Osteoporosis screening using computed tomography for men with prostate cancer: results of a prospective study

We performed a prospective study using both FRAX and computed tomography to screen for osteoporosis in men undergoing radiation for prostate cancer. We found that implementing routine computed tomography (CT)-based screening was feasible in the setting of a prospective study, but the yield of osteoporosis identification was low in this population.

PURPOSE

Men with prostate cancer (PCa) are at increased risk of hip fracture for multiple reasons. Estimation of hip fracture risk with the FRAX tool is currently recommended, but FRAX alone may not identify a portion of men with osteoporosis. We hypothesized that adding bone mineral density (BMD) screening using CT to FRAX is feasible and would identify more men with osteoporosis.

METHODS

Men with PCa scheduled to undergo CT simulation for radiation treatment were enrolled in a single-arm prospective study. The mean attenuation of the mid-L5 vertebral body trabecular bone (L5_CT) was calculated on a single slice using the radiation simulation CT scan. The 10-year risk of hip fracture was calculated using the FRAX tool. Dual energy X-ray absorptiometry (DXA) was performed for men whose L5_CT measurement was less than 130 Hounsfield units (HU).

RESULTS

A total of 98 eligible men were enrolled and underwent FRAX and CT screening. The median 10-year risk of hip fracture was 1.1% and exceeded 3% in 16 cases; the median L5_CT was 162.28 HU (range 55.6-526.1 HU). DXA scan was completed in 15 men who had L5_CT < 130 HU but 10-year calculated hip fracture risk < 3%, 1 of whom was found to have osteoporosis (T-score ≤ -2.5).

CONCLUSIONS

Implementing CT-based BMD screening was feasible in the setting of a prospective study for men receiving radiation for PCa, but fewer cases than anticipated of osteoporosis were identified.

Human papillomavirus as a driver of head and neck cancers

The human papillomavirus (HPV) family includes more than 170 different types of virus that infect stratified epithelium. High-risk HPV is well established as the primary cause of cervical cancer, but in recent years, a clear role for this virus in other malignancies is also emerging. Indeed, HPV plays a pathogenic role in a subset of head and neck cancers-mostly cancers of the oropharynx-with distinct epidemiological, clinical and molecular characteristics compared with head and neck cancers not caused by HPV. This review summarises our current understanding of HPV in these cancers, specifically detailing HPV infection in head and neck cancers within different racial/ethnic subpopulations, and the differences in various aspects of these diseases between women and men. Finally, we provide an outlook for this disease, in terms of clinical management, and consider the issues of 'diagnostic biomarkers' and targeted therapies.

Impact of Primary Care Access on Mortality of Lung Cancer Patients in an Underserved Community

BACKGROUND

Lack of access to primary care physicians (PCPs) may be an important contributor to mortality differences attributed to race/ethnicity. This study examined the effects of primary care access on mortality of lung cancer patients in an underserved community.

METHODS

Medical records of all newly diagnosed patients with primary lung cancer from 2012 to 2016 at a National Cancer Institute (NCI)-designated center in Bronx, New York were reviewed. Demographic data, PCP status, and residence in primary care shortage areas (PCSAs) were collected. Survival data from time of first imaging to death or the end of follow-up on January 1, 2018 were recorded. Survival analysis was performed using Kaplan-Meier and Cox hazards modeling.

RESULTS

Among 1062 patients, 874 (82%) were PCSA residents, 314 (30%) were Hispanic, and 445 (42%) were African American. PCSA residents were likely Hispanics (P<0.001), African Americans (P<0.001), of lower income (P<0.001), and had advanced disease at diagnosis (P=0.01). Patients without established PCPs had more comorbidities (P=0.04), more advanced disease (P<0.001), and less in-network cancer treatment (P<0.001). PCSA residence (P=0.03, hazard ratio [HR]=1.27) and no established PCP (P<0.001, HR=1.50) were associated with increased mortality. In multivariable modeling, lack of established PCP remained a predictor of increased mortality (P=0.02, HR=1.25).

DISCUSSION

Among newly diagnosed lung cancer patients, lack of established PCP is associated with increased mortality. Hispanics and African Americans increasingly resided in PCSAs, suggesting race/ethnicity mortality differences may be mediated by primary care shortage. Patients without PCPs had worse health outcomes. Effective health policy efforts to reduce mortality in lung cancer patients must include approaches to improve primary care access.

A Prospective Study of Community Mediators on the Risk of Sepsis After Cancer

BACKGROUND

Few studies have examined whether community factors mediate the relationship between patients surviving cancer and future development of sepsis. We determined the influence of community characteristics upon risk of sepsis after cancer, and whether there are differences by race.

METHODS

We performed a prospective analysis using data from the REasons for Geographic and Racial Differences in Stroke cohort years 2003 to 2012 complemented with county-level community characteristics from the American Community Survey and County Health Rankings. We categorized those with a self-reported prior cancer diagnosis as "cancer survivors" and those without a history of cancer as "no cancer history." We defined sepsis as hospitalization for a serious infection with ≥2 systemic inflammatory response syndrome criteria. We examined the mediation effect of community characteristics on the association between cancer survivorship and sepsis incidence using Cox proportional hazards models adjusted for age, sex, race, and total number of comorbidities. We repeated analysis stratified by race.

RESULTS

There were 28 840 eligible participants, of which 2860 (9.92%) were cancer survivors, and 25 289 (90.08%) were no cancer history participants. The only observed community-level mediation effects were from income (% mediated 0.07%; natural indirect effect [NIE] on hazard scale] = 1.001, 95% confidence interval [95% CI]: 1.000-1.005) and prevalence of adult smoking (% mediated = 0.21%; NIE = 1.002, 95% CI: 1.000-1.004). We observed similar effects when stratified by race.

CONCLUSION

Cancer survivors are at increased risk of sepsis; however, this association is weakly mediated by community poverty and smoking prevalence.

Socioeconomic disparities in timeliness of care and outcomes for anal cancer patients

Background

Socioeconomic status (SES) is associated with diagnostic and treatment delays and survival in multiple cancers, but less data exist for anal squamous cell carcinoma (ASCC). This study investigated the association between SES and outcomes for patients undergoing definitive chemoradiation therapy for ASCC.

