Mediation model with a categorical exposure and a censored mediator with application to a genetic study

Mediation analysis is a statistical method for evaluating the direct and indirect effects of an exposure on an outcome in the presence of a mediator. Mediation models have been widely used to determine direct and indirect contributions of genetic variants in clinical phenotypes. In genetic studies, the additive genetic model is the most commonly used model because it can detect effects from either recessive or dominant models (or any model in between). However, the existing approaches for mediation model cannot be directly applied when the genetic model is additive (e.g. the most commonly used model for SNPs) or categorical (e.g. polymorphic loci), and thus modification to measures of indirect and direct effects is warranted. In this study, we proposed overall measures of indirect, direct, and total effects for a mediation model with a categorical exposure and a censored mediator, which accounts for the frequency of different values of the categorical exposure. The proposed approach provides the overall contribution of the categorical exposure to the outcome variable. We assessed the empirical performance of the proposed overall measures via simulation studies and applied the measures to evaluate the mediating effect of a women’s age at menopause on the association between genetic variants and type 2 diabetes.

Genetic Factors Associated With Pain Severity, Daily Opioid Dose Requirement, and Pain Response Among Advanced Cancer Patients Receiving Supportive Care

BACKGROUND

Current understanding of genetic factors associated with pain severity, and improvement of pain with opioids in advanced cancer patients (AC) is inadequate for delivery of personalized pain therapy (PPT). Therefore, the aim of this study was to determine the genetic factors associated with pain severity, daily opioid dose, and pain response in AC patients receiving supportive care.

METHODS

In this prospective study, AC patients were eligible if they had cancer pain ≥4/10 on Edmonton Symptom Assessment Scale (ESAS) - Pain Item and needed opioid rotation for pain control by specialist at the outpatient supportive care center. Association of genetic factors with pain phenotype was assessed using logistic regression models and SKATO (Gene-block) analysis.

RESULTS

About 174/178 (98%) patient samples were analyzed. After adjustment for demographic and clinical variables, pain severity was negatively associated with intron variant alleles in OPRM1 rs9322446, P = 0.02; rs2270459, P = 0.038; rs62052210, P = 0.038. Opioid daily dose was positively associated NFKBIA rs2233419, P = 0.008; rs2233417, P = 0.007; rs3138054, P = 0.008; rs1050851, P = 0.015; ORPM1 rs9479759, P = 0.046; rs2003185, P = 0.047; rs636433, P = 0.044; COMT (rs9306234, P = 0.014; rs165728, P = 0.014; rs2020917, P = 0.036; rs165728, P = 0.034); ARRB2 (rs1045280, P = 0.045); and pain response to opioids was negatively associated OPRM1 rs1319339, P = 0.024; rs34427887, P = 0.048; and COMT rs4646316, P = 0.03; rs35478083, P = 0.028, respectively. SKATO analysis showed association between pain severity and CXCL8 (P = 0.0056), and STAT6 (P = 0.0297) genes respectively, and pain response with IL-6 (P = 0.00499).

CONCLUSIONS

This study identified that SNPs of OPRM1, COMT, NFKBIA, CXCL8, IL-6, STAT6, and ARRB2 genes were associated with pain severity, opioid daily dose, and pain response in AC receiving supportive care. Additional studies are needed to validate our findings for PPT.

Safety Concerns or Adverse Effects as the Main Reason for Human Papillomavirus Vaccine Refusal: National Immunization Survey-Teen, 2008 to 2019

This secondary analysis assesses safety concerns and adverse effects as reported reasons for HPV vaccine refusal.

Differences in Breast and Colorectal Cancer Screening Adherence Among Women Residing in Urban and Rural Communities in the United States

Importance

Screening for breast and colorectal cancer has resulted in reductions in mortality; however, questions remain regarding how these interventions are being diffused to all segments of the population. If an intervention is less amenable to diffusion, it could be associated with disparities in mortality rates, especially in rural vs urban areas.

Objectives

To compare the prevalence of breast and colorectal cancer screening adherence and to identify factors associated with screening adherence among women residing in rural vs urban areas in the United States.

Design, Setting, and Participants

This population-based cross-sectional study of women aged 50 to 75 years in 11 states was conducted from 2017 to 2020.

Main Outcomes and Measures

Adherence to cancer screening based on the US Preventative Services Task Force guidelines. For breast cancer screening, women who had mammograms in the past 2 years were considered adherent. For colorectal cancer screening, women who had (1) a stool test in the past year, (2) a colonoscopy in the past 10 years, or (3) a sigmoidoscopy in the past 5 years were considered adherent. Rural status was coded using Rural Urban Continuum Codes, and other variables were assessed to identify factors associated with screening.

