Cancer survival among US whites and minorities: a SEER (Surveillance, Epidemiology, and End Results) Program population-based study

Symptom Experience, Management, and Outcomes According to Race and Social Determinants Including Genomics, Epigenomics, and Metabolomics (SEMOARS + GEM): an Explanatory Model for Breast Cancer Treatment Disparity

Even after controlling for stage, comorbidity, age, and insurance status, black women with breast cancer (BC) in the USA have the lowest 5-year survival as compared with all other races for stage-matched disease. One potential cause of this survival difference is the disparity in cancer treatment, evident in many population clinical trials. Specifically, during BC chemotherapy, black women receive less relative dose intensity with more dose reductions and early chemotherapy cessation compared with white women. Symptom incidence, cancer-related distress, and ineffective communication, including the disparity in patient-centeredness of care surrounding patient symptom reporting and clinician assessment, are important factors contributing to racial disparity in dose reduction and early therapy termination. We present an evidence-based overview and an explanatory model for racial disparity in the symptom experience during BC chemotherapy that may lead to a reduction in dose intensity and a subsequent disparity in outcomes. This explanatory model, the Symptom Experience, Management, Outcomes and Adherence according to Race and Social determinants + Genomics Epigenomics and Metabolomics (SEMOARS + GEM), considers essential factors such as social determinants of health, clinician communication, symptoms and symptom management, genomics, epigenomics, and pharmacologic metabolism as contributory factors.

Perceptions of Cancer Causes, Prevention, and Treatment Among Navajo Cancer Survivors

Native Americans experience cancer-related health disparities. Yet, little is known about the current cancer experience in one of the largest Native American tribe, Navajo. A qualitative study of among Navajo cancer survivors, in which focus groups and individual interviews included questions related to perceptions of cancer causes, prevention, and treatment, allowed us to evaluate several aspects of the cancer experience from the Navajo perspective. An experienced, bilingual facilitator led the discussions using a standardized guide. Discussions were audio-recorded, documented by field notes, translated, as needed, and transcribed. NVivo software was used to summarize major themes according to the PEN-3 and health belief models. Navajo cancer survivors (N = 32) were both males (n = 13) and females (n = 19) that had been previously diagnosed with a variety of cancers: colorectal, breast, ovarian, cervical, esophageal, gall bladder, stomach, prostate, kidney, and hematologic. Many survivors had accurate knowledge of risk factors for cancer. Barriers to screening and clinical care included language, expense, geography, fear, lack of information, skepticism related to Western medicine, and treatment side effects. While some survivors experienced familial support, others were isolated from the family and community due to the perspective of cancer as a contagion. However, resilience, hope, trust in select community organizations, a desire to restore balance, and to support younger generations were positive attributes expressed regarding the treatment and recovery process. These evaluations need to be replicated across a larger cross-section of the Native cancer survivor community.

Connecting Social, Clinical, and Home Care Services for Persons with Serious Illness in the Community

The medical, psychological, cognitive, and social needs of older adults with serious illness are best met by coordinated and team-based services and support. These services are best provided in a seamless care model anchored by integrated biopsychosocial assessments focused on what matters to older adults and their social determinants of health; individualized care plans with shared goals; care provision and management; and quality measurement with continuous improvement. This model requires (1) racially and ethnically diverse healthcare professionals, including mental health and direct service workers, with training in aging and team collaboration; (2) an integrated network of community-based organizations (CBOs) providing in-home services; (3) an electronic communication platform that spans the system of providers and organizations with skilled technology staff; and (4) payment models that incentivize team-based care across the continuum of services, including CBOs, with adequate salaries and academic loan forgiveness to recruit and retain high-quality team members. Assuring that this model is effective requires ongoing quality assurance measures that include not only quality of care and utilization data to demonstrate cost offsets of service integration, but also quality of life for both the older adults and the family members caring for them. Although this may seem a lofty ideal in comparison with our current fragmented system, we review models that provide the key elements effectively and cost efficiently. We then propose an Essential Care Model that defines best practice in meeting the needs of older adults with serious illness and their families. J Am Geriatr Soc 67:S412-S418, 2019.

Family history of prostate cancer and the incidence of ERG- and phosphatase and tensin homolog-defined prostate cancer

Family history is among the strongest known risk factors for prostate cancer (PCa). Emerging data suggest molecular subtypes of PCa, including two somatic genetic aberrations: fusions of androgen-regulated promoters with ERG and, separately, phosphatase and tensin homolog (PTEN) loss. We examined associations between family history and incidence of these subtypes in 44,126 men from the prospective Health Professionals Follow-up Study. ERG and PTEN status were assessed by immunohistochemistry. Multivariable competing risks models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for associations between self-reported family history of PCa and molecular subtypes of disease. Thirteen percent of men had a positive family history of PCa at baseline. During a median follow-up of 18.5 years, 5,511 PCa cases were diagnosed. Among them, 888 were assayed for ERG status (47% ERG-positive) and 715 were assayed for PTEN loss (14% PTEN null). Family history was more strongly associated with risk of ERG-negative (HR: 2.15; 95% CI: 1.71-2.70) than ERG-positive (HR: 1.49; 95% CI: 1.13-1.95) disease (p_{heterogeneity} : 0.04). The strongest difference was among men with an affected father (HR_ERG-negative : 2.09; 95% CI: 1.64-2.66; HR_ERG-positive : 1.30; 95% CI: 0.96-1.76; p_{heterogeneity} : 0.01). Family history of PCa was positively associated with both PTEN null (HR: 2.10; 95% CI: 1.26-3.49) and PTEN intact (HR: 1.72; 95% CI: 1.39-2.13) PCa (p_{heterogeneity} : 0.47). Our results indicate that PCa family history may be positively associated with PCa in all ERG and PTEN subtypes, suggesting a role of genetic susceptibility in their development. It is possible that ERG-negative disease could be especially associated with positive family history.

Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer Is Associated with Indigenous American Ancestry in Latin American Women

Women of Latin American origin in the United States are more likely to be diagnosed with advanced breast cancer and have a higher risk of mortality than non-Hispanic White women. Studies in U.S. Latinas and Latin American women have reported a high incidence of HER2 positive (+) tumors; however, the factors contributing to this observation are unknown. Genome-wide genotype data for 1,312 patients from the Peruvian Genetics and Genomics of Breast Cancer Study (PEGEN-BC) were used to estimate genetic ancestry. We tested the association between HER2 status and genetic ancestry using logistic and multinomial logistic regression models. Findings were replicated in 616 samples from Mexico and Colombia. Average Indigenous American (IA) ancestry differed by subtype. In multivariate models, the odds of having an HER2+ tumor increased by a factor of 1.20 with every 10% increase in IA ancestry proportion (95% CI, 1.07-1.35; P = 0.001). The association between HER2 status and IA ancestry was independently replicated in samples from Mexico and Colombia. Results suggest that the high prevalence of HER2+ tumors in Latinas could be due in part to the presence of population-specific genetic variant(s) affecting HER2 expression in breast cancer. SIGNIFICANCE: The positive association between Indigenous American genetic ancestry and HER2+ breast cancer suggests that the high incidence of HER2+ subtypes in Latinas might be due to population and subtype-specific genetic risk variants.