Methods

One hundred and eleven patients diagnosed with nonmetastatic ASCC between 2005 and 2018 were retrospectively reviewed. Socioeconomic predictor variables included primary payer, race, income, employment, and partnership status. Outcomes included the tumor‐node (TN) stage at diagnosis, the duration from diagnosis to treatment initiation, relapse‐free survival (RFS), and overall survival (OS). Age, gender, TN stage, and HIV status were analyzed as covariates in survival analysis.

Results

SES was not associated with the TN stage at diagnosis. SES factors associated with treatment initiation delays were Medicaid payer (P = .016) and single partnership status (P = .016). Compared to privately insured patients, Medicaid patients had lower 2‐year RFS (64.4% vs 93.8%, P = .021) and OS (82.9% vs 93.5%, P = .038). Similarly, relative to patients in the racial majority, racial minority patients had lower 2‐year RFS (53.3% vs 93.5%, P = .001) and OS (73.7% vs 92.6%, P = .008). Race was an independent predictor for both RFS (P = .027) and OS (P = .047).

Conclusions

These results highlight the impact of social contextual factors on health. Interventions targeted at socioeconomically vulnerable populations are needed to reduce disparities in ASCC outcomes.

Outcomes and prognostic factors in African American and black patients with mycosis fungoides/Sézary syndrome: Retrospective analysis of 157 patients from a referral cancer center

BACKGROUND

The prevalence of mycosis fungoides/Sézary syndrome (MF/SS) is higher in the black population than in the white population in the United States and worse outcomes have been observed in black patients.

OBJECTIVE

To describe the outcomes and to identify prognostic factors in African American and black patients with MF/SS.

METHODS

Clinical features and follow-up data were analyzed in 157 self-identified African American or black patients seen during 1994-2018.

RESULTS

We included 122 patients with early stage MF and 35 patients with advanced-stage disease (median follow-up of 25 months). Overall, >80% of the patients who died from disease or progressed had erythema or hyperpigmentation without hypopigmentation. Patients with hypopigmentation, either as the sole manifestation or in combination with other lesions, had better overall survival (P = .002) and progression-free survival (P = .014). Clinical stage, TNMB classification, plaque disease, and elevated serum lactate dehydrogenase were also significantly associated with outcomes. Demographic and socioeconomic parameters were not associated with prognosis.

LIMITATIONS

A retrospective study at a single cancer center.

CONCLUSION

MF/SS manifestations and outcomes in African American and black patients are heterogeneous. Demographic and socioeconomic factors do not seem to have a prognostic role, while clinical characteristics might help in the stratification of risk of progression and shorter survival, allowing for individually tailored therapeutic interventions.

Emerging Cancer Survival Trends, Disparities, and Priorities in Adolescents and Young Adults: A California Cancer Registry-Based Study

BACKGROUND

Although landmark studies in the 1990s demonstrated that adolescents and young adults (AYAs, ages 15-39 years) with cancer had lower survival improvement compared to other ages, therapeutic advances warrant reappraisal of those observations. We utilized more recent data to study site-specific AYA survival trends and disparities and gain a more contemporary understanding of this problem.

METHODS

Using California Cancer Registry data from 1988 to 2014, we calculated 1) 5-year overall survival improvement for AYAs compared to other age groups; 2) hazard ratios (HRs) of death for AYAs comparing 2001-2014 with 1988-2000 stratified by site, stage, sex, age group, race and ethnicity, and socioeconomic status (SES); and 3) site-specific adjusted HRs (aHRs) for AYA risk groups and interaction analyses by time period.

RESULTS

For all cancers combined, AYAs demonstrated survival improvement that exceeded all other age groups, largely due to reduced mortality in human immunodeficiency virus and acquired immunodeficiency syndrome-related cancers. The strongest predictor of death was cancer stage (aHR = 6.32 for distant vs localized, 95% confidence interval [CI] = 6.20 to 6.45). The aHR of death was statistically significantly higher for blacks (1.46, 95% CI = 1.42 to 1.50), Asian and Pacific Islanders (1.12, 95% CI = 1.09 to 1.15), and Latino whites (1.06, 95% CI = 1.04 to 1.08) compared to non-Latino whites, and was statistically significantly higher for low SES compared to high (1.31, 95% CI = 1.29 to 1.34). Survival disparities by stage, race and ethnicity, and SES worsened over time.

CONCLUSIONS

For AYAs in aggregate, the historical cancer survival improvement gap has been closed. However, the growing survival disparities in AYA subsets reported here, including advanced stage disease, racial and ethnic minorities, and low SES, highlight new priorities in need of increased attention, including inequities in cancer care and delivery within this vulnerable population.

A novel clinical nomogram to predict bilateral hyperaldosteronism in Chinese patients with primary aldosteronism

CONTEXT

Adrenal venous sampling (AVS) is recommended as the gold standard for subtype classification in primary aldosteronism (PA); however, this approach has limited availability.

OBJECTIVE

We aimed to develop a novel clinical nomogram to predict PA subtype based on routine variables, thereby reducing the number of candidates for AVS.

PATIENTS AND METHOD

Patients were randomly divided into a training set (n = 185) and a validation set (n = 79). Risk factors for idiopathic hyperaldosteronism (IHA) differentiating from aldosterone-producing adenoma (APA) were identified using logistic regression analysis. A nomogram was constructed to predict the probability of IHA. A receiver operating characteristic (ROC) curve and a calibration plot were applied to assess the predictive value. Then, 115 patients were prospectively enrolled, and a nomogram was used to predict the subtypes before AVS.

RESULTS

Body mass index (BMI), serum potassium and computed tomography (CT) finding were adopted in the nomogram. The nomogram presented an area under the ROC (AUC) of 0.924 (95% CI: 0.875-0.957), sensitivity of 86.59% and specificity of 87.38% in the training set and an AUC of 0.894 (95% CI: 0.804-0.952), sensitivity of 82.86% and specificity of 84.09% in the validation set. Predicted probability and actual probability matched well in the nomogram (Hosmer-Lemeshow test: P > 0.05). Using the nomogram as a surrogate to predict IHA in the prospective set before AVS, the specificity reached 100% when we increased the threshold to a probability of 90%.