Results

The overall sample of 2897 women included 1090 (38.4%) rural residents; 2393 (83.5%) non-Hispanic White women; 263 (9.2%) non-Hispanic Black women; 68 (2.4%) Hispanic women; 1629 women (56.2%) aged 50 to 64 years; and 712 women (24.8%) with a high school education or less. Women residing in urban areas were significantly more likely to be adherent to colorectal cancer screening compared with women residing in rural areas (1429 [82%] vs 848 [78%]; P = .01), whereas the groups were equally likely to be adherent to breast cancer screening (1347 [81%] vs 830 [81%]; P = .78). Multivariable mixed-effects logistic regression analyses confirmed that rural residence was associated with lower odds of being adherent to colorectal cancer screening (odds ratio [OR], 0.81; 95% CI, 0.66-0.99, P = .047). Non-Hispanic Black race was associated with adherence to breast cancer screening guidelines (OR, 2.85; 95% CI, 1.78-4.56; P < .001) but not colorectal cancer screening guidelines.

Conclusions and Relevance

In this cross-sectional study, women residing in rural areas were less likely to be adherent to colorectal cancer screening guidelines but were similarly adherent to breast cancer screening. This suggests that colorectal cancer screening, a more recent intervention, may not be as available in rural areas as breast cancer screening, ie, colorectal screening has lower amenability.

Trends in the rates of health-care providers' recommendation for HPV vaccine from 2012 to 2018: a multi-round cross-sectional analysis of the health information national trends survey

The 2012 report of the President's Cancer Panel highlighted the overriding contribution of missed clinical opportunities to suboptimal HPV vaccination coverage. Since then, it remains unknown whether the rates of provider recommendations for the HPV vaccine in the US population have increased. We conducted an analysis of four rounds of the Health Information National Trends Survey (HINTS), a household survey of civilian US residents aged 18 y or older. A total of 1,415 (2012), 1,476 (2014), 1,208 (2017), and 1,344 (2018) respondents to the HINTS survey who were either HPV vaccine-eligible or living with HPV vaccine-eligible individuals were included. Overall, the rates of providers' recommendations remained stagnated from 2012 to 2018 in all categories of the study population, except for non-Hispanic Blacks (NHBs), where this prevalence increased during the study period (AAPC = 16.4%, p < .001). In vaccine-eligible individuals (18-27 y), declining trends were noted overall (AAPC = -21.6%, p < .001), among NHWs (AAPC = -30.2%, p < .001) and urban dwellers (AAPC = -21.4%, p < .001). Among vaccine-ineligible respondents (˃27 y) living with vaccine-eligible individuals, trends in the prevalence of provider recommendations for HPV vaccine were stagnating overall (AAPC = 0.5%, p = .90), and increasing only among NHBs (AAPC = 13.9%, p < .001). Despite recent progress, our findings indicate variations of trends in provider recommendations for the HPV vaccine in the US adult population according to age, sex, race/ethnicity, and residence. To accelerate HPV vaccination uptake, immediate actions to enhance provider recommendation for HPV vaccine are needed.

Political Ideology and the Support or Opposition to United States Tobacco Control Policies

This cross-sectional study examines the association between US adults’ self-reported political ideology and support of or opposition to policies that limit visibility and restrict advertisement of tobacco products.

Determinants of patient-reported xerostomia among long-term oropharyngeal cancer survivors

BACKGROUND

This study was conducted to identify clinicodemographic risk factors for xerostomia among long-term oropharyngeal cancer (OPC) survivors.

METHODS

This cross-sectional study included 906 disease-free, adult OPC survivors with a median survival duration at the time of survey of 6 years (range, 1-16 years); self-reported xerostomia scores were available for 877 participants. Study participants had completed curative treatment between January 2000 and December 2013 and responded to a survey administered from September 2015 to July 2016. The primary outcome variable was cancer patient-reported xerostomia measured with the MD Anderson Symptom Inventory Head and Neck Cancer Module. Clinicodemographic risk factors for moderate to severe xerostomia were identified via multivariable logistic regression.

RESULTS

Moderate to severe xerostomia was reported by 343 of the respondents (39.1%). Female sex (odds ratio [OR], 1.82; 95% CI, 1.22-2.71; P = .003; Bayesian false-discovery probability [BFDP] = 0.568), high school or lower education (OR, 1.73; 95% CI, 1.19-2.52; P = .004; BFDP = 0.636), and current cigarette smoking at the time of survey (OR, 2.56; 95% CI, 1.19-5.47; P = .016; BFDP = 0.800) were risk factors for moderate to severe xerostomia, and bilateral intensity-modulated radiotherapy (IMRT) combined with proton therapy and ipsilateral IMRT were protective.

CONCLUSIONS

In this large xerostomia study, modern radiotherapy was a protective factor, and continued cigarette smoking at the time of survey, female sex, and high school or lower education were identified as other contributing risk factors associated with moderate to severe xerostomia. Importantly, these findings need to be confirmed in prospective studies. These results can inform future research and targeted patient-centered interventions to monitor and manage radiation therapy-associated xerostomia and preserve quality of life among patients with OPC.