Racial/ethnic disparities in colorectal cancer treatment utilization and phase-specific costs, 2000-2014

BACKGROUND

Our study analyzed disparities in utilization and phase-specific costs of care among older colorectal cancer patients in the United States. We also estimated the phase-specific costs by cancer type, stage at diagnosis, and treatment modality.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify patients aged 66 or older diagnosed with colon or rectal cancer between 2000-2013, with follow-up to death or December 31, 2014. We divided the patient's experience into separate phases of care: staging or surgery, initial, continuing, and terminal. We calculated total, cancer-attributable, and patient-liability costs. We fit logistic regression models to determine predictors of treatment receipt and fit linear regression models to determine relative costs. All costs are reported in 2019 US dollars.

RESULTS

Our cohort included 90,023 colon cancer patients and 25,581 rectal cancer patients. After controlling for patient and clinical characteristics, Non-Hispanic Blacks were less likely to receive treatment but were more likely to have higher cancer-attributable costs within different phases of care. Overall, in both the colon and rectal cancer cohorts, mean monthly cost estimates were highest in the terminal phase, next highest in the staging phase, decreased in the initial phase, and were lowest in the continuing phase.

CONCLUSIONS

Racial/ethnic disparities in treatment utilization and costs persist among colorectal cancer patients. Additionally, colorectal cancer costs are substantial and vary widely among stages and treatment modalities. This study provides information regarding cost and treatment disparities that can be used to guide clinical interventions and future resource allocation to reduce colorectal cancer burden.

Greater Survival Improvement in African American vs. Caucasian Women with Hormone Negative Breast Cancer

Background: African American women have not benefited equally from recently improved breast cancer survival. We investigated if this was true for all subsets.

Methods: We identified 395,170 patients with breast adenocarcinoma from the SEER database from 1990 to 2011 with designated race, age, stage, grade, ER and PR status, marital status and laterality, as control. We grouped patients into two time periods, 1990-2000 and 2001-2011, three age categories, under 40, 40-69 and ≥ 70 years and two stage categories, I-III and IV. We used the Kaplan-Meier and logrank tests to compare survival curves. We stratified data by patient- and tumor-associated variables to determine co-variation among confounding factors using the Pearson Chi-square test and Cox proportional hazards regression to determine hazard ratios (HR) to compare survival.

Results: Stage I-III patients of both races ≥ 70 years old, African American widowed patients and Caucasians with ER- and PR- tumors had worse improvements in survival in 2001-2011 than younger, married or hormone receptor positive patients, respectively. In contrast, African Americans with ER- (Cox HR 0.70 [95% CI 0.65-0.76]) and PR- (Cox HR 0.67 [95% CI 0.62-0.72]) had greater improvement in survival in 2001-2011 than Caucasians with ER- (Cox HR 0.81 [95% CI 0.78-0.84]) and PR- disease (Cox HR 0.75 [95% CI 0.73-0.78]). This was not associated with changes in distribution of tumor or patient attributes.

Conclusions: African American women with stage I-III ER- and PR- breast cancer had greater improvement in survival than Caucasians in 2001-2011. This is the first report of an improvement in racial disparities in survival from breast cancer in a subset of patients.

Disparity in Tumor Immune Microenvironment of Breast Cancer and Prognostic Impact: Asian Versus Western Populations

BACKGROUND

The clinicopathological features and prognosis of breast cancer in Asia are different from those in the Western countries. Tumor-infiltrating immune cells can influence the outcome of patients with breast cancer, but they have not been systemically evaluated in Asian patients with breast cancer.

METHODS

We compared the immune score, composition, and prognostic impact of infiltrating immune cells between Asian and Western patients with breast cancer by analyzing gene expression profiles from eight Gene Expression Omnibus data sets and The Cancer Genome Atlas data set. The Estimation of Stromal and Immune Cells in Malignant Tumours Using Expression Data (ESTIMATE) and Cell Type Identification by Estimating Relative Subsets of Known RNA Transcripts (CIBERSORT) algorithms were used to determine the immune score and composition of tumor-infiltrating immune cells, respectively.

FINDINGS

This study included 462 Asian patients and 2,186 Western patients. Tumors of Asian patients had significantly higher immune score, particularly in the luminal B and HER2-enriched subtypes. High immune score was associated with favorable prognosis in both Asian and Western patients, and Asian race with a high ESTIMATE immune score provided additional power to predict longer disease-free survival. Activated CD4 T cells and M2 macrophages were the most strongly associated with survival in both Asian and Western patients.

INTERPRETATION

Our study highlights the difference in tumor immune microenvironments between Asian and Western patients. The higher ESTIMATE immune score, which represents more abundant tumor-infiltrating immune cells, in tumors of Asian patients partly explains their favorable prognosis.

IMPLICATIONS FOR PRACTICE

The tumor microenvironment serves as an interface that affects the human body's reaction to cancer cells. Evidence has revealed that tumor-infiltrating immune cells were associated with patient prognosis. This study demonstrated the disparity of tumor microenvironments and their prognostic impact between Asian and Western patients with breast cancer. The differences in immune score partially explained the racial survival differences noted in recent studies. Integrated analysis of tumor cells, tumor microenvironment, and racial effect may significantly improve recurrence risk prediction for patients with stage I-III breast cancer. Because the effect of tumor microenvironment varies across different populations, a model of interaction between immune score and race/ethnicity is recommended in accessing the risk of patients with cancer.

Vitamin D intake, blood vitamin D levels, and the risk of breast cancer: a dose-response meta-analysis of observational studies

Epidemiological studies have indicated that blood vitamin D levels are linked to cancer. Here we conducted a dose-response meta-analysis based on published observational studies to evaluate the association of vitamin D intake and blood vitamin D levels with breast cancer susceptibility. PubMed, EMBASE, and Web of Science databases were searched up to January 2019. The pooled odds ratio (OR) and 95% confidence intervals (CIs) were extracted to estimate the risk. We identified 70 relevant studies on blood vitamin D levels (50 studies) and vitamin D intake (20 studies), respectively. Linear and nonlinear trend analyses were performed and showed that an increase in blood vitamin D levels by 5 nmol/l was associated with a 6% decrease in breast cancer risk (OR = 0.94, 95% CI = 0.93-0.96). Similar results were obtained for premenopausal (OR = 0.96, 95% CI = 0.93-0.99) and postmenopausal women (OR = 0.96, 95% CI = 0.94-0.98). The pooled OR of breast cancer risk for a 400IU/day increase in vitamin D intake was 0.97 (95% CI = 0.92-1.02). In conclusion, we found that breast cancer risk was inversely related to blood vitamin D levels; however, no significant association was observed in vitamin D intake.

Relationship Distress as a Mediator of Adverse Childhood Experiences and Health: Implications for Clinical Practice with Economically Vulnerable Racial and Ethnic Minorities

Adverse childhood experiences (ACE) are interpersonal sources of distress negatively correlated with physical and mental health, as well as maladaptive intimate partner conflict strategies in adulthood. Economically vulnerable racial and ethnic minorities report the greatest disparities in exposure to ACE, as well as relationship distress and health. Yet, little is known about the connections between ACE, relationship distress, and health. We therefore tested a theoretical model for the mediating role of relationship distress to explain the ACE-health connection with a sample (N = 96) predominantly racial/ethnic minorities (87%) with low income. We applied partial least squares structural equation modeling with bootstrapping (N = 500). Relationship distress strengthened the predictive relationship between ACE and health, and accounted for 42% of the variance in health. The results provide preliminary support for relationship distress as a social determinant of health disparities with implications for interdisciplinary health intervention.