CONCLUSION

We have developed a tool that is able to predict IHA in patients with PA and potentially avoid AVS.

Enrollment of Racial Minorities in Clinical Trials: Old Problem Assumes New Urgency in the Age of Immunotherapy

Minority U.S. populations are underrepresented in cancer clinical trials. This review appraises the impact of the disparity in clinical trial participation by minority patients in the current era of cancer immunotherapy. Enrollment on pivotal trials leading to U.S. regulatory approval of immune checkpoint inhibitors showed poor representation of minority ethnic groups. Specifically, we found that black patients constitute less than 4% of all patients enrolled across multiple trials that supported the approval of immune checkpoint inhibitors for the treatment of lung cancer. Similar underrepresentation was observed for trials conducted in renal cell carcinoma and other tumor types. Since efficacy of immunotherapy is only observed in a subset of patients, the use of predictive biomarkers to identify responders along with new strategies to expand the benefit to a larger subset of patients are current areas of active investigation. The inadequate representation of minority patients on immunotherapy clinical trials could perpetuate outcome disparity because the unique biology of the host and the tumors from this subpopulation is not accounted for as new treatment algorithms to guide optimal use of immunotherapy are developed for use in the real world.

The Detroit Research on Cancer Survivors (ROCS) Pilot Study: A Focus on Outcomes after Cancer in a Racially Diverse Patient Population

BACKGROUND

African Americans are often diagnosed with advanced stage cancer and experience higher mortality compared with whites in the United States. Contributing factors, like differences in access to medical care and the prevalence of comorbidities, do not entirely explain racial differences in outcomes.

METHODS

The Detroit Research on Cancer Survivors (ROCS) pilot study was conducted to investigate factors related to short- and long-term outcomes among patients with cancer. Participants completed web-based surveys, and mailed saliva specimens were collected for future genetic studies.

RESULTS

We recruited 1,000 participants with an overall response rate of 68%. Thirty-one percent completed the survey without any interviewer support and the remaining participated in an interviewer-administered survey. Seventy-four percent provided a saliva specimen and 64% consented for tumor tissue retrieval. African American survivors required more interviewer support (P < 0.001); however, their response rate (69.6%) was higher than non-Hispanic whites (65.4%). African Americans reported poorer overall cancer-related quality of life compared with non-Hispanic whites, measured by FACT-G score (P < 0.001), however, this relationship was reversed after controlling for socioeconomic factors, marital status, and the presence of comorbidities.

CONCLUSIONS

In this pilot study, we demonstrated that a web-based survey supplemented with telephone interviews and mailed saliva kits are cost-effective methods to collect patient-reported data and DNA for large studies of cancer survivors with a high proportion of minority patients. The preliminary data collected reinforces differences by race in factors affecting cancer outcomes. Our efforts continue as we expand this unique cohort to include more than 5,000 African American cancer survivors.

IMPACT

Formal investigation of factors influencing adverse outcomes among African American cancer survivors will be critical in closing the racial gap in morbidity and mortality.

A system-based intervention to reduce Black-White disparities in the treatment of early stage lung cancer: A pragmatic trial at five cancer centers

BACKGROUND

Advances in early diagnosis and curative treatment have reduced high mortality rates associated with non-small cell lung cancer. However, racial disparity in survival persists partly because Black patients receive less curative treatment than White patients.

METHODS

We performed a 5-year pragmatic, trial at five cancer centers using a system-based intervention. Patients diagnosed with early stage lung cancer, aged 18-85 were eligible. Intervention components included: (1) a real-time warning system derived from electronic health records, (2) race-specific feedback to clinical teams on treatment completion rates, and (3) a nurse navigator. Consented patients were compared to retrospective and concurrent controls. The primary outcome was receipt of curative treatment.

RESULTS

There were 2841 early stage lung cancer patients (16% Black) in the retrospective group and 360 (32% Black) in the intervention group. For the retrospective baseline, crude treatment rates were 78% for White patients vs 69% for Black patients (P < 0.001); difference by race was confirmed by a model adjusted for age, treatment site, cancer stage, gender, comorbid illness, and income-odds ratio (OR) 0.66 for Black patients (95% CI 0.51-0.85, P = 0.001). Within the intervention cohort, the crude rate was 96.5% for Black vs 95% for White patients (P = 0.56). Odds ratio for the adjusted analysis was 2.1 (95% CI 0.41-10.4, P = 0.39) for Black vs White patients. Between group analyses confirmed treatment parity for the intervention.

CONCLUSION

A system-based intervention tested in five cancer centers reduced racial gaps and improved care for all.

Lung cancer health disparities

Compared with all other racial and ethnic groups in the United States, African Americans are disproportionally affected by lung cancer, both in terms of incidence and survival. It is likely that smoking, as the main etiological factor associated with lung cancer, contributes to these disparities, but the precise mechanism is still unclear. This paper seeks to explore the history of lung cancer disparities and review to the literature regarding the various factors that contribute to them.

County of Residence and Screening Practices among Latinas and Non-Latina Whites in Two Rural Communities

Objectives

Latinas are less likely than non-Latina Whites (NLW) to utilize mammographic screening and are more likely to be diagnosed with late-stage breast cancer. Here, we examine the effects of county-level factors on guideline-concordant breast-cancer screening behaviors in Latinas and NLWs.

Design

Latinas (N=108) and NLW women (N=132) aged >40 years, residing in two adjacent rural, medically underserved counties in eastern Washington State, completed a baseline questionnaire on mammography utilization and demographics.

Main Outcome Measures

Differences in socioeconomic variables and knowledge of screening practices were examined by ethnicity and county of residence. Predictors of having had a mammogram within the past two years were analyzed using multivariate logistic regression.

Results

Ethnicity was not associated with having a guideline-concordant mammogram; however, age (odds ratio [OR]=1.04, 95%CI:1.01-1.08); having >12 years of education (OR=2.09, 95%CI:1.16-3.79); having a regular clinic for health care (OR=2.22, 95%CI:1.05-4.70); having had a prior clinical breast exam (OR=5.07, 95%CI:1.71-15.02), and county of residence (OR=2.27, 95%CI:1.18-4.37) were all associated with having had a guideline-concordant mammogram.

