention- and National Cancer Institute-funded population-based cancer registry programs compiled by the North American Association of Central Cancer Registries. Data on cancer deaths from 2001 to 2018 were obtained from the National Center for Health Statistics' National Vital Statistics System. Trends in age-standardized incidence and death rates and 2-year relative survival were estimated by joinpoint analysis, and trends in incidence and mortality were expressed as average annual percent change (AAPC) during the most recent 5 years (2013-2017 for incidence and 2014-2018 for mortality).

RESULTS

Overall cancer incidence rates (per 100 000 population) for all ages during 2013-2017 were 487.4 among males and 422.4 among females. During this period, incidence rates remained stable among males but slightly increased in females (AAPC = 0.2%, 95% confidence interval [CI] = 0.1% to 0.2%). Overall cancer death rates (per 100 000 population) during 2014-2018 were 185.5 among males and 133.5 among females. During this period, overall death rates decreased in both males (AAPC = -2.2%, 95% CI = -2.5% to -1.9%) and females (AAPC = -1.7%, 95% CI = -2.1% to -1.4%); death rates decreased for 11 of the 19 most common cancers among males and for 14 of the 20 most common cancers among females, but increased for 5 cancers in each sex. During 2014-2018, the declines in death rates accelerated for lung cancer and melanoma, slowed down for colorectal and female breast cancers, and leveled off for prostate cancer. Among children younger than age 15 years and adolescents and young adults aged 15-39 years, cancer death rates continued to decrease in contrast to the increasing incidence rates. Two-year relative survival for distant-stage skin melanoma was stable for those diagnosed during 2001-2009 but increased by 3.1% (95% CI = 2.8% to 3.5%) per year for those diagnosed during 2009-2014, with comparable trends among males and females.

CONCLUSIONS

Cancer death rates in the United States continue to decline overall and for many cancer types, with the decline accelerated for lung cancer and melanoma. For several other major cancers, however, death rates continue to increase or previous declines in rates have slowed or ceased. Moreover, overall incidence rates continue to increase among females, children, and adolescents and young adults. These findings inform efforts related to prevention, early detection, and treatment and for broad and equitable implementation of effective interventions, especially among under resourced populations.

Association of Medicaid Expansion With Cancer Stage and Disparities in Newly Diagnosed Young Adults

BACKGROUND

Young adults (YAs) experience higher uninsurance rates and more advanced stage at cancer diagnosis than older counterparts. We examined the association of the Affordable Care Act Medicaid expansion with insurance coverage and stage at diagnosis among YAs newly diagnosed with cancer.

METHODS

Using the National Cancer Database, we identified 309 413 YAs aged 18-39 years who received a first cancer diagnosis in 2011-2016. Outcomes included percentages of YAs without health insurance at diagnosis, with stage I (early-stage) diagnoses, and with stage IV (advanced-stage) diagnoses. We conducted difference-in-difference (DD) analyses to examine outcomes before and after states implemented Medicaid expansion compared with nonexpansion states. All statistical tests were 2-sided.

RESULTS

The percentage of uninsured YAs decreased more in expansion than nonexpansion states (adjusted DD = -1.0 percentage points [ppt], 95% confidence interval [CI] = -1.4 to -0.7 ppt, P < .001). The overall percentage of stage I diagnoses increased (adjusted DD = 1.4 ppt, 95% CI = 0.6 to 2.2 ppt, P < .001) in expansion compared with nonexpansion states, with greater improvement among YAs in rural areas (adjusted DD = 7.2 ppt, 95% CI = 0.2 to 14.3 ppt, P = .045) than metropolitan areas (adjusted DD = 1.3 ppt, 95% CI = 0.4 to 2.2 ppt, P = .004) and among non-Hispanic Black patients (adjusted DD = 2.2 ppt, 95% CI = -0.03 to 4.4 ppt, P = .05) than non-Hispanic White patients (adjusted DD = 1.4 ppt, 95% CI = 0.4 to 2.3 ppt, P = .008). Despite the non-statistically significant change in stage IV diagnoses overall, the percentage declined more (adjusted DD = -1.2 ppt, 95% CI = -2.2 to -0.2 ppt, P = .02) among melanoma patients in expansion relative to nonexpansion states.

CONCLUSIONS

We provide the first evidence, to our knowledge, on the association of Medicaid expansion with shifts to early-stage cancer at diagnosis and a narrowing of rural-urban and Black-White disparities in YA cancer patients.

Presentation, patterns of care, and outcomes of patients with prostate cancer in sub-Saharan Africa: A population-based registry study

BACKGROUND

Although prostate cancer (PCa) is the most commonly diagnosed cancer in men of sub-Saharan Africa (SSA), little is known about its management and survival. The objective of the current study was to describe the presentation, patterns of diagnosis, treatment, and survival of patients with PCa in 10 countries of SSA.

METHODS

In this observational registry study with data collection from 2010 to 2018, the authors drew a random sample of 738 patients with PCa who were registered in 11 population-based cancer registries. They described proportions of patients receiving recommended care and presented survival estimates. Multivariable Cox regression was used to calculate hazard ratios comparing the survival of patients with and without cancer-directed therapies (CDTs).