Prostate cancer characteristics and cancer-specific mortality of Native American patients

BACKGROUND

Historical epidemiological data indicate that Native American patients may have worse prostate cancer (PCa) characteristics than Caucasian patients (CAP). To test for cancer-specific mortality (CSM) differences among Native American vs. CAP, the most contemporary version of the SEER database (Surveillance, Epidemiology, and End Results database [2004-2016]) was used.

METHODS

Descriptives and time trend analyses focused on a combined cohort of 357,289 Caucasian and Native American PCa patients of all stages. After 1:4 propensity-score (PS) matching for stage, grade, and other patient characteristics, cumulative incidence plots, and competing-risks-regression-models (CRR) were used, with further stratification according to non-metastatic (T_anyN₀M₀) vs. metastatic (T_anyN₁ and/or M₁) stages.

RESULTS

Native American patients accounted for 1804 (0.5%) of the study cohort. Native American patients had higher PSA (8 ng/ml vs. 6.3 ng/ml), higher rate of D'Amico high-risk PCa (30.8 vs. 24.8%), higher rate of T3/T4-PCa (5.5 vs. 3.7%), higher rate of N1 stage (4.5 vs. 2.8%), and higher rate of M1 stage (7.5 vs. 3.9%, all p < 0.001) than CAP. In T_anyN₀M₀ patients after PS-matching, 10-year CSM was 5.7 vs. 6.2% in Native American vs. CAP. In T_anyN₁ and/or M₁ patients, 10-year CSM was 64.3 vs. 63.3% in Native American vs. CAP, (both p = 0.8). In CRR, Native American race did not represent an independent predictor of CSM.

CONCLUSIONS

Native American patients have more unfavorable stage and grade at presentation. However, after adjustment for these characteristics, CSM in Native American patients is not higher than in CAP. In consequence, PCa prognosis does not differ between Native American and Caucasian race. Therefore, efforts should be made to diagnose PCa in Native Americans at an earlier and more favorable stage like in CAP.

Socioeconomic Factors Associated with Lack of Treatment in Early Stage Non-Small Cell Lung Cancer

With modern radiotherapy, stage I non-small cell lung cancer (S1NSCLC) cure is extended to nonsurgical candidates. Despite this, some S1NSCLC remains untreated. We aim to identify factors associated with no treatment. 62,213 S1NSCLC cases were identified (SEER: 2004-2012). Demographics were compared using Chi-squared. Multivariate analysis was performed using COX proportional HR. 11.9% of the 7373 patients lacked treatment. No insurance, Medicaid-dependence, unmarried status, advancing age, lower income, African American and Asian/Pacific Islander race, and male sex are associated with no treatment (p < .0001). No treatment portends a worse cancer-specific survival (21% vs 66% at 5Y, p < .0001) and OS (10% vs 50% at 5Y, p < .0001).

Low colorectal cancer survival in the Mountain West state of Nevada: A population-based analysis

Colorectal cancer (CRC) is the third greatest cancer burden in the United States. The remarkably diverse Mountain West state of Nevada has uncharacteristically high CRC mortality compared to other Western states. We aimed to study the determinants of the CRC excess burden by using data from the Nevada Central Cancer Registry from 2003-2013. Five-year cause-specific age-adjusted survival from colorectal cancer was calculated and stratified by sex, race/ethnicity and region of Nevada. Cox Proportional Hazards regression modelling was used to study the impact of demographic, social, and clinical factors on CRC survival in Nevada, assessing follow-up as accurately as possible. The extent to which differences in survival can be explained by receipt of stage-appropriate treatment was also assessed. 12,413 CRC cases from 2003-2013 in Nevada were analyzed. Five-year CRC survival was low: 56.0% (95% CI: 54.6-57.5) among males and 59.5% (95% CI: 58.0-61.1) among females; significantly lower than national 5-year survival of 65.1% and 66.5%, respectively. Low survival was driven by populous Southern Nevada; after adjustment for all covariates, Southern Nevadans were at 17% higher risk of death than their counterparts in Northwestern Nevada (HR:1.17; 95% CI:1.08-1.27). Many patients did not receive stage-appropriate treatment, although this only partly explained the poor survival, uniformly low for every race/ethnicity in Nevada. The observed disparity for this one state within a single nation merits public health attention; regardless of the state or region of residence, all Americans deserve equal opportunity for optimum health outcomes in the face of a cancer diagnosis. The current study provides baseline information critical to clinicians, public health professionals, and all relevant stakeholders as they attempt to discern why Nevada's outcomes are vastly divergent from its neighboring Western states and make plans for remediation.

A retrospective evaluation of the impact of patient ethnicity on the use of epidural analgesia or blood transfusions in children undergoing major oncologic surgery

Background

The impact of patient ethnicity on healthcare delivery is well documented. In this study of children who had undergone open abdominal or pelvic surgery for tumor resection, we sought to compare the use of epidural analgesia or intraoperative blood transfusions between Caucasian and non-Caucasian children.

Methods

A retrospective study of 139 children was performed. Logistic regression models were used to evaluate the association between the specified perioperative factors and patient ethnicity.

Results

The average age (standard deviation) was 11 years (± 5), 50% were female, and 58% were Caucasian. Compared to Caucasian children, non-Caucasian children were younger (difference in mean, − 2.6 years; 95% confidence interval [− 4.3, − 0.9], p = 0.003), underwent shorter procedures (difference in mean anesthesia minutes, − 134; 95% confidence interval [−  230, − 39], p = 0.006), and had a lower proportion of patients who received epidural analgesia (66% versus 81%, p = 0.042) or blood transfusions (48% versus 65%, p = 0.039). In the adjusted model, patient ethnicity was not associated with the receipt of epidural analgesia (odds ratio 0.53, 95% confidence interval [0.23, 1.21], p = 0.132) or blood transfusions (odds ratio 0.77, 95% confidence interval [0.29, 2.04], p = 0.600). The use of epidural analgesia or blood transfusions was associated with abnormal coagulation factors (odds ratio 0.32, 95% confidence interval [0.14, 0.71], p = 0.005) and the duration of surgery (odds ratio 1.007, 95% confidence interval [1.005, 1.009], p < 0.001), respectively.

Conclusion

In this study of children who had undergone major oncologic surgery, the use of epidural analgesia or blood transfusions was not associated with patient ethnicity.

Weaning outcome of solid cancer patients requiring mechanical ventilation in the intensive care unit

BACKGROUND

Whether the weaning outcome of solid cancer patients receiving mechanical ventilation (MV) in the intensive care unit (ICU) is comparable to that in non-cancer patients is unknown. The aim of this study was to compare the weaning outcomes between non-cancer patients and patients with different types of cancer.

METHODS

We studied patients requiring MV during ICU stay for medical reasons between 2012 and 2014. Cancer patients were grouped into those with lung cancer (LC), head and neck cancer (HNC), hepatocellular carcinoma (HCC), and other cancers (OC). The primary endpoint was successful weaning at day 90 after the initiation of MV, and the main secondary endpoints were 28-day and 90-day mortality after ICU admission.

RESULTS

Five hundred and eighteen patients with solid cancers and 1362 non-cancer patients were recruited. The rate of successful weaning at day 90 was 57.9% in cancer patients, which was lower than 68.9% in non-cancer patients (p < 0.001). Compared to non-cancer patients, LC was associated with a lower probability of weaning at day 90 (hazard ratio 0.565, 95% CI 0.446 to 0.715), while HNC, HCC, and OC had similar probabilities. The 28-day and 90-day mortality rates were higher in cancer patients than in non-cancer patients (45.2% vs. 29.4%, and 65.6% vs. 37.7%, respectively, both p < 0.001).