Conclusions

County of residence and having had a prior CBE were strong predictors of screening utilization. Community-level factors in medically underserved areas may influence screening patterns.

Association between Race and Cancer-Related Mortality among Patients with Colorectal Cancer in the United States: A Retrospective Cohort Study

Colorectal cancer (CRC) is the third most common cause of mortality in the United States (US). Differences in CRC mortality according to race have been extensively studied; however, much more understanding with regard to tumor characteristics’ effect on mortality is needed. The objective was to investigate the association between race and mortality among CRC patients in the US during 2007–2014. A retrospective cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) Program, which collects cancer statistics through selected population-based cancer registries during in the US, was conducted. The outcome variable was CRC-related mortality in adult patients (≥18 years old) during 2007–2014. The independent variable was race of white, black, Asian/Pacific Islander (API), and American Indian/Alaska Native (others). The covariates were, age, sex, marital status, health insurance, tumor stage at diagnosis, and tumor size and grade. Bivariate analysis was performed to identify possible confounders (chi-square tests). Unadjusted and adjusted logistic regression models were used to study the association between race and CRC-specific mortality. The final number of participants consisted of 70,392 patients. Blacks had a 32% higher risk of death compared to whites (adjusted odds ratio (OR) 1.32; 95% confidence interval (CI) 1.22–1.43). Corresponding OR for others were 1.41 (95% CI 1.10–1.84). API had nonsignificant adjusted odds of mortality compared to whites (0.95; 95% CI 0.87–1.03). In conclusion, we observed a significant increased risk of mortality in black and American Indian/Alaska Native patients with CRC compared to white patients.

Impact of tumor, treatment, and access on outcomes in bladder cancer: Can equal access overcome race-based differences in survival?

BACKGROUND

There are race-based differences in bladder cancer survival. To better understand this phenomenon, this study was designed to assess the statistical contributions of tumor, treatment, and access variables to race-based differences in survival.

METHODS

Data were extracted from the National Cancer Data Base on black and white adults with muscle-invasive bladder cancer from 2004 to 2015. The impact of tumor, access, and treatment variables on differences in survival was inferred by the performance of sequential propensity score-weighted analyses in which black and white patients were balanced with respect to demographics and health status (comorbidities) tumor characteristics, treatment, and access-related variables. The propensity score-weighted hazard of death (black vs white) was calculated after each iteration.

RESULTS

This study identified 44,577 patients with a median follow-up of 77 months. After demographics and health status were balanced, black race was associated with 18% worse mortality (hazard ratio, 1.18; 95% confidence interval [CI], 1.12-1.25; P < .001). Balancing by tumor characteristics reduced this to 16%, balancing by treatment reduced this to 10%, and balancing by access-related variables resulted in no difference. Access-related variables explained 40% (95% CI, 22.9%-57.0%) of the excess risk of death in blacks, whereas treatment factors explained 35% (95% CI, 22.2%-46.9%). The contribution of tumor characteristics was not significant.

CONCLUSIONS

In the models, differences in survival for black and white patients with bladder cancer are best explained by disparities in access and treatment, not tumor characteristics. Access to care is likely a key factor in racial disparities in cancer.

Identifying the barriers to gastric cancer care at safety-net hospitals: A novel comparison of a safety-net hospital to a neighboring quaternary referral academic center in the same healthcare system

BACKGROUND

The three-delays model describes delays in seeking, reaching, and receiving care for vulnerable populations needing treatment. The dominant delay for patients with gastric adenocarcinoma (GAC) is unknown. We aimed to define patients with GAC who reached and received care at our regional safety-net hospital (Grady Memorial Hospital [GMH]) and our neighboring quaternary referral hospital (Emory University Hospital [EUH]).

METHODS

Clinicopathologic data from National Cancer Database (NCDB) participating academic centers were compared with GMH from 2004 to 2014. Outcomes of patients undergoing surgery at GMH were compared to those at EUH.

RESULTS

At presentation, compared to NCDB centers (n = 69 662), GMH patients (n = 154) were more often black (85.1 vs 17.2%; P < 0.001), uninsured (30.5 vs 4.7%; P < 0.001), have stage IV disease (43.5 vs 30.1%; P = 0.017), and received no treatment (40.3 vs 18.4%; P < 0.001). When only comparing patients who underwent curative-intent resection at GMH (n = 23) to EUH (n = 137), median overall survival was similar between both groups (GMH: median not reached; EUH: 59.8 mos; P = 0.785).

CONCLUSION

Although vulnerable patients with GAC within a safety-net hospital present with later stages of the disease, those who received surgery have acceptable outcomes. Thus, efforts should be made to overcome barriers in seeking care.

Overall Survival of Black and White Men With Metastatic Castration-Resistant Prostate Cancer Treated With Docetaxel

PURPOSE

Several studies have reported that among patients with localized prostate cancer, black men have a shorter overall survival (OS) time than white men, but few data exist for men with advanced prostate cancer. The primary goal of this analysis was to compare the OS in black and white men with metastatic castration-resistant prostate cancer (mCRPC) who were treated in phase III clinical trials with docetaxel plus prednisone (DP) or a DP-containing regimen.

METHODS

Individual participant data from 8,820 men with mCRPC randomly assigned in nine phase III trials to DP or a DP-containing regimen were combined. Race was based on self-report. The primary end point was OS. The Cox proportional hazards regression model was used to assess the prognostic importance of race (black v white) adjusted for established risk factors common across the trials (age, prostate-specific antigen, performance status, alkaline phosphatase, hemoglobin, and sites of metastases).

RESULTS

Of 8,820 men, 7,528 (85%) were white, 500 (6%) were black, 424 (5%) were Asian, and 368 (4%) were of unknown race. Black men were younger and had worse performance status, higher testosterone and prostate-specific antigen, and lower hemoglobin than white men. Despite these differences, the median OS was 21.0 months (95% CI, 19.4 to 22.5 months) versus 21.2 months (95% CI, 20.8 to 21.7 months) in black and white men, respectively. The pooled multivariable hazard ratio of 0.81 (95% CI, 0.72 to 0.91) demonstrates that overall, black men have a statistically significant decreased risk of death compared with white men ( P < .001).