RESULTS

The study included 693 patients, and tumor characteristics and treatment information were available for 365 patients, 37.3% of whom had metastatic disease. Only 11.2% had a complete diagnostic workup for risk stratification. Among the nonmetastatic patients, 17.5% received curative-intent therapy, and 27.5% received no CDT. Among the metastatic patients, 59.6% received androgen deprivation therapy. The 3- and 5-year age-standardized relative survival for 491 patients with survival time information was 58.8% (95% confidence interval [CI], 48.5%-67.7%) and 56.9% (95% CI, 39.8%-70.9%), respectively. In a multivariable analysis, survival was considerably poorer among patients without CDT versus those with therapy.

CONCLUSIONS

This study shows that a large proportion of patients with PCa in SSA are not staged or are insufficiently staged and undertreated, and this results in unfavorable survival. These findings reemphasize the need for improving diagnostic workup and access to care in SSA in order to mitigate the heavy burden of the disease in the region.

Unemployment and cancer screening: Baseline estimates to inform health care delivery in the context of COVID-19 economic distress

Background

During the coronavirus disease 2019 pandemic, US unemployment rates rose to historic highs, and they remain nearly double those of prepandemic levels. Employers are the most common source of health insurance among nonelderly adults. Thus, job loss may lead to a loss of health insurance and reduce access to cancer screening. This study examined associations between unemployment, health insurance, and cancer screening to inform the pandemic's potential impacts on early cancer detection.

Methods

Up‐to‐date and past‐year breast, cervical, colorectal, and prostate cancer screening prevalences were computed for nonelderly respondents (aged <65 years) with 2000‐2018 National Health Interview Survey data. Multivariable logistic regression models with marginal probabilities were used to estimate unemployed‐versus‐employed unadjusted and adjusted prevalence ratios.

Results

Unemployed adults (2000‐2018) were 4 times more likely to lack insurance than employed adults (41.4% vs 10.0%; P < .001). Unemployed adults had a significantly lower up‐to‐date prevalence of screening for cervical cancer (78.5% vs 86.2%; P < .001), breast cancer (67.8% vs 77.5%; P < .001), colorectal cancer (41.9 vs 48.5%; P < .001), and prostate cancer (25.4% vs 36.4%; P < .001). These differences were eliminated after accounting for health insurance coverage.

Conclusions

Unemployment was adversely associated with up‐to‐date cancer screening, and this was fully explained by a lack of health insurance. Ensuring the continuation of health insurance coverage after job loss may mitigate the pandemic's economic distress and future economic downturns' impact on cancer screening.

Unemployment is adversely associated with up‐to‐date cancer screening, and this is fully explained by a lack of health insurance.

Annual Report to the Nation on the Status of Cancer, Part 2: Patient Economic Burden Associated With Cancer Care

BACKGROUND

The American Cancer Society, National Cancer Institute, Centers for Disease Control and Prevention, and North American Association of Central Cancer Registries provide annual information about cancer occurrence and trends in the United States. Part 1 of this annual report focuses on national cancer statistics. This study is part 2, which quantifies patient economic burden associated with cancer care.

METHODS

We used complementary data sources, linked Surveillance, Epidemiology, and End Results-Medicare, and the Medical Expenditure Panel Survey to develop comprehensive estimates of patient economic burden, including out-of-pocket and patient time costs, associated with cancer care. The 2000-2013 Surveillance, Epidemiology, and End Results-Medicare data were used to estimate net patient out-of-pocket costs among adults aged 65 years and older for the initial, continuing, and end-of-life phases of care for all cancer sites combined and separately for the 21 most common cancer sites. The 2008-2017 Medical Expenditure Panel Survey data were used to calculate out-of-pocket costs and time costs associated with cancer among adults aged 18-64 years and 65 years and older.

RESULTS

Across all cancer sites, annualized net out-of-pocket costs for medical services and prescriptions drugs covered through a pharmacy benefit among adults aged 65 years and older were highest in the initial ($2200 and $243, respectively) and end-of-life phases ($3823 and $448, respectively) and lowest in the continuing phase ($466 and $127, respectively), with substantial variation by cancer site. Out-of-pocket costs were generally higher for patients diagnosed with later-stage disease. Net annual time costs associated with cancer were $304.3 (95% confidence interval = $257.9 to $350.9) and $279.1 (95% confidence interval = $215.1 to $343.3) for adults aged 18-64 years and ≥65 years, respectively, with higher time costs among more recently diagnosed survivors. National patient economic burden, including out-of-pocket and time costs, associated with cancer care was projected to be $21.1 billion in 2019.

CONCLUSIONS

This comprehensive study found that the patient economic burden associated with cancer care is substantial in the United States at the national and patient levels.