CONCLUSION

Among mechanically ventilated patients in the ICU, those with LC were associated with a lower probability of weaning at day 90 compared to non-cancer patients.

Blood and dietary magnesium levels are not linked with lower prostate cancer risk in black or white men

Recent studies suggest a diet low in dietary magnesium intake or lower blood magnesium levels is linked with increased prostate cancer risk. This study investigates the race-specific link between blood magnesium and calcium levels, or dietary magnesium intake, and the diagnosis of low-grade and high-grade prostate cancer. The study included 637 prostate cancer cases and 715 biopsy-negative controls (50% black) recruited from Nashville, TN or Durham, NC. Blood was collected at the time of recruitment, and dietary intake was assessed by food frequency questionnaire. Percent genetic African ancestry was determined as a compliment to self-reported race. Blood magnesium levels and dietary magnesium intake were significantly lower in black compared to white men. However, magnesium levels or intake were not associated with risk of total prostate cancer or aggressive prostate cancer. Indeed, a higher calcium-to-magnesium diet intake was significantly protective for high-grade prostate cancer in black (OR = 0.66 (0.45, 0.96), p = 0.03) but not white (OR = 1.00 (0.79, 1.26), p = 0.99) men. In summary, there was a statistically significant difference in magnesium intake between black and white men, but the biological impact was unclear, and we did not confirm a lower prostate cancer risk associated with magnesium levels.

Combined Effects of Race and Socioeconomic Status on Cancer Beliefs, Cognitions, and Emotions

AIM

To determine whether socioeconomic status (SES; educational attainment and income) explains the racial gap in cancer beliefs, cognitions, and emotions in a national sample of American adults.

METHODS

For this cross-sectional study, data came from the Health Information National Trends Survey (HINTS) 2017, which included a nationally representative sample of American adults. The study enrolled 2277 adults who were either non-Hispanic Black (n = 409) or non-Hispanic White (n = 1868). Race, demographic factors (age and gender), SES (i.e., educational attainment and income), health access (insurance status, usual source of care), family history of cancer, fatalistic cancer beliefs, perceived risk of cancer, and cancer worries were measured. We ran structural equation models (SEMs) for data analysis.

RESULTS

Race and SES were associated with perceived risk of cancer, cancer worries, and fatalistic cancer beliefs, suggesting that non-Hispanic Blacks, low educational attainment and low income were associated with higher fatalistic cancer beliefs, lower perceived risk of cancer, and less cancer worries. Educational attainment and income only partially mediated the effects of race on cancer beliefs, emotions, and cognitions. Race was directly associated with fatalistic cancer beliefs, perceived risk of cancer, and cancer worries, net of SES.

CONCLUSIONS

Racial gap in SES is not the only reason behind racial gap in cancer beliefs, cognitions, and emotions. Racial gap in cancer related beliefs, emotions, and cognitions is the result of race and SES rather than race or SES. Elimination of racial gap in socioeconomic status will not be enough for elimination of racial disparities in cancer beliefs, cognitions, and emotions in the United States.

Development of a culturally relevant physical activity intervention for Navajo cancer survivors

Despite well-documented benefits of physical activity for cancer survivors, few interventions have been developed for Native American cancer survivors, the population with the poorest survival rates of any group. This paper describes the development and cultural adaptation of a physical activity intervention for Navajo cancer survivors using Intervention Mapping (IM). IM procedures were guided by the PEN-3 (Perceptions-Enablers-Nurturers) and Health Belief Models and informed by a qualitative study with 40 Navajo cancer survivors and family members. For each theoretical construct (perceived benefits, barriers, enablers of healthy behaviors, etc.), a measurable objective was identified. These objectives were then matched with intervention strategies. The IM process indicated the need for a highly culturally sensitive environment (site and providers), culturally acceptable measurements and materials, and integrating cultural and environmental activity preferences. Program objectives aligned directly with these areas. Intervention strategies included: (a) collaboration with providers sensitive to historical/cultural context and environmental barriers; (b) cultural adaptation of surveys, non-invasive physical measurements, no biospecimen storage; (c) materials, terminology and symbols embracing cultural values of return to harmony; (d) physical activities that are flexible and aligned with cultural preferences and environment/travel issues (e.g., outdoor walking; community and home-based options; portable, inexpensive resistance equipment; local resources; family/friends participation and more community cancer education); (e) clinical adaptations by site and symptoms. This study is the first to document the process of adaptation of a physical activity program for Navajo cancer survivors. Objectives and strategies incorporated via IM are expected to foster sustainability and enhance uptake, satisfaction, and adherence.

Rural/urban residence and childhood and adolescent cancer survival in the United States

BACKGROUND

To the authors' knowledge, no previous study has examined the relationship between rural/urban residence and childhood or adolescent cancer survival in the United States. Using the Surveillance, Epidemiology, and End Results 18 registries database, the authors examined childhood and adolescent cancer survival by rural/urban residence as defined by Rural-Urban Continuum Codes (RUCCs).

METHODS

The authors obtained data from Surveillance, Epidemiology, and End Results 18 registries for individuals diagnosed at ages birth to 19 years with a first primary malignant cancer from 2000 through 2010. Rural/urban residence at the time of diagnosis was defined using both metropolitan/nonmetropolitan county classifications and individual RUCC categories. Cox proportional hazards regression was used to compute adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between rural/urban residence and cancer survival. The authors also examined effect modification by age group, sex, race/ethnicity, and cancer type.

RESULTS

Among 41,879 cancer cases, approximately 54.7% were non-Hispanic white, 54.3% were male, and 90.4% lived in a metropolitan county. Individuals living in nonmetropolitan counties versus metropolitan counties had a similar risk of cancer death (HR,  1.03; 95% CI, 0.94-1.13) as did those living in nonmetropolitan rural counties with <2500 individuals nonadjacent to a metropolitan area versus those living in metropolitan counties of ≥1 million individuals (HR,  0.98; 95% CI, 0.71-1.37). Evidence for effect modification largely was absent.

CONCLUSIONS

The results of the current study suggest that childhood and adolescent cancer survival in the United States does not vary by rural/urban residence at the time of diagnosis as defined by RUCCs. The widespread availability of public health insurance for children and adolescents and a nationwide network of pediatric cancer providers may explain this finding.

Impact of sex, body mass index and initial pathologic diagnosis age on the incidence and prognosis of different types of cancer

Cancer represents a significant challenge for humankind, as early diagnosis and treatment are difficult to achieve. To systemically investigate the effect of sex, body mass index (BMI) and age on cancer incidence and prognosis, the data from 14,504 cases of cancer were downloaded from The Cancer Genome Atlas (TCGA). BMI was used to categorize each person as underweight, normal weight, overweight or obese. Two‑ and five‑year survival rates were applied to estimate the prognosis for each cancer type. All data were statistically analyzed. We identified that males were more susceptible to lung, liver and skin cancer when compared with females, whereas females were more susceptible to thyroid, breast and adrenal cortex cancer. High BMI (>25) was positively associated with the occurrence of cancer, although patients with high BMI at the time of initial diagnosis had higher two/five‑year survival rates. The survival rates for cancer were positively correlated with the age at initial pathologic diagnosis. Some types of cancer were associated with particularly young ages of onset, including adrenocortical carcinoma, cervical and endocervical cancers, brain lower grade glioma, pheochromocytoma and paraganglioma, testicular germ cell tumors and thyroid carcinoma. Hence, the early diagnosis and prognosis for these cancers need to be improved. In conclusion, sex, BMI and age are associated with the incidence and survival rates for cancers. These results could be used to supplement precision and personalized medicine.