CONCLUSION

When adjusted for known prognostic factors, we observed a statistically significant increased OS in black versus white men with mCRPC who were enrolled in these clinical trials. The mechanism for these differences is not known.

Racial and Ethnic Trends in Prostate Cancer Incidence and Mortality in Philadelphia, PA: an Observational Study

BACKGROUND

To learn more about local prostate cancer (PCa) disparities, we conducted descriptive analyses of the role of race and age in PCa using the Pennsylvania Cancer Registry data for Philadelphia (2005-2014).

METHODS

We focused on the most prevalent race/ethnic groups: white (33%), black (44%), and Hispanic (9%). Outcomes included PCa rates, tumor stage, and tumor grade. Percent change was used to describe changes in age-adjusted incidence and mortality rates. Frequency tables and logistic regression models were used to describe trends in proportions of advanced PCa by race and time. Race-by-time interaction terms were retained in the models if statistically significant.

RESULTS

PCa incidence was highest for black men over time. Incidence rates declined over time for all race groups (- 28% for white men to - 38% for Hispanic men). PCa mortality rates declined in a less universal manner (- 5% for blacks to - 32% for whites). Each year, odds increased across all race groups for advanced tumor stage (4% each year among white and Hispanic men and 9% each year among black men) and for advanced tumor grade (4% each year among white and black men and 23% each year among Hispanic men). Among younger men, black men experienced significantly increased odds of advanced tumor stage each year (8%) and Hispanics experienced significantly increased odds of advanced tumor grade each year (30%).

CONCLUSIONS

Black men remain at highest PCa risk relative to other racial/ethnic groups in Philadelphia. Younger black and Hispanic men are at particular risk for advanced PCa at diagnosis.

Racial and Socioeconomic Disparities in Cancer-Related Knowledge, Beliefs, and Behaviors in Indiana

BACKGROUND

This statewide survey examined differences in cancer-related knowledge, beliefs, and behaviors between racial and socioeconomic groups in select counties in Indiana.

METHODS

A stratified random sample of 7,979 people aged 18-75 who lived in one of 34 Indiana counties with higher cancer mortality rates than the state average, and were seen at least once in the past year in a statewide health system were mailed surveys.

RESULTS

Completed surveys were returned by 970 participants, yielding a 12% response rate. Black respondents were less likely to perceive they were at risk for cancer and less worried about getting cancer. Individuals most likely to perceive that they were unlikely to get cancer were more often black, with low incomes (less than $20,000) or high incomes ($50,000 or more), or less than a high school degree. Black women were greater than six times more likely to be adherent to cervical cancer screening. Higher income was associated with receiving a sigmoidoscopy in the last 5 years and a lung scan in the past year. Those with the highest incomes were more likely to engage in physical activity. Both income and education were inversely related to smoking.

CONCLUSIONS

Socioeconomic and racial disparities were observed in health behaviors and receipt of cancer screening. Black individuals had less worry about cancer.

IMPACT

Understanding populations for whom cancer disparities exist and geographic areas where the cancer burden is disproportionately high is essential to decision-making about research priorities and the use of public health resources.

Does race predict the development of metastases in men who receive androgen-deprivation therapy for a biochemical recurrence after radical prostatectomy?

BACKGROUND

In this study among men who underwent radical prostatectomy (RP), African American men (AAM) were 28% more likely to develop recurrent disease compared with Caucasian men (CM). However, among those who had nonmetastatic, castration-resistant prostate cancer (CRPC), race did not predict metastases or overall survival. Whether race predicts metastases among men who receive androgen-deprivation therapy (ADT) after a biochemical recurrence (BCR) (ie, before CRPC but after BCR) is untested.

METHODS

The authors identified 595 AAM and CM who received ADT for a BCR that developed after RP between 1988 and 2015 in the Shared Equal-Access Regional Cancer Hospital (SEARCH) database. Univariable and multivariable Cox models were used to test the association between race and the time from ADT to metastases. Secondary outcomes included the time to CRPC, all-cause mortality, and prostate cancer-specific mortality.

RESULTS

During a median follow-up of 66 months after ADT, 62 of 354 CM (18%) and 38 of 241 AAM (16%) developed metastases. AAM were younger at the time they received ADT (63 vs 67 years; P < .001), had received ADT in a more recent year (2008 vs 2006; P < .001), had higher prostate-specific antigen levels at RP (11.1 vs 9.2 ng/mL; P < .001), lower pathologic Gleason scores (P = .004), and less extracapsular extension (38% vs 48%; P = .022). On multivariable analysis, there was no association between race and metastases (hazard radio, 1.20; P = .45) or any of the other secondary outcomes (all P > .5).

CONCLUSIONS

Among veterans who received ADT post-BCR after RP, race was not a predictor of metastases or other adverse outcomes. The current findings suggest that research efforts to understand racial differences in prostate cancer biology should focus on early stages of the disease (ie, closer to the time of diagnosis).

Racial Disparities in Lung Cancer Survival: The Contribution of Stage, Treatment, and Ancestry

INTRODUCTION

Lung cancer is a leading cause of cancer-related death worldwide. Racial disparities in lung cancer survival exist between blacks and whites, yet they are limited by categorical definitions of race. We sought to examine the impact of African ancestry on overall survival among blacks and whites with NSCLC cases.

METHODS

Incident cases of NSCLC in blacks and whites from the prospective Southern Community Cohort Study (N = 425) were identified through linkage with state cancer registries in 12 southern states. Vital status was determined by linkage with the National Death Index and Social Security Administration. We evaluated the impact of African ancestry (as estimated by using genome-wide ancestry-informative markers) on overall survival by calculating the time-dependent area under the curve (AUC) for Cox proportional hazards models, adjusting for relevant covariates such as stage and treatment. We replicated our findings in an independent population of NSCLC cases in blacks.

RESULTS

Global African ancestry was not significantly associated with overall survival among NSCLC cases. There was no change in model performance when Cox proportional hazards models with and without African ancestry were compared (AUC = 0.79 for each model). Removal of stage and treatment reduced the average time-dependent AUC from 0.79 to 0.65. Similar findings were observed in our replication study.