Association of Risk Factors With Patient-Reported Voice and Speech Symptoms Among Long-term Survivors of Oropharyngeal Cancer

Importance

Voice and speech production are critical physiological functions that affect quality of life and may deteriorate substantially after oropharyngeal cancer (OPC) treatment. There is limited knowledge about risk factors associated with voice and speech outcomes among survivors of OPC.

Objective

To identify the risk factors of voice and speech symptoms among long-term survivors of OPC.

Design, Setting, and Participants

This retrospective cohort study with cross-sectional survivorship survey administration includes cancer-free survivors of OPC who were treated curatively between January 2000 and December 2013 at MD Anderson Cancer Center (Houston, Texas) who participated in a survey from September 2015 to July 2016. Of 906 survivors of OPC with a median survival duration at time of survey of 6 years (range, 1-16 years), patient-rated voice and speech outcomes for 881 were available and analyzed. The data were analyzed from June 30, 2020, to February 28, 2021.

Main Outcomes and Measures

The primary outcome variable was patient-reported voice and speech scores that were measured using the MD Anderson Symptom Inventory-Head and Neck Cancer Module. Voice and speech scores of 0 to 4 were categorized as none to mild symptoms, and scores of 5 to 10 were categorized as moderate to severe symptoms. Risk factors for moderate to severe voice and speech symptoms were identified by multivariable logistic regression.

Results

Among 881 survivors of OPC (median [range] age, 56 [32-84] years; 140 women [15.5%]; 837 White [92.4%], 17 Black [1.9%], and 35 Hispanic individuals [3.8%]), 113 (12.8%) reported moderate to severe voice and speech scores. Increasing survival time (odds ratio [OR], 1.17; 95% CI, 1.06-1.30) and increasing total radiation dose (OR, 1.16; 95% CI, 1.00-1.34), Black race (OR, 3.90; 95% CI, 1.02-14.89), Hispanic ethnicity (OR, 3.74; 95% CI, 1.50-9.35), current cigarette smoking at the time of survey (OR, 3.98; 95% CI, 1.56-10.18), treatment with induction and concurrent chemotherapy (OR, 1.94; 95% CI, 1.06-3.57), and late (OR, 7.11; 95% CI, 3.08-16.41) and baseline lower cranial neuropathy (OR, 8.70; 95% CI, 3.01-25.13) were risk factors associated with moderate to severe voice and speech symptoms. Intensity-modulated radiotherapy split-field regimen (OR, 0.31; 95% CI, 0.12-0.80; P = .01) was associated with lower likelihood of moderate to severe voice and speech symptoms.

Conclusions and Relevance

This large OPC survivorship cohort study identified many treatment-related factors, including increasing total radiotherapy dose, multimodality induction and concurrent chemotherapy regimens, and continued smoking, as well as clinical and demographic factors, as risk factors that were associated with moderate to severe voice and speech symptoms. The key findings in this study were the protective associations of split-field radiation and that longer-term survivors, and those who continued to smoke, had worse voice and speech symptoms. These findings may inform research and effective targeted clinical voice and speech preservation interventions and smoking cessation interventions to maximize voice and speech function and address quality of life among patients with OPC.

Abstract 22: Screening and Treatment of Female Sex Workers for Cervical Precancers in Cameroon

Purpose: To prevent cervical cancer among female sex workers (FSWs) who are at high risk of acquiring HPV infections (through occupational exposure) that may progress to invasive cervical cancer (ICC) if not treated.

Methods: With funding from a Prevent Cancer Foundation grant and in collaboration with Horizons Femmes, an NGO that provides services to FSWs, the Women's Health Program (WHP) of the Cameroon Baptist Convention Health Services screened FSWs in three large Cameroonian cities with visual inspection with acetic acid and Lugol's iodine (VIA/VILI) enhanced by digital cervicography (DC) and collected vaginal specimens from FSWs aged 30+ years for AmpFire HPV genotyping.

Results: Of the 757 FSWs who were screened in August 2020, 510 (67.4%) were aged 30 or over, 308 (60.4%) had one or more high risk HPV types and 47(9.2%) had positive VIA/VILI-DC (34 with ablative eligible lesions and 13 with LEEP eligible lesions). Of the women less than age 30, 27(10.9%) had positive VIA/VILI-DC (92.6% with ablative and 7.4% LEEP eligible lesions). Of the 74 women with ablative and LEEP eligible lesions, 38 (64.4%) and 8 (53.3%) respectively were treated. Of 272 women aged 30+years who were HPV positive but DC negative, 61 (22.4%) were treated with thermal ablation. The WHP continues to follow up on FSWs who need treatment and is analyzing HPV genotypes' frequency and their relation to the VIA/VILI-DC results.

Conclusions: With appropriate education and support, FSWs can be screened for cervical cancer and a high proportion of those with positive screening tests can be appropriately treated to reduce their risk of ICC.

Citation Format: Simon Manga, Kathleen Nulah, Florence Manjuh, Joel Fokom, Denisse Ngatchou, Edith Welty, Sanjay Shete, Margaret Liang, Thomas Welty. Screening and Treatment of Female Sex Workers for Cervical Precancers in Cameroon [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 22.