Establishment of three novel cell lines derived from African American patients with colorectal carcinoma: A unique tool for assessing racial health disparity

The incidence and mortality rates of colorectal carcinoma (CRC) are higher among African Americans (AAs) compared with Caucasian Americans (CAs). To assess the molecular properties associated with racial health disparity, three cell lines derived from colorectal tumors of three AA subjects were established. Cellular and molecular characterization of the cell lines designated CHTN06, SB501 and SB521 was performed using standard technologies, including immunofluorescence, electron microscopy, karyotyping, reverse transcription-polymerase chain reaction, ELISA and immunoblot analysis. The histology and morphology of CHTN06 xenografts were examined by hematoxylin and eosin staining. A total of three AA CRC cell lines derived from primary tumors were established and characterized. These cell lines were successfully cultured without immortalization and were found to be tumorigenic as mouse xenografts. In the present study, immunoblotting and immunofluorescence confirmed the expression of proteins known to be dysregulated in CRC, such as p53, DNA mismatch repair proteins and villin-1. Oncogenic miRNAs (i.e., miR-17, miR-21, miR-182, miR-210 and miR-222) were overexpressed in the AA CRC lines compared with the CA CRC lines (HT-29, HCT116 and SW480). Additionally, the AA CRC cell lines exhibited a differential inflammatory profile compared with HT-29 (CA CRC cell line); specifically noted was IL-8 secretion in response to inflammatory stimuli. In conclusion, three novel cell lines derived from AA CRC tissues were generated. These cell lines were characterized as epithelial in nature and exhibited differential expression of several miRNAs and inflammatory responses compared with commercially available cell lines of CA origin. The CRC cell lines CHTN06, SB501 and SB521 represent novel tools that may be used to provide diverse in vitro and in vivo models for studying CRC and racial health disparity.

Lung Adenocarcinoma Survival in EGFR-Mutated African-Caribbean Patients: A Multicenter Study in the French West Indies

BACKGROUND

Lung cancer is the leading cause of cancer-related death worldwide. Shorter survival has been repeatedly reported for patients of African ancestry. Multivariate analysis demonstrated that this gap could be a consequence of socio-economic disparities instead of genetic specificities. However, those results were obtained in a pre-targeted therapies era and the effect of tyrosine kinase inhibitors targeting EGFR are not known in this population.

OBJECTIVE

In this French West Indies study, we report overall survival (OS) in a frequently mutated population treated for lung adenocarcinoma within an equal-access healthcare system.

PATIENTS AND METHODS

Clinical, demographic, survival, and treatment data have been retrospectively assessed for all patients diagnosed with lung adenocarcinoma in the islands of Martinique and Guadeloupe between 2013 and 2015.

RESULTS

Two hundred and forty-one patients (82% African-Caribbean) were included. EGFR mutations were detected in 37% of all tumor specimens and were associated with non-smoker status in multivariate analysis. Median OS was 16.2 months. For patients with advanced disease, median OS was 11.5 months, depending on EGFR mutation (23 vs. 8.3 months for non-mutated patients, p = 0.0012). There was no difference in survival according to ethnicity or island. In multivariate analysis, performance status (PS) and EGFR mutation were the only independent prognostic factors.

CONCLUSIONS

Despite a higher frequency of EGFR mutations in African-Caribbean patients, ethnicity was not an independent factor of OS in lung adenocarcinoma. Lower initial PS in this mainly non-smoking African-Caribbean population may explain the absence of a difference in OS.

Real-world cost-effectiveness of cetuximab in the third-line treatment of metastatic colorectal cancer based on patient chart review in the Netherlands

OBJECTIVE

To assess the cost effectiveness of cetuximab in third-line treatment of patients with KRAS wild-type (wt) metastatic colorectal cancer (mCRC) in routine clinical practice compared with best supportive care (BSC).

METHODS

Patients (n = 287) with KRAS wt mCRC treated with cetuximab or BSC in eight hospitals in the Netherlands between 2009 and 2012 were included in our real-world study. Outcome measures were costs per life-year (LY) and costs per quality-adjusted LY (QALY) gained. A Markov model was developed, and a time horizon of four years was applied. Outcomes were calculated from Kaplan-Meier survival curves from patient-level data and literature. Direct medical costs were estimated in all centers (2013 values), and incremental cost-effectiveness ratios (ICERs) were calculated. Results were discounted, and a probabilistic sensitivity analysis was performed.

RESULTS

Administration of cetuximab in third-line treatment of mCRC resulted in a gain of 0.29 LYs and 0.25 QALYs compared with BSC. In the four-year study period, average discounted healthcare costs were €36,637 in the cetuximab group vs. €3648 in the BSC group. The discounted ICERs of cetuximab vs. BSC in the real-world setting were €114,907and €133,527 per LY and QALY gained, respectively.

CONCLUSIONS

Results of this cost-effectiveness analysis showed that third-line treatment with cetuximab for patients with KRAS (exon 2) wt mCRC offered clinical benefits at additional cost. The real-world ICERs were in line with those of previously published cetuximab and panitumumab cost-utility models.

Gallbladder cancer: review of a rare orphan gastrointestinal cancer with a focus on populations of New Mexico

Gallbladder cancer is a rare malignancy of the biliary tract with a poor prognosis, frequently presenting at an advanced stage. While rare in the United States overall, gallbladder cancer has an elevated incidence in geographically distinct locations of the globe including Chile, North India, Korea, Japan and the state of New Mexico in the United States. People with Native American ancestry have a much elevated incidence of gallbladder cancer compared to Hispanic and non-Hispanic white populations of New Mexico. Gallbladder cancer is also one of the few bi-gendered cancers with an elevated female incidence compared to men. Similar to other gastrointestinal cancers, gallbladder cancer etiology is likely multi-factorial involving a combination of genomic, immunological, and environmental factors. Understanding the interplay of these unique epidemiological factors is crucial in improving the prevention, early detection, and treatment of this lethal disease. Previous studies have failed to identify a distinct genomic mutational profile in gallbladder cancers, however, work to identify promising clinically actionable targets is this form of cancer is ongoing. Examples include, interest in the HER2/Neu signaling pathway and the recognition that chronic inflammation plays a crucial role in gallbladder cancer pathogenesis. In this review, we provide a comprehensive overview of gallbladder cancer epidemiology, risk factors, pathogenesis, and treatment with a specific focus on the rural and Native American populations of New Mexico. We conclude this review by discussing future research directions with the goal of improving clinical outcomes for patients of this lethal malignancy.

Cancer survival among Alaska Native people

BACKGROUND

Recent cancer survival trends among American Indian and Alaska Native (AN) people are not well understood; survival has not been reported among AN people since 2001.

METHODS

This study examined cause-specific survival among AN cancer patients for lung, colorectal, female breast, prostate, and kidney cancers. It evaluated whether survival differed between cancers diagnosed in 1992-2002 (the earlier period) and cancers diagnosed in 2003-2013 (the later period) and by the age at diagnosis (<65 vs ≥65 years), stage at diagnosis (local or regional/distant/unknown), and sex. Kaplan-Meier and Cox proportional hazards models were used to estimate univariate and multivariate-adjusted cause-specific survival for each cancer.