CONCLUSIONS

Stage and treatment are more important predictors of survival than African ancestry is. These findings suggest that racial disparities in lung cancer survival may disappear with similar early detection efforts for blacks and whites.

Unpacking Hispanic Ethnicity-Cancer Mortality Differentials Among Hispanic Subgroups in the United States, 2004-2014

Introduction: National data on the epidemiology of cancer are commonly reported by broad racial/ethnic categories, such as "Hispanic." However, few studies have disaggregated Hispanic groups and explored mortality differentials in this heterogeneous population. This paper aims to further examine cancer mortality differentials among Hispanic subgroups in the U.S. Materials and Methods: The study examined cancer deaths in the United States from 2004 to 2014 among decedents classified as Mexican, Puerto Rican, Cuban, Dominican, Central/South American and non-Hispanic white on the death certificate among those who were 20 years or older at the time of death. Data were obtained from the National Vital Statistics System. Sex-specific age-adjusted mortality rates were computed for a 10-year period and each individual year, for all cancers combined. Differences by age group, cancer sites, and age distribution were also assessed. Results: A total of 296,486 Hispanic cancer deaths were identified. Mortality rates of the Hispanic subgroups compare favorably with those of non-Hispanic whites. The mortality rates for Mexicans are very similar to those of all Hispanics combined, whereas the rates for Cuban and Puerto Ricans are higher. Dominicans and Central/South Americans had the overall lowest mortality rates. Statistically significant decreases in cancer mortality rates were noted in some sub-groups, but rates increased among Dominican women. Age-adjusted mortality rates by cancer site varied among Hispanics subgroups and gender. Among Cubans, only 5% of cancer deaths occurred before the age of 50 compared to 16% of cancer deaths among Central/South American. Conclusion: While it is common to present data on the burden of cancer among Hispanics as an aggregate group, this study illustrates that the burden of cancer varies by Hispanic subgroups. The disaggregation of Hispanics by ancestry/country of origin allows for a clearer understanding of the health status of this growing population and is needed if health disparities are to be adequately identified, understood and addressed.

Increased utilization of external beam radiotherapy relative to cystectomy for localized, muscle-invasive bladder cancer: a SEER analysis

OBJECTIVE

To assess recent utilization patterns of radiotherapy (RT) relative to cystectomy for muscle-invasive bladder cancer (MIBC) and evaluate survival trends over time in patients receiving RT.

MATERIALS AND METHODS

The surveillance, epidemiology, and end results program (SEER) was used to identify patients diagnosed between 1992 and 2013 with localized MIBC. Patients with a prior history of non-bladder malignancy, who received no treatment, or did not have available treatment information, were excluded. Treatment utilization patterns were assessed using Cochran-Armitage tests for trend, and patient characteristics were compared using chi-square tests. Overall survival (OS) and cause-specific survival (CSS) were estimated using the Kaplan-Meier method. All-cause (ACM) and cause-specific mortality (CSM) were evaluated with multivariable Cox proportional hazards regression.

RESULTS

Of 16175 patients analyzed, 11917 (74%) underwent cystectomy, and 4258 (26%) were treated with RT. Patients who received RT were older (median age 79 vs. 68, P < 0.01). Over time, the proportion of patients receiving RT relative to cystectomy increased (24% 1992–2002 vs. 28% 2003–2013, P < 0.01), despite median patient age throughout the study period remaining unchanged (71 for each 1992–2002 and 2003–2013, P = 0.41). For RT, compared with patients diagnosed earlier, those diagnosed from 2010–2013 showed improved OS (64% vs. 60% at 1 year, P < 0.01; 38% vs. 29% at 3 years, P < 0.01) and CSS (71% vs. 67% at 1 year, P = 0.01; 51% vs. 40% at 3 years, P < 0.01). On multivariable analysis, diagnosis from 2010–2013 was associated with a lower estimated risk of ACM (hazard ratio 0.77; 95% confidence interval 0.66–0.89, P < 0.001) and CSM (hazard ratio 0.81; 95% confidence interval 0.67–0.97, P = 0.02).

CONCLUSION

Utilization of RT for localized MIBC increased relative to cystectomy from 1992 to 2013, despite the median age of treated patients remaining unchanged. More recent survival outcomes for patients receiving RT were improved, supporting continued use of bladder preservation strategies utilizing RT.

The Clinical Use of Stem Cell Research in Chronic Obstructive Pulmonary Disease: A Critical Analysis of Current Policies

Chronic obstructive pulmonary disease (COPD) is a disorder affecting more than 200 million people around the world, resulting in three million deaths per year. COPD is characterized by the loss of lung tissue and airway remodelling, with chronic inflammation of the airways and progressive destruction of lung parenchyma. The use of stem cells may lead to regenerative processes that address biological damage. However, this approach raises ethical issues that need to be considered in clinical trials using stem cell therapy, such as informed consent, patient recruitment and harm minimization, as well as the inherent uncertainty of these medical procedures on human beings. Indeed, up to now, these experiments have been performed in preclinical studies using animal models, with few studies involving humans. Additional efforts should be made to assess this promising procedure.

Does Race Influence Risk Assessment and Recommendations for Lung Resection? A Randomized Trial

BACKGROUND

Racial disparities in use of surgical therapy for lung cancer exist in the United States. Videos of standardized patients (SPs) can help identify factors that influence physicians' surgical risk estimation. We hypothesized that physician race and SP race in videos influence surgeon decision making.

METHODS

Four race-neutral clinical vignettes representing lung resection candidates were paired with risk-level concordant short silent videos of SPs. Vignette/video combinations were classified as low or high risk. Trainees and practicing thoracic surgeons read a race-neutral vignette, provided an initial estimate of the percentage risk of major surgical complications, viewed a video randomized to a black or white SP, provided a final estimate of risk, and scored the likelihood that they would recommend operative therapy. Changes in risk estimates were assessed.

RESULTS

Participants included 113 surgeons (38 practicing surgeons, 75 trainees); of these, 76 were white non-Hispanic (67%), and 37 were other self-identified racial categories. Percentage changes between initial and final risk estimates were not significantly related to patient race (p = 0.11) or surgeon race (white versus other; p = 0.52). Videos of black SPs were associated with a similar likelihood of recommending an operation compared with that of videos of white SPs (p = 0.90). Physician race (white versus other) was not related to the likelihood of recommending surgical intervention (p = 0.79).