Examining lung cancer screening utilization with public-use data: Opportunities and challenges

Lung cancer screening with low-dose computed tomography is recommended for high-risk smokers who meet specific eligibility criteria. Current guidelines suggest that eligible adults with a heavy smoking history will benefit from annual low dose computed tomography but due to several associated risks (e.g., false-positives, radiation exposure, overdiagnosis) a shared decision-making consultation is required by the Centers for Medicare & Medicaid Services, and endorsed by the United States Preventive Services Task Force. In order to examine potential for tracking LCS uptake, adherence, and patient-provider communication at a national level, we reviewed four regularly publicly available national surveys (National Health Interview Survey [NHIS], Behavioral Risk Factor Surveillance System [BRFSS], National Health and Nutrition Examination Survey [NHANES], and Health Information National Trends Survey [HINTS]) to assess available data; an overview of 37 publications using these sources is also provided. The results show that none of the surveys include items that fully assess current LCS guidelines. Implications for future research-including the potential to examine factors associated with LCS uptake and patient-provider communication-are addressed.

Trends in HPV Vaccination Initiation and Completion Within Ages 9-12 Years: 2008-2018

BACKGROUND AND OBJECTIVES

Routine human papillomavirus (HPV) vaccination is recommended at ages 11 to 12 years and may be initiated as early as 9 years of age.

METHODS

Data were derived from the National Immunization Survey-Teen, spanning 2008-2018. Using health care provider-verified vaccination histories, we examined trends in human papillomavirus vaccination up-to-date (HPV-UTD) rates within ages 9 to 12 years. Furthermore, we assessed vaccination status by sociodemographic factors and US state of residence.

RESULTS

Overall, amid evidence of recent stagnation, HPV vaccination between ages 9 to 12 increased over the years. Initiation rates rose from 17.3% in 2008 to 62.8% in 2018, and HPV-UTD rates rose from 13.5% in 2011 to 32.8% in 2018. After the inception of gender-neutral HPV vaccination, HPV-UTD rates between 2011 and 2018 rose by 31.9% among boys and only 6.6% among girls. For most of the study period, non-Hispanic Black and Hispanic individuals had higher rates of initiation and HPV-UTD than non-Hispanic white individuals. In 2018, vaccination initiation rates exceeded 70% in several states; however, HPV-UTD rates in most US states were <50%, excluding Rhode Island (61.6%), Colorado (58.7%), Hawaii (53.5%), District of Columbia (53.2%), and Ohio (50%).

CONCLUSIONS

HPV vaccination within ages 9 to 12 years is suboptimal. To leverage the substantial benefits of HPV vaccination within this age range, it is imperative that conscious efforts are taken at the national and state levels to promote HPV vaccination for this age group.

Real-world patient-reported and clinical outcomes of BNT162b2 mRNA COVID-19 vaccine in patients with cancer

6510

Background: Most COVID-19 (C19) vaccine trials excluded patients with active cancer. Here, we report our real-world patient-reported and clinical outcomes of BNT162b2 mRNA C19 vaccine in patients with cancer. Methods: Our institutional Data-Driven Determinants for COVID-19 Oncology Discovery Effort (D3CODE) follows a longitudinal observational cohort of pts w cancer getting C19 vaccine. Pts complete a validated PRO tool, MD Anderson Symptom Inventory (MDASI, 13 core, 6 interference plus 17 items of symptoms from prior vaccine trials) pre-dose 1, then daily x 6d, then weekly, then on day of dose 2, then daily x 6d, then weekly x 3w. Demographics, cancer variables, prior immune checkpoint inhibitors (ICI), C19 status pre- & post-vaccine are aggregated via Syntropy platform: Palantir Foundry. Primary outcome is incidence of PRO symptoms bw dose 1 & 2 across AYA 15-39y, mid-age 40-64y & senior 65y+ cohorts. Secondary outcomes include PRO symptom incidence post-dose 2, post-vaccine change in cancer symptoms, post-vaccine symptom severity based on prior ICI, and confirmed C19 > 7 days post-dose 2. First planned 8-wk interim analysis is reported here. Results: 6388 pts w cancer (4973 w mets) received a BNT162b2 vaccine dose (4811 both doses, 1577 received one & await dose 2). Overall, median age 64y (range 16-95y); 382 AYAs, 2927 mid-age, 3079 seniors (65-70y n = 1158, 70-79y n = 1521, 80-89y n = 378, 90y+ n = 22). 4099 (64%) are White, 823 (13%) AA, 791 (12%) Hispanic, 441 (7%) Asians. Primary cancers: breast (1397), GU (821), heme (775), thoracic/HN (745), and CRC (385). Prior to dose 1, 1862 had no prior systemic tx while 4526 pts did including 3243 who had only non-IO tx (chemo, targeted tx), 1,283 had immunotherapy including 857 who had ICIs prior to dose 1. Patient-reported symptoms after C19 Vaccine: Of 6388 pts, 4714 (74% response rate, median age 67y, range 16-95y) completed 16485 PRO surveys. After 2 doses, seniors reported lower mean scores vs mid-age or AYAs on 22 of 36 symptoms including injection site pain, palpitations, itch, rash, malaise, fevers/chills, arthralgia, myalgia, headache, pain, fatigue, nausea, disturbed sleep, distress (p < 0.05). Pts w prior ICIs had higher severity of itch, rash (p < 0.05) from baseline after both dose 1 & 2 vs pts without systemic tx. Post dose 1, pts with prior ICI had higher increase in fatigue, malaise, itch, rash, myalgia, anorexia from their baseline vs pts without systemic tx (p < 0.05). C19 Outcomes: Of 6388 pts, 616 had a C19 test at any time post-dose 1: 23 (0.36%) tested positive of whom 20 (0.3%) were between dose 1 & 2; two (0.031%) were within 7 days post-dose 2, and one patient (0.016%) tested positive 16 days after dose 2, requiring admission. Conclusions: This real-world observational cohort demonstrates post-vaccine symptom burden and outcomes in patients with cancer. Second interim analysis is planned at 16 weeks.