RESULTS

An improvement was observed in 5-year survival over time from lung cancer (hazard ratio [HR] for the later period vs the earlier period, 0.83; 95% confidence interval [CI], 0.72-0.97), and a marginally nonsignificant improvement was observed for colorectal cancer (HR, 0.81; 95% CI, 0.66-1.01). Site-specific differences in survival were observed by age and stage at diagnosis.

CONCLUSIONS

This study presents the first data on cancer survival among AN people in almost 2 decades. During this time, AN people have experienced improvements in survival from lung and colorectal cancers. The reasons for these improvements may include increased access to care (including screening) as well as improvements in treatment. Improving cancer survival should be a priority for reducing the burden of cancer among AN people and eliminating cancer disparities. Cancer 2018;124:2570-7. © 2018 American Cancer Society.

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

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

Impact of individual and neighborhood factors on disparities in prostate cancer survival

BACKGROUND

We addressed the hypothesis that individual-level factors act jointly with social and built environment factors to influence overall survival for men with prostate cancer and contribute to racial/ethnic and socioeconomic (SES) survival disparities.

METHODS

We analyzed multi-level data, combining (1) individual-level data from the California Collaborative Prostate Cancer Study, a population-based study of non-Hispanic White (NHW), Hispanic, and African American prostate cancer cases (N = 1800) diagnosed from 1997 to 2003, with (2) data on neighborhood SES (nSES) and social and built environment factors from the California Neighborhoods Data System, and (3) data on tumor characteristics, treatment and follow-up through 2009 from the California Cancer Registry. Multivariable, stage-stratified Cox proportional hazards regression models with cluster adjustments were used to assess education and nSES main and joint effects on overall survival, before and after adjustment for social and built environment factors.

RESULTS

African American men had worse survival than NHW men, which was attenuated by nSES. Increased risk of death was associated with residence in lower SES neighborhoods (quintile 1 (lowest nSES) vs. 5: HR = 1.56, 95% CI: 1.11-2.19) and lower education (

CONCLUSION

Both individual- and contextual-level SES influence overall survival of men with prostate cancer. Additional research is needed to identify the mechanisms underlying these robust associations.

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Key Words

• Built environment
• Disparities
• Education
• Neighborhood socioeconomic status
• Prostate cancer
• Race/ethnicity
• Survival

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MESH Headings

• Black or African American
• Aged
• California
• Ethnicity
• Hispanic or Latino
• Humans
• Male
• Middle Aged
• Prostatic Neoplasms/epidemiology
• Racial Groups
• Registries
• Residence Characteristics
• Social Class
• Socioeconomic Factors
• White People

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Grants

• HHSN261201000035C NCI NIH HHS
• HHSN261201000035I NCI NIH HHS
• HHSN261201000034C NCI NIH HHS
• U58 DP003862 NCCDPHP CDC HHS
• HHSN261201000140C NCI NIH HHS
• R01 CA084979 NCI NIH HHS

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Affiliation(s)

Mindy C DeRouen Cancer Prevention Institute of California, Fremont, CA, USA; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
Clayton W Schupp Cancer Prevention Institute of California, Fremont, CA, USA
Jocelyn Koo Cancer Prevention Institute of California, Fremont, CA, USA
Juan Yang Cancer Prevention Institute of California, Fremont, CA, USA
Andrew Hertz Cancer Prevention Institute of California, Fremont, CA, USA
Salma Shariff-Marco Cancer Prevention Institute of California, Fremont, CA, USA; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Health Research Policy (Epidemiology), Stanford University School of Medicine, Stanford, CA, USA
Myles Cockburn Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
David O Nelson Cancer Prevention Institute of California, Fremont, CA, USA; Department of Health Research Policy (Epidemiology), Stanford University School of Medicine, Stanford, CA, USA
Sue A Ingles Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
Esther M John Cancer Prevention Institute of California, Fremont, CA, USA; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Health Research Policy (Epidemiology), Stanford University School of Medicine, Stanford, CA, USA
Scarlett L Gomez Cancer Prevention Institute of California, Fremont, CA, USA; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA.

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Cancer incidence and survival among Métis adults in Canada: results from the Canadian census follow-up cohort (1992-2009)

BACKGROUND

Métis people are 1 of 3 Aboriginal groups recognized by the Canadian constitution. We estimated site-specific incidence rates and survival for the most common cancers among Métis adults in Canada and compared these with rates among non-Aboriginal adults in Canada.

METHODS

We examined responses to the 1991 long-form census, including self-reported Métis ancestry linked to national mortality and cancer databases for followup from 1992 to 2009. We estimated age-standardized incidence rates and 5-year relative survival. We determined relative risk (RR) of cancer among Métis and non-Aboriginal adults using Poisson regression, and estimated excess mortality rate ratios using ethnicity-specific life tables.

RESULTS

For all cancers and both sexes combined, cancer incidence was similar for Métis and non-Aboriginal adults. However, incidence was significantly higher among Métis adults than among non-Aboriginal adults for the following cancers: female breast (RR 1.18, 95% confidence interval [CI] 1.02-1.37), lung (RR 1.34, 95% CI 1.18-1.52), liver (RR 2.09, 95% CI 1.30-3.38), larynx (RR 1.60, 95% CI 1.03-2.48), gallbladder (RR 2.35, 95% CI 1.12-4.96) and cervix (RR 1.84, 95% CI 1.23-2.76). Métis people had poorer survival for prostate cancer (excess mortality rate ratio 2.60, 95% CI 1.52-4.46).

INTERPRETATION

We found higher incidence for several cancers and poorer survival after prostate cancer among Métis adults. Several of these disparities may be related to lifestyle factors (including tobacco use, obesity and lack of cancer screening), providing evidence to support development of public health policy and health care to address cancer burden in the Métis people of Canada.

Literature review of data-based models for identification of factors associated with racial disparities in breast cancer mortality

In the United States, early detection methods have contributed to the reduction of overall breast cancer mortality but this pattern has not been observed uniformly across all racial groups. A vast body of research literature shows a set of health care, socio-economic, biological, physical, and behavioural factors influencing the mortality disparity. In this paper, we review the modelling frameworks, statistical tests, and databases used in understanding influential factors, and we discuss the factors documented in the modelling literature. Our findings suggest that disparities research relies on conventional modelling and statistical tools for quantitative analysis, and there exist opportunities to implement data-based modelling frameworks for (1) exploring mechanisms triggering disparities, (2) increasing the collection of behavioural data, and (3) monitoring factors associated with the mortality disparity across time.

Racial and Ethnic Disparities in Cancer Survival: The Contribution of Tumor, Sociodemographic, Institutional, and Neighborhood Characteristics

Purpose Racial/ethnic disparities in cancer survival in the United States are well documented, but the underlying causes are not well understood. We quantified the contribution of tumor, treatment, hospital, sociodemographic, and neighborhood factors to racial/ethnic survival disparities in California. Materials and Methods California Cancer Registry data were used to estimate population-based cancer-specific survival for patients diagnosed with breast, prostate, colorectal, or lung cancer between 2000 and 2013 for each racial/ethnic group (non-Hispanic black, Hispanic, Asian American and Pacific Islander, and separately each for Chinese, Japanese, and Filipino) compared with non-Hispanic whites. The percentage contribution of factors to overall racial/ethnic survival disparities was estimated from a sequence of multivariable Cox proportional hazards models. Results In baseline models, black patients had the lowest survival for all cancer sites, and Asian American and Pacific Islander patients had the highest, compared with whites. Mediation analyses suggested that stage at diagnosis had the greatest influence on overall racial/ethnic survival disparities accounting for 24% of disparities in breast cancer, 24% in prostate cancer, and 16% to 30% in colorectal cancer. Neighborhood socioeconomic status was an important factor in all cancers, but only for black and Hispanic patients. The influence of marital status on racial/ethnic disparities was stronger in men than in women. Adjustment for all covariables explained approximately half of the overall survival disparities in breast, prostate, and colorectal cancer, but it explained only 15% to 40% of disparities in lung cancer. Conclusion Overall reductions in racial/ethnic survival disparities were driven largely by reductions for black compared with white patients. Stage at diagnosis had the largest effect on racial/ethnic survival disparities, but earlier detection would not entirely eliminate them. The influences of neighborhood socioeconomic status and marital status suggest that social determinants, support mechanisms, and access to health care are important contributing factors.