CONCLUSIONS

Neither patient nor physician race was significantly associated with risk estimation or surgical recommendations. These findings do not provide an explanation for documented racial disparities in lung cancer therapy. Further investigation is needed to identify the mechanism underlying these disparities.

Mediating Effects of Frailty Indicators on the Risk of Sepsis After Cancer

BACKGROUND

Cancer survivors are at increased risk of sepsis, possibly attributed to weakened physiologic conditions. The aims of this study were to examine the mediation effect of indicators of frailty on the association between cancer survivorship and sepsis incidence and whether these differences varied by race.

METHODS

We performed a prospective analysis using data from the REasons for Geographic and Racial Differences in Stroke cohort from years 2003 to 2012. We categorized frailty as the presence of ≥2 frailty components (weakness, exhaustion, and low physical activity). We categorized participants as "cancer survivors" or "no cancer history" derived from self-reported responses of being diagnosed with any cancer. We examined the mediation effect of frailty on the association between cancer survivorship and sepsis incidence using Cox regression. We repeated analysis stratified by race.

RESULTS

Among 28 062 eligible participants, 2773 (9.88%) were cancer survivors and 25 289 (90.03%) were no cancer history participants. Among a total 1315 sepsis cases, cancer survivors were more likely to develop sepsis (12.66% vs 3.81%, P < .01) when compared to participants with no cancer history (hazard ratios: 2.62, 95% confidence interval: 2.31-2.98, P < .01). The mediation effects of frailty on the log-hazard scale were very small: weakness (0.57%), exhaustion (0.31%), low physical activity (0.20%), frailty (0.75%), and total number of frailty indicators (0.69%). Similar results were observed when stratified by race.

CONCLUSION

Cancer survivors had more than a 2-fold increased risk of sepsis, and indicators of frailty contributed to less than 1% of this disparity.

A widening longevity gap between people with schizophrenia and general population: A literature review and call for action

Individuals with schizophrenia have higher mortality rates than the population at large. General mortality rates have declined in developed countries since the early 1970s, extending average lifespan by nearly a decade. This review of eight longitudinal studies of mortality in schizophrenia found that the mean standardized mortality ratio (SMR, a measure of mortality rate in schizophrenia compared to the general population) increased 37%, from 2.2 in the pre-1970s studies to 3.0 in the post-1970s reports. Major changes in societal stigma, healthcare, and economic policy are urgently warranted to ensure that this vulnerable segment of the population participates in the longevity revolution.

Overall survival is similar between women who seek care at one or more institutions after diagnosis of operable breast cancer in the community

BACKGROUND

As breast cancer diagnoses increase, so does the number of patients who are critically evaluating hospital attributes to determine where to receive their treatment. Evidence suggests that complex surgeries have better outcomes in high volume academic centers. Whether clinical outcomes of women diagnosed with operable breast cancer, who are treated by multiple disciplines including non-complex surgical approaches, differ for those received all or part of their treatment at their community cancer center is unclear. We hypothesize that the clinical outcomes do not differ for those who received all or part of their care at their community cancer center. Our aim is to analyze data from the National Cancer Database (NCDB) to assess the clinical characteristics and outcomes of patients who received all their treatment at community cancer center when compared with those who had part or all of their care elsewhere.

METHODS

A cohort of 162,803 women diagnosed at a community cancer center with an operable breast cancer (clinical stage I - III) between 2005 and 2014 from the NCDB was evaluated. Demographics, cancer-specific characteristics and overall survival differences between patients who stay at or leave their home institution for breast cancer treatment were compared.

RESULTS

Within this cohort, patients treated at multiple institutions were younger, traveled further from home for their care, and were more likely to have no comorbidities (p < 0.001). Overall survival adjusted for demographics and cancer stage and subtype did not differ based on treatment at one or multiple institutions.

CONCLUSIONS

The decision for patients to undergo breast cancer treatment in a different institution after being diagnosed in a community center does not appear to impact overall survival.

A prospective study of cancer survivors and risk of sepsis within the REGARDS cohort

BACKGROUND

Hospitalized cancer patients are nearly 10 times more likely to develop sepsis when compared to patients with no cancer history. We compared the risk of sepsis between cancer survivors and no cancer history participants, and examined whether race was an effect modifier.

METHODS

We performed a prospective analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. We categorized participants as "cancer survivors" or "no cancer history" derived from self-reported responses of being diagnosed with any cancer, excluding non-melanoma skin cancer. We defined sepsis as hospitalization for a serious infection with ≥2 systemic inflammatory response syndrome criteria. We performed Cox proportional hazard models to examine the risk of sepsis after cancer (adjusted for sociodemographics, health behaviors, and comorbidities), and stratified by race.

RESULTS

Among 29,693 eligible participants, 2959 (9.97%) were cancer survivors, and 26,734 (90.03%) were no cancer history participants. Among 1393 sepsis events, the risk of sepsis was higher for cancer survivors (adjusted HR: 2.61, 95% CI: 2.29-2.98) when compared to no cancer history participants. Risk of sepsis after cancer survivorship was similar for Black and White participants (p value for race and cancer interaction = 0.63).

CONCLUSION

In this prospective cohort of community-dwelling adults we observed that cancer survivors had more than a 2.5-fold increased risk of sepsis. Public health efforts should attempt to mitigate sepsis risk by awareness and appropriate treatment (e.g., antibiotic administration) to cancer survivors with suspected infection regardless of the number of years since cancer remission.

Racial disparities in guideline-concordant cancer care and mortality in the United States

Purpose

We identified the frequency of racial disparities in guideline-concordant cancer care for select common disease sites in the United States and the impact of guideline concordance on mortality disparities.

Methods and materials

Using Surveillance, Epidemiology, and End Results Medicare data, we evaluated patients age >65 years of black or non-Hispanic white race who were diagnosed with stage III breast (n = 3607), stage I (n = 14,605) or III (n = 15,609) non-small cell lung, or stage III prostate (n = 3548) cancer between 2006 and 2011. Chemotherapy, surgery, and radiation therapy (RT) treatments were identified using claims data. Pearson χ² was used to test the associations between race and guideline concordance on the basis of National Comprehensive Cancer Network curative treatment guidelines. Mortality risks were modeled using Cox proportional hazards.