Lower respiratory tract disease (LRTD) in patients with cancer and COVID-19: A COVID-19 and Cancer Consortium (CCC19) study

6563

Background: Immunodeficiency in patients (pts) with cancer can lead to the progression of common respiratory viral infections to lower respiratory tract disease (LRTD) with potentially high mortality. Understanding risk factors of SARS-CoV-2 related LRTD in pts with cancer is imperative for the development of preventive measures. Methods: We examined all patients aged 18 years or older with cancer and laboratory-confirmed SARS-CoV-2 infection reported between March 16, 2020 and February 6, 2021 in the international CCC19 registry. We examined frequency of LRTD (pneumonia, pneumonitis, acute respiratory distress syndrome, or respiratory failure), demographic and clinicopathologic factors associated with LRTD, and 30-day and overall mortality in pts with and without LRTD. Results: Of 7,289 pts with a median follow-up time of 42 (21-90) days, 2187 (30%) developed LRTD. Pts of older age (65 yrs or older), male sex, pre-existing comorbidities, baseline immunosuppressants, baseline corticosteroids, and ECOG performance status of 2 or more had substantially higher rates of LRTD compared to those without these risk factors (Table). We did not observe differences in LRTD rates between pts of different racial/ethnic groups, smoking history, hypertension, obesity, cancer status, timing or type of anti-cancer therapy. LRTD was more likely in pts with thoracic malignancy (39%), hematological malignancy (39%) compared to those with other solid tumors (27%). The majority of pts (86%) had symptomatic presentation; however, 8% of pts with asymptomatic presentation developed LRTD. 30-day and overall mortality rates were significantly higher in pts with LRTD than those without LRTD (31% vs. 4% and 38% vs. 6%, P < 0.05). Conclusions: COVID-19 related LRTD rate is high and associated with worse mortality rates in pts with cancer. The majority of risk factors associated with LRTD demonstrate underlying immunodeficiency or lung structural damage as a driving force in this population. Identifying pts at high-risk for developing LRTD can help guide clinical management, improve pt outcomes, increase the cost-effectiveness of antiviral therapy, and direct future clinical trial designs for vaccine or antiviral agents.[Table: see text]

Factors Influencing Discussion of Cancer Genetic Testing with Health-Care Providers in a Population-Based Survey

INTRODUCTION

Discussion of cancer genetic testing with health-care providers (HCPs) is necessary to undergo testing to inform cancer risk assessment and prevention. Given the rapid evolution in genetic testing practice in oncology, we describe the current landscape of population-level cancer genetic testing behaviors.

METHODS

A questionnaire including items regarding discussion of cancer genetic testing with HCPs was administered to a nonprobability sample (N = 2,029) of the Texas population.

RESULTS

Overall, 11% of respondents discussed cancer genetic testing with HCPs. In multivariable analysis, discussion was significantly related to having a personal history of breast/ovarian/colon cancer (OR = 11.57, 95% CI = 5.34-25.03), personal history of other cancer (OR = 3.18, 95% CI = 1.69-5.97), and health information-seeking behaviors (OR = 1.73, 95% CI = 1.12-2.66). Surprisingly, respondents who believed that inherited predispositions in addition to other modifiable risk factors cause cancer were less likely to discuss genetic testing compared to those who did not believe that inherited cancer predispositions cause cancer (OR = 0.54, 95% CI = 0.36-0.79).

DISCUSSION

The high discussion rate may be attributed to increased public awareness of genetic testing and adoption of more inclusive clinical genetic testing guidelines. The findings suggest that efforts to increase public awareness of the utility of genetic testing on personalized cancer risk assessment and cancer prevention are needed.