Representation of Minorities and Women in Oncology Clinical Trials: Review of the Past 14 Years

Purpose:

Many cancer clinical trials lack appropriate representation of specific patient populations, limiting their generalizability. Therefore, we determined the representation of ethnic minorities and women in cancer clinical trials.

Methods:

Enrollment data from all therapeutic trials reported as completed in ClinicalTrials.gov from 2003 to 2016 were analyzed. We calculated enrollment fractions (EFs) for each group, defined as the number of enrollees divided by the 2013 Surveillance, Epidemiology, and End Results (SEER) database cancer prevalence.

Results:

Of 1,012 clinical trials, 310 (31%) reported ethnicity with a total of 55,689 enrollees. Participation varied significantly across ethnic groups. Non-Hispanic whites were more likely to be enrolled in clinical trials (EF, 1.2%) than African Americans (EF, 0.7%; P < .001) and Hispanics (EF, 0.4%; P < .001). A decrease in African American (6% v 9.2%) and Hispanic (2.6% v 3.1%) enrollment was observed when compared with historical data from 1996 to 2002. Younger patients (age younger than 65 years) were more likely to be enrolled in clinical trials than the elderly (64% v 36%; P < .001). Low recruitment of female patients was observed in clinical trials for melanoma (35%), lung cancer (39%), and pancreatic cancer (40%).

Conclusion:

We observed a decrease in recruitment of minorities over the past 14 years compared with historical data. African Americans, Hispanics, and women were less likely to be enrolled in cancer clinical trials. Future trials should take extra measures to recruit participants that adequately represent the US cancer population.

Disparities in Prostate, Lung, Breast, and Colorectal Cancer Survival and Comorbidity Status among Urban American Indians and Alaskan Natives

Cancer is the second leading cause of death among American Indians and Alaskan Natives (AIAN), although cancer survival information in this population is limited, particularly among urban AIAN. In this retrospective cohort study, we compared all-cause and prostate, breast, lung, and colorectal cancer-specific mortality among AIAN (n = 582) and non-Hispanic white (NHW; n = 82,696) enrollees of Kaiser Permanente Northern California (KPNC) diagnosed with primary invasive breast, prostate, lung, or colorectal cancer from 1997 to 2015. Tumor registry and other electronic health records provided information on sociodemographic, comorbidity, tumor, clinical, and treatment characteristics. Cox regression models were used to estimate adjusted survival curves and hazard ratios (HR) with 95% confidence intervals (CI). AIAN had a significantly higher comorbidity burden compared with NHW (P < 0.05). When adjusting for patient, disease characteristics, and Charlson comorbidity scores, all-cause mortality and cancer-specific mortality were significantly higher for AIAN than NHW patients with breast cancer (HR, 1.47; 95% CI, 1.13-1.92) or with prostate cancer (HR, 1.87; 95% CI, 1.14-3.06) but not for AIAN patients with lung and colorectal cancer. Despite approximately equal access to preventive services and cancer care in this setting, we found higher mortality for AIAN than NHW with some cancers, and a greater proportion of AIAN cancer patients with multiple comorbid conditions. This study provides severely needed information on the cancer experience of the 71% of AIANs who live in urban areas and access cancer care outside of the Indian Health Services, from which the vast majority of AIAN cancer information comes. Cancer Res; 77(23); 6770-6. ©2017 AACR.

Influence of race, insurance status, and geographic access to plastic surgeons on immediate breast reconstruction rates

BACKGROUND

This study evaluates the rates of immediate breast reconstruction (IBR) among racial and insurance status subgroups, in the setting of a changing plastic surgeon workforce.

METHODS

Using state level inpatient and ambulatory surgery data, we identified discharges for adult women who underwent mastectomy for breast cancer. This information was supplemented with plastic surgeon workforce data and aggregated to the health service area-level (HSA). Hierarchical linear models were used to risk standardized IBR rates for 8 race-payer subgroups.

RESULTS

The final cohort included 65,246 women treated across 67 HSAs. The plastic surgeon density per 100,000 population directly related to the IBR rate. While all subgroups saw a modest increase in IBR rates, Caucasian women with private insurance realized the largest absolute increase (46%) while African-American and Asian women with public insurance saw the smallest increase (6%).

CONCLUSION

Significant disparities persist in the provision of IBR according to the form of insurance a patient possesses. Of heightened concern is the novel finding that even within privately insured patients, women of color have significantly lower IBR rates compared to Caucasian women.

Contribution of clinical and socioeconomic factors to differences in breast cancer subtype and mortality between Hispanic and non-Hispanic white women

PURPOSE

To assess tumor subtype distribution and the relative contribution of clinical and sociodemographic factors on breast cancer survival between Hispanic and non-Hispanic whites (NHWs).

METHODS

We analyzed data from the California Cancer Registry, which included 29,626 Hispanic and 99,862 NHW female invasive breast cancer cases diagnosed from 2004 to 2014. Logistic regression was used to assess ethnic differences in tumor subtype, and Cox proportional hazard modeling to assess differences in breast cancer survival.

RESULTS

Hispanics compared to NHWs had higher odds of having triple-negative (OR = 1.29; 95% CI 1.23-1.35) and HER2-overexpressing tumors (OR = 1.19; 95% CI 1.14-1.25 [HR-] and OR = 1.39; 95% CI 1.31-1.48 [HR+]). In adjusted models, Hispanic women had a higher risk of breast cancer mortality than NHW women (mortality rate ratio [MRR] = 1.24; 95% CI 1.19-1.28). Clinical factors accounted for most of the mortality difference (MRR = 1.05; 95% CI 1.01-1.09); however, neighborhood socioeconomic status (SES) and health insurance together accounted for all of the mortality difference (MRR = 1.01; 95% CI 0.97-1.05).

CONCLUSIONS

Addressing SES disparities, including increasing access to health care, may be critical to overcoming poorer breast cancer outcomes in Hispanics.

Hispanic ethnicity is associated with younger age at presentation but worse survival in acute myeloid leukemia

SEER data and a Bronx validation cohort demonstrate that Hispanics present with AML at younger age but have shorter survival than whites.Increased frequency of high-risk mutations in Hispanics provides a potential biologic explanation for poorer outcomes in Hispanics.

Understanding PSA and its derivatives in prediction of tumor volume: Addressing health disparities in prostate cancer risk stratification

Objectives

To address health disparities in risk stratification of U.S. Hispanic/Latino men by characterizing influences of prostate weight, body mass index, and race/ethnicity on the correlation of PSA derivatives with Gleason score 6 (Grade Group 1) tumor volume in a diverse cohort.