Colorectal cancer survival in sub-Saharan Africa by age, stage at diagnosis and Human Development Index: A population-based registry study

There are limited population-based survival data for colorectal cancer (CRC) in sub-Saharan Africa. Here, 1707 persons diagnosed with CRC from 2005 to 2015 were randomly selected from 13 population-based cancer registries operating in 11 countries in sub-Saharan Africa. Vital status was ascertained from medical charts or through next of kin. 1-, 3- and 5-year overall and relative survival rates for all registries and for each registry were calculated using the Kaplan-Meier estimator. Multivariable analysis was used to examine the associations of 5-year relative survival with age at diagnosis, stage and country-level Human Development Index (HDI). Observed survival for 1448 patients with CRC across all registries combined was 72.0% (95% CI 69.5-74.4%) at 1 year, 50.4% (95% CI 47.6-53.2%) at 3 years and 43.5% (95% CI 40.6-46.3%) at 5 years. We estimate that relative survival at 5 years in these registry populations is 48.2%. Factors associated with poorer survival included living in a country with lower HDI, late stage at diagnosis and younger or older age at diagnosis (<50 or ≥70 years). For example, the risk of death was 1.6 (95% CI 1.2-2.1) times higher for patients residing in medium-HDI and 2.7 (95% CI 2.2-3.4) times higher for patients residing in low-HDI compared to those residing in high-HDI countries. Survival for CRC remains low in sub-Saharan African countries, though estimates vary considerably by HDI. Strengthening health systems to ensure access to prevention, early diagnosis and appropriate treatment is critical in improving outcomes of CRC in the region.

Contemporary treatment patterns and survival of cervical cancer patients in Ethiopia

Background

Cervical cancer is the second commonly diagnosed cancer and the second leading cause of cancer death in women in Ethiopia, with rates among the highest worldwide. However, there are limited data on cervical cancer treatment patterns and survival in the country. Herein, we examine treatment patterns and survival of cervical cancer patients treated in Tikur Anbessa Hospital Radiotherapy Center (TAHRC), the only hospital with radiotherapy facility in the country.

Methods

Women with histologically verified cervical cancer who were seen in 2014 (January 1, 2014 to December 31, 2014) at TAHRC were included. Information about clinical characteristics and treatments were extracted from the patients’ medical record files. The information on vital status was obtained from medical chart and through telephone calls.

Result

Among 242 patients included in the study, the median age at diagnosis was 48 years. The median waiting time for radiotherapy was 5.6 months (range 2 to 9 months). Stage migration occurred in 13% of patients while waiting for radiotherapy. Consequently, the proportion of patients with stage III or IV disease increased from 66% at first consultation to 74% at the initiation of radiotherapy. Among 151 patients treated with curative intent, only 34 (22.5%) of the patients received concurrent chemotherapy while the reaming patients received radiotherapy alone. The 5-year overall survival rate was 28.4% (20.5% in the worst-case scenario). As expected, survival was lower in patients with advanced stage at initiation of radiotherapy and in those treated as palliative care.

Conclusion

The survival of cervical cancer patients remains low in Ethiopia because of late presentation and delay in receipt of radiotherapy, leading to stage migration in substantial proportion of the cases. Concerted and coordinated multisectoral efforts are needed to promote early presentation of cervical cancer and to shorten the unacceptable, long waiting time for radiotherapy.

Proportion of Cancer Cases Attributable to Physical Inactivity by US State, 2013-2016

INTRODUCTION/PURPOSE

Little is known concerning the cancer burden attributable to physical inactivity by state. Our objective was to calculate the proportion of incident cancer cases attributable to physical inactivity among adults aged ≥30 years in 2013-2016 in all 50 states and District of Columbia.

METHODS

State-level, self-reported physical activity data from the Behavioral Risk Factor Surveillance System were adjusted by sex, age, and race/ethnicity using national level, self-reported physical activity data from the National Health and Nutrition Examination Survey. Age-, sex-, and state-specific cancer incidence data were obtained from the US Cancer Statistics database. Sex-, age-, and state-specific adjusted prevalence estimates for 8 physical activity categories and cancer-specific relative risks for the same categories from a large-scale pooled analysis were used to calculate PAFs by state for stomach, kidney, esophageal (adenocarcinoma), colon, bladder, breast, and endometrial cancer.

RESULTS

When optimal physical activity was defined ≥5 hours/week of moderate-intensity activity, equivalent to ≥15 metabolic equivalent task (MET)-hours/week, 3.0% (95% CI 2.9%-3.0%) of all incident cancer cases (excluding non-melanoma skin cancers) were attributable to physical inactivity, accounting for an average of 46,356 attributable cases per year. The PAF ranged from 2.3% (95% CI 2.2%-2.5%) in Utah to 3.7% (95% CI 3.4%-3.9%) in Kentucky. By cancer site, the PAF ranged from 3.9% (95% CI 3.6%-4.2%) for urinary bladder to 16.9% (95% CI 16.1%-17.7%) for stomach.

CONCLUSION

Our results indicate that promoting physical activity through broad implementation of interventions could prevent many cancer cases. Over 46,000 cancer cases annually could be potentially avoided if the American population met the recommended 5 hours/week of moderate-intensity (or 15 (MET)-hours/week) physical activity.