Comprehensive functional annotation of susceptibility variants identifies genetic heterogeneity between lung adenocarcinoma and squamous cell carcinoma

Although genome-wide association studies have identified more than eighty genetic variants associated with non-small cell lung cancer (NSCLC) risk, biological mechanisms of these variants remain largely unknown. By integrating a large-scale genotype data of 15 581 lung adenocarcinoma (AD) cases, 8350 squamous cell carcinoma (SqCC) cases, and 27 355 controls, as well as multiple transcriptome and epigenomic databases, we conducted histology-specific meta-analyses and functional annotations of both reported and novel susceptibility variants. We identified 3064 credible risk variants for NSCLC, which were overrepresented in enhancer-like and promoter-like histone modification peaks as well as DNase I hypersensitive sites. Transcription factor enrichment analysis revealed that USF1 was AD-specific while CREB1 was SqCC-specific. Functional annotation and gene-based analysis implicated 894 target genes, including 274 specifics for AD and 123 for SqCC, which were overrepresented in somatic driver genes (ER = 1.95, P = 0.005). Pathway enrichment analysis and Gene-Set Enrichment Analysis revealed that AD genes were primarily involved in immune-related pathways, while SqCC genes were homologous recombination deficiency related. Our results illustrate the molecular basis of both well-studied and new susceptibility loci of NSCLC, providing not only novel insights into the genetic heterogeneity between AD and SqCC but also a set of plausible gene targets for post-GWAS functional experiments.

Genome-wide association meta-analysis identifies pleiotropic risk loci for aerodigestive squamous cell cancers

Squamous cell carcinomas (SqCC) of the aerodigestive tract have similar etiological risk factors. Although genetic risk variants for individual cancers have been identified, an agnostic, genome-wide search for shared genetic susceptibility has not been performed. To identify novel and pleotropic SqCC risk variants, we performed a meta-analysis of GWAS data on lung SqCC (LuSqCC), oro/pharyngeal SqCC (OSqCC), laryngeal SqCC (LaSqCC) and esophageal SqCC (ESqCC) cancers, totaling 13,887 cases and 61,961 controls of European ancestry. We identified one novel genome-wide significant (Pmeta<5x10-8) aerodigestive SqCC susceptibility loci in the 2q33.1 region (rs56321285, TMEM273). Additionally, three previously unknown loci reached suggestive significance (Pmeta<5x10-7): 1q32.1 (rs12133735, near MDM4), 5q31.2 (rs13181561, TMEM173) and 19p13.11 (rs61494113, ABHD8). Multiple previously identified loci for aerodigestive SqCC also showed evidence of pleiotropy in at least another SqCC site, these include: 4q23 (ADH1B), 6p21.33 (STK19), 6p21.32 (HLA-DQB1), 9p21.33 (CDKN2B-AS1) and 13q13.1(BRCA2). Gene-based association and gene set enrichment identified a set of 48 SqCC-related genes rel to DNA damage and epigenetic regulation pathways. Our study highlights the importance of cross-cancer analyses to identify pleiotropic risk loci of histology-related cancers arising at distinct anatomical sites.

Cross-sectional survey for assessing cancer care providers' characteristics and attitudes on smoking cessation in Colombia and Mexico

OBJECTIVE

Cancer care providers' (CCPs) attitudes towards smoking cessation are influenced by many factors, including their smoking status and knowledge. Our objective was to assess CCPs' characteristics, tobacco use and smoking cessation practices in two Latin American cancer centres.

DESIGN

Cross-sectional survey.

SETTINGS

Two urban cancer centres located in Colombia and Mexico.

PARTICIPANTS

A total of 238 CCPs.

MEASURES

Online survey consisted of 28 close-ended questions adapted from the 2012 International Association for the Study of Lung Cancer survey and the Global Adult Tobacco Survey developed by the WHO. Means, frequencies and proportions were reported for each country. Factors associated to providing of smoking cessation treatment or referral at initial visit were evaluated using logistic regression.

RESULTS

Current smoking prevalence was 10.5% and 12.3% among Colombian and Mexican CCPs, respectively. Around three quarters of the Colombian (86.4%) and Mexican CCPs (66.1%) considered to have inadequate training in smoking cessation. Approximately two-thirds of Colombian (67.5%) and Mexican CCPs (63.9%) reported always or most of the time asking patients about tobacco use during the initial visit. In Colombia and Mexico, the most relevant barriers for providing cessation services were (1) difficulties for motivating patients with cancer, (2) patient resistance in quitting smoking, (3) lack of local resources or referral centres for smoking cessation and (4) lack of training in smoking cessation. CCPs appointed at Instituto Nacional de Cancerología were less likely to provide cessation treatment or referral to their patients if they had less than 50% of their time devoted to patient care and were former or current smokers. The regression model for Instituto de Cancerología did not retain statistically significant variables.

CONCLUSION

Our findings highlight an urgent need for assisting Latin American CCPs in their quitting efforts as well as expanding formal smoking cessation training specifically tailored to these professionals for improving patients' cancer prognosis and quality of life.