Results

Using published PSA density and PSA mass density cutoff values, men with higher body mass indices and prostate weights were less likely to have a tumor volume <0.5 cm³. Variability across race/ethnicity was found in the univariable analysis for all PSA derivatives when predicting for tumor volume. In receiver operator characteristic analysis, area under the curve values for all PSA derivatives varied across race/ethnicity with lower optimal cutoff values for Hispanic/Latino (PSA=2.79, PSA density=0.06, PSA mass=0.37, PSA mass density=0.011) and Non-Hispanic Black (PSA=3.75, PSA density=0.07, PSA mass=0.46, PSA mass density=0.008) compared to Non-Hispanic White men (PSA=4.20, PSA density=0.11 PSA mass=0.53, PSA mass density=0.014).

Materials and Methods

We retrospectively analyzed 589 patients with low-risk prostate cancer at radical prostatectomy. Pre-operative PSA, patient height, body weight, and prostate weight were used to calculate all PSA derivatives. Receiver operating characteristic curves were constructed for each PSA derivative per racial/ethnic group to establish optimal cutoff values predicting for tumor volume ≥0.5 cm³.

Conclusions

Increasing prostate weight and body mass index negatively influence PSA derivatives for predicting tumor volume. PSA derivatives’ ability to predict tumor volume varies significantly across race/ethnicity. Hispanic/Latino and Non-Hispanic Black men have lower optimal cutoff values for all PSA derivatives, which may impact risk assessment for prostate cancer.

Racial disparities in pancreatic neuroendocrine tumors survival: a SEER study

Pancreatic neuroendocrine tumor (pancreatic NETs), is an important cause of cancer‐related death worldwide. No study has rigorously explored the impact of ethnicity on pancreatic NETs. We aimed to demonstrate the relationship between ethnicity and the survival of patients with pancreatic NETs. We used the SEER database to identify patients with pancreatic NETs from 2004 to 2013. Kaplan–Meier methods and Cox proportional hazard models were used to evaluate the impact of race on survival in pancreatic NETs patients. A total of 3850 patients were included: 3357 Non‐Blacks, 493 Blacks. We stratified races as “Black” and “White/Other.” Blacks were more likely to be diagnosed with later stages of tumors (P = 0.021). As for the treatment, the access to surgery seemed to be more limited in Blacks than non‐Black patients (P = 0.012). Compared with non‐Black patients, Black patients have worse overall survival (OS) (HR = 1.17, 95% CI: 1.00–1.37, P = 0.046) and pancreatic neuroendocrine tumors specific survival (PNSS) (HR = 1.22, 95% CI: 1.01–1.48, P = 0.044). Multivariate Cox analysis identified that disease extension at the time of diagnosis and surgical status contributed to the ethnical survival disparity. Black patients whose stages at diagnosis were localized had significantly worse OS (HR = 2.09, 95% CI: 1.18–3.71, P = 0.011) and PNSS (HR = 3.79, 95% CI: 1.62–8.82, P = 0.002). As for the patients who did not receive surgery, Blacks also have a worse OS (HR = 1.18, 95% CI: 1.00–1.41, P = 0.045). The Black patients had both worse OS and PNSS compared to non‐Black patients. The restricted utilization of surgery, and the advanced disease extension at the time of diagnosis are the possible contributors to poorer survival of Blacks with pancreatic NETs.

Understanding Quality-of-Life Issues in Chinese Women with Breast Cancer: A Qualitative Investigation

Little is known about the cultural beliefs and quality of life (QOL) of US-born and foreign-born Chinese women with breast cancer. We conducted individual semistructured qualitative interviews to explore the meaning of QOL, identify beliefs about cancer, and make comparison between US-born and foreign-born survivors. Women in this study identified the stigma of breast cancer that exists in the Asian community. They also described interpersonal support as central to a good QOL. However, when describing QOL, foreign-born Chinese women referred to wealth more frequently, while US-born Chinese women indicated friendship more frequently. The study findings support the need for culturally appropriate interventions that take into consideration the cancer-related beliefs and QOL of breast cancer survivors in the Chinese community.

Racial and Ethnic Variation in Health-Related Quality of Life Scores Prior to Prostate Cancer Treatment

Introduction

Many men diagnosed with prostate cancer are concerned with how the disease and its course of treatment could affect their health-related quality of life (HRQOL). To aid in the decision-making process on a course of treatment and to better understand how these treatments can affect HRQOL, knowledge of pretreatment HRQOL is essential.

Aims

To assess the racial and ethnic variations in HRQOL scores in men newly diagnosed with prostate cancer before electing a course of treatment.

Methods

Male members of the Kaiser Permanente of Southern California health plan who were newly diagnosed with prostate cancer completed the five-domain specific Expanded Prostate Index Composite–26 (EPIC-26) HRQOL questionnaire from March 1, 2011 through August 31, 2013 (N = 2,579). Domain scores were compared across racial and ethnic subgroups and multiple logistic regression analyses were used to assess the association after adjusting for sociodemographic and clinical characteristics.

Main Outcome Measures

The five EPIC-26 domain scores (sexual, bowel, hormonal, urinary incontinence, and urinary irritation and obstruction).

Results

Results from the fully adjusted analyses indicated that non-Hispanic black men were more likely to be above the sample median on the sexual (odds ratio [OR] = 1.43, 95% CI = 1.09–1.88), hormonal (OR = 1.35, 95% CI = 1.03–1.77), and urinary irritation and obstruction (OR = 1.34, 95% CI = 1.03–1.74) domains compared with non-Hispanic white men. The Asian or Pacific Islander men were less likely to be above the sample median on the sexual domain (OR = 0.60, 95% CI = 0.44–0.83) compared with non-Hispanic white men. No additional statistically significant differences were identified.

Conclusions

Within an integrated health care organization, we found minimal racial and ethnic differences, aside from sexual function, in pretreatment HRQOL in men newly diagnosed with prostate cancer. These findings provide important insight with which to interpret HRQOL changes in men newly diagnosed with prostate cancer during and after prostate cancer treatment.

Reading SR, Porter KR, Slezak JM, et al. Racial and Ethnic Variation in Health-Related Quality of Life Scores Prior to Prostate Cancer Treatment. Sex Med 2017;5:e219–e228.

Does social selection explain the association between state-level racial animus and racial disparities in self-rated health in the United States?

PURPOSE

Racism, whether defined at individual, interpersonal, or structural levels, is associated with poor health among Blacks. This association may arise because exposure to racism causes poor health, but geographic mobility patterns pose an alternative explanation-namely, Black individuals with better health and resources can move away from racist environments.

METHODS

We examine the evidence for selection effects using nationally representative, longitudinal data (1990-2009) from the Panel Study on Income Dynamics (n = 33,852). We conceptualized state-level racial animus as an ecologic measure of racism and operationalized it as the percent of racially-charged Google search terms in each state.

RESULTS

Among those who move out of state, Blacks reporting good self-rated health (SRH) are more likely to move to a state with less racial animus than Blacks reporting poor SRH (P = .01), providing evidence for at least some selection into environments with less racial animus. However, among Blacks who moved states, over 80% moved to a state within the same quartile of racial animus, and fewer than 5% resided in states with the lowest level of racial animus.

CONCLUSIONS

Geographic mobility patterns are therefore likely to explain only a small part of the relationship between racial animus and SRH. These results require replication with alternative measures of racist attitudes and health outcomes.