Results

Black patients were less likely to receive guideline-concordant curative treatment than non-Hispanic white patients for stage III breast cancer postmastectomy RT (53% black, 61% white; P = .0014), stage I non-small cell lung cancer stereotactic radiation or surgery (61% black, 75% white; P < .0001), stage III non-small cell lung cancer chemotherapy in addition to RT or surgery (36% black, 41% white; P = .0001), and stage III prostate cancer RT or prostatectomy (82% black, 95% white; P < .0001). Disparities in guideline concordance impacted racial mortality disparities. Specifically, hazard ratios that demonstrated elevated all-cause mortality risks in black patients were lowered (and more closely approached hazard ratio of 1.00) after adjusting for guideline concordance. A similar impact for cause-specific mortality was observed.

Conclusions

Racial disparities in the receipt of curative cancer therapy impacted racial mortality disparities across multiple cancer sites. Benchmarking adherence to guideline-concordant care could represent an opportunity to stimulate improvements in disparities in cancer treatment and survival.

African-American men and prostate cancer-specific mortality: a competing risk analysis of a large institutional cohort, 1989-2015

Significant racial disparities in prostate cancer (PCa) outcomes have been reported, with African-American men (AAM) more likely to endure adverse oncologic outcomes. Despite efforts to dissipate racial disparities in PCa, a survival gap persists and it remains unclear to what extent this disparity can be explained by known clinicodemographic factors. In this study, we leveraged our large institutional database, spanning over 25 years, to investigate whether AAM continued to experience poor PCa outcomes and factors that may contribute to racial disparities in PCa. A total of 7307 patients diagnosed with PCa from 1989 through 2015 were included. Associations of race and clinicodemographic characteristics were analyzed using chi-square for categorical and Mann-Whitney U-test for continuous variables. Racial differences in prostate cancer outcomes were analyzed using competing risk analysis methods of Fine and Gray. Median follow-up time was 106 months. There were 2304 deaths recorded, of which 432 resulted from PCa. AAM were more likely to be diagnosed at an earlier age (median 60 vs. 65 years, P = <0.001) and were more likely to have ≥1 comorbidities (13.6% vs. 7.5%, P < 0.001). In a multivariate competing risk model, adjusted for baseline covariates, AAM experienced significantly higher risk of PCSM compared to NHW men (HR, 1.62, 95% CI, 1.02-2.57, P = 0.03) NHW. Among men diagnosed at an older age (>60 years), racial differences in PCSM were more pronounced, with AAM experiencing higher rates of PCSM (HR, 2.05, 95% CI, 1.26-3.34, P = 0.003). After adjustment of clinicodemographic and potential risk factors, AAM continue to experience an increased risk of mortality from PCa, especially older AAM. Furthermore, AAM are more likely to be diagnosed at an early age and more likely to have higher comorbidity indices.

Race is an independent predictor of survival in patients with soft tissue sarcoma of the extremities

BACKGROUND

In the United States, race and socioeconomic status are well known predictors of adverse outcomes in several different cancers. Existing evidence suggests that race and socioeconomic status may impact survival in soft tissue sarcoma (STS). We investigated the National Cancer Database (NCDB), which contains several socioeconomic and medical variables and contains the largest sarcoma patient registry to date. Our goal was to determine the impact of race, ethnicity and socioeconomic status on patient survival in patients with soft tissue sarcoma of the extremities (STS-E).

METHODS

We retrospectively analyzed 14,067 STS-E patients in the NCDB from 1998 through 2012. Patients were stratified based on race, ethnicity and socioeconomic status. Univariate and multivariate analyses were used to correlate specific outcomes and survival measures with these factors. Then, long-term survival between groups was evaluated using the Kaplan-Meier (KM) method with comparisons based on the log-rank test. Multiple variables were analyzed between two groups.

RESULTS

Of the 14,067 patients analyzed, 84.9% were white, 11% were black and 4.1% were Asian. Black patients were significantly more likely (7.18% vs 5.65% vs 4.47%) than white or Asian patients to receive amputation (p = 0.027). Black patients were also less likely to have either an above-median education level or an above-median income level (p < 0.001). In addition, black patients were more likely to be uninsured (p < 0.001) and more likely to have a higher Charleson Comorbidity Score than white or Asian patients. Tumors were larger in size upon presentation in black patients than in white or Asian patients (p < 0.001). Black patients had significantly poorer overall survival than did white or Asian patients (p < 0.001) with a KM 5-year survival of 61.4% vs 66.9% and 69.9% respectively, and a 24% higher independent likelihood of dying in a multivariate analysis.

CONCLUSION

This large database review reveals concerning trends in black patients with STS-E. These include larger tumors, poorer resources, a greater likelihood of amputation, and poorer survival than white and Asian patients. Future studies are warranted to help ensure adequate access to effective treatment for all patients.

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.

Analysis of Tumor Biology to Advance Cancer Health Disparity Research

Cancer mortality rates in the United States continue to decline. Reductions in tobacco use, uptake of preventive measures, adoption of early detection methods, and better treatments have resulted in improved cancer outcomes for men and women. Despite this progress, some population groups continue to experience an excessive cancer burden when compared with other population groups. One of the most prominent cancer health disparities exists in prostate cancer. Prostate cancer mortality rates are highest among men of African ancestry when compared with other men, both in the United States and globally. This disparity and other cancer health disparities are largely explained by differences in access to health care, diet, lifestyle, cultural barriers, and disparate exposures to carcinogens and pathogens. Dietary and lifestyle factors, pathogens, and ancestry-related factors can modify tumor biology and induce a more aggressive disease. There are numerous examples of how environmental exposures, like tobacco, chronic stress, or dietary factors, induce an adverse tumor biology, leading to a more aggressive disease and decreased patient survival. Because of population differences in the exposure to these risk factors, they can be the cause of cancer disparities. In this review, we will summarize recent advances in our understanding of prostate and breast cancer disparities in the United States and discuss how the analysis of tumor biology can advance health disparity research.