The relationship between body-mass index and overall survival in non-small cell lung cancer by sex, smoking status, and race: A pooled analysis of 20,937 International lung Cancer consortium (ILCCO) patients

INTRODUCTION

The relationship between Body-Mass-Index (BMI) and lung cancer prognosis is heterogeneous. We evaluated the impact of sex, smoking and race on the relationship between BMI and overall survival (OS) in non-small-cell-lung-cancer (NSCLC).

METHODS

Data from 16 individual ILCCO studies were pooled to assess interactions between BMI and the following factors on OS: self-reported race, smoking status and sex, using Cox models (adjusted hazard ratios; aHR) with interaction terms and adjusted penalized smoothing spline plots in stratified analyses.

RESULTS

Among 20,937 NSCLC patients with BMI values, females = 47 %; never-smokers = 14 %; White-patients = 76 %. BMI showed differential survival according to race whereby compared to normal-BMI patients, being underweight was associated with poor survival among white patients (OS, aHR = 1.66) but not among black patients (aHR = 1.06; pinteraction = 0.02). Comparing overweight/obese to normal weight patients, Black NSCLC patients who were overweight/obese also had relatively better OS (pinteraction = 0.06) when compared to White-patients. BMI was least associated with survival in Asian-patients and never-smokers. The outcomes of female ever-smokers at the extremes of BMI were associated with worse outcomes in both the underweight (pinteraction<0.001) and obese categories (pinteraction = 0.004) relative to the normal-BMI category, when compared to male ever-smokers.

CONCLUSION

Underweight and obese female ever-smokers were associated with worse outcomes in White-patients. These BMI associations were not observed in Asian-patients and never-smokers. Black-patients had more favorable outcomes in the extremes of BMI when compared to White-patients. Body composition in Black-patients, and NSCLC subtypes more commonly seen in Asian-patients and never-smokers, may account for differences in these BMI-OS relationships.

Disparities in Secondhand Smoke Exposure in the United States: National Health and Nutrition Examination Survey 2011-2018

This cross-sectional study examines National Health and Nutrition Examination Survey data to assess the prevalence of secondhand smoke exposure in nonsmokers in the US population 3 years and older.

Genetic Determinants of Lung Cancer Prognosis in Never Smokers: A Pooled Analysis in the International Lung Cancer Consortium

BACKGROUND

Lung cancer remains the leading cause of cancer death worldwide, with 15% to 20% occurring in never smokers. To assess genetic determinants for prognosis among never smokers, we conducted a genome-wide investigation in the International Lung Cancer Consortium (ILCCO).

METHODS

Genomic and clinical data from 1,569 never-smoking patients with lung cancer of European ancestry from 10 ILCCO studies were included. HRs and 95% confidence intervals of overall survival were estimated. We assessed whether the associations were mediated through mRNA expression-based 1,553 normal lung tissues from the lung expression quantitative trait loci (eQTL) dataset and Genotype-Tissue Expression (GTEx). For cross-ethnicity generalization, we assessed the associations in a Japanese study (N = 887).

RESULTS

One locus at 13q22.2 was associated with lung adenocarcinoma survival at genome-wide level, with carriers of rs12875562-T allele exhibiting poor prognosis [HR = 1.71 (1.41-2.07), P = 3.60 × 10-8], and altered mRNA expression of LMO7DN in lung tissue (GTEx, P = 9.40 × 10-7; Lung eQTL dataset, P = 0.003). Furthermore, 2 of 11 independent loci that reached the suggestive significance level (P < 10-6) were significant eQTL affecting mRNA expression of nearby genes in lung tissues, including CAPZB at 1p36.13 and UBAC1 at 9q34.3. One locus encoding NWD2/KIAA1239 at 4p14 showed associations in both European [HR = 0.50 (0.38-0.66), P = 6.92 × 10-7] and Japanese populations [HR = 0.79 (0.67-0.94), P = 0.007].

CONCLUSIONS

Based on the largest genomic investigation on the lung cancer prognosis of never smokers to date, we observed that lung cancer prognosis is affected by inherited genetic variants.

IMPACT

We identified one locus near LMO7DN at genome-wide level and several potential prognostic genes with cis-effect on mRNA expression. Further functional genomics work is required to understand their role in tumor progression.

Differentiating anomalous disease intensity with confounding variables in space

Background

The investigation of perceived geographical disease clusters serves as a preliminary step that expedites subsequent etiological studies and analysis of epidemicity. With the identification of disease clusters of statistical significance, to determine whether or not the detected disease clusters can be explained by known or suspected risk factors is a logical next step. The models allowing for confounding variables permit the investigators to determine if some risk factors can explain the occurrence of geographical clustering of disease incidence and to investigate other hidden spatially related risk factors if there still exist geographical disease clusters, after adjusting for risk factors.

Methods

We propose to develop statistical methods for differentiating incidence intensity of geographical disease clusters of peak incidence and low incidence in a hierarchical manner, adjusted for confounding variables. The methods prioritize the areas with the highest or lowest incidence anomalies and are designed to recognize hierarchical (in intensity) disease clusters of respectively high-risk areas and low-risk areas within close geographic proximity on a map, with the adjustment for known or suspected risk factors. The data on spatial occurrence of sudden infant death syndrome with a confounding variable of race in North Carolina counties were analyzed, using the proposed methods.

Results

The proposed Poisson model appears better than the one based on SMR, particularly at facilitating discrimination between the 13 counties with no cases. Our study showed that the difference in racial distribution of live births explained, to a large extent, the 3 previously identified hierarchical high-intensity clusters, and a small region of 4 mutually adjacent counties with the higher race-adjusted rates, which was hidden previously, emerged in the southwest, indicating that unobserved spatially related risk factors may cause the elevated risk. We also showed that a large geographical cluster with the low race-adjusted rates, which was hidden previously, emerged in the mid-east.

Conclusion

With the information on hierarchy in adjusted intensity levels, epidemiologists and public health officials can better prioritize the regions with the highest rates for thorough etiologic studies, seeking hidden spatially related risk factors and precisely moving resources to areas with genuine highest abnormalities.

Oral microbiome and onset of oral mucositis in patients with squamous cell carcinoma of the head and neck

BACKGROUND

Oral mucositis (OM) is a debilitating sequela for patients treated for squamous cell carcinoma of the head and neck (HNSCC). This study investigated whether oral microbial features before treatment or during treatment are associated with the time to onset of severe OM in patients with HNSCC.

METHODS

This was a cohort study of newly diagnosed patients with locoregional HNSCC who received chemotherapy with or without radiotherapy from April 2016 to September 2017. OM was based on the National Cancer Institute's Common Terminology Criteria for Adverse Events, version 4.0. The oral microbiome was characterized on the basis of the 16S ribosomal RNA V4 region with the Illumina platform. A mixture cure model was used to generate hazard ratios for the onset of severe OM.

RESULTS

Eighty-six percent of the patients developed OM (n = 57 [33 nonsevere cases and 24 severe cases]) with a median time to onset of OM of 21 days. With adjustments for age, sex, and smoking status, genera abundance was associated with the hazard for the onset of severe OM as follows: 1) at the baseline (n = 66), Cardiobacterium (P = .03) and Granulicatella (P = .04); 2) immediately before the development of OM (n = 57), Prevotella (P = .03), Fusobacterium (P = .03), and Streptococcus (P = .01); and 3) immediately before the development of severe OM (n = 24), Megasphaera (P = .0001) and Cardiobacterium (P = .03). There were no differences in α-diversity between the baseline samples and Human Microbiome Project data.

CONCLUSIONS

Changes in the abundance of genera over the course of treatment were associated with the onset of severe OM. The mechanism and therapeutic implications of these findings need to be investigated in future studies.

Abstract 1140: Declining awareness of HPV and HPV vaccination within the general US population

Background: Programs aimed at boosting awareness on Human Papillomavirus (HPV) and HPV vaccination are considered one of the most effective strategies for increasing vaccination uptake and eliminating HPV-associated cancers. Several US states have demonstrated a strong commitment to this effort through legislation and dedicated funds, however the impact of this intervention over time remains poorly studied.

Methods: Using a nationally representative population of US adults from the Health Information National Trends Survey (HINTS), we examined for awareness of HPV and HPV vaccination between 2009 and 2018. Prevalence estimates and confidence intervals were calculated for HPV and HPV vaccination awareness. Further, we assessed awareness status after stratifying by key sociodemographic characteristics.

Results: Overall, the awareness of HPV and HPV vaccination declined over time. This finding was consistent across gender and socioeconomic strata. The lowest rates of awareness were found among those with educational level at or below high school completion, those who earned less than $35,000 per annum, rural residents, and male adults, aged 60 years and older. Declines in awareness of HPV or HPV vaccination between 2014 and 2018 were more than 10% among male adults, those with educational level at or below high school completion and those who earned less than $35,000 per annum. Only 36.1% of adults with high school education or lower had ever heard of HPV vaccine in 2018, a 15.6% reduction from 2009. In 2018 awareness of HPV and HPV vaccine was highest among non-Hispanic whites (65.8% and 66.5%) and female adults (70.5% and 71.4%), however these figures represented declines of at least 5% from rates observed in 2009.

Discussion: Amid a background of sub-optimal HPV vaccination uptake and a growing incidence of HPV-associated cancers in the US, the awareness of HPV and HPV vaccination within the general population has declined over time. This calls for stricter enforcement of legislature aimed at boosting HPV awareness, as well as frequent evaluations of government-funded HPV awareness programs.

Citation Format: Onyema G. Chido-Amajuoyi, Inimfon Jackson, Robert Yu, Sanjay Shete. Declining awareness of HPV and HPV vaccination within the general US population [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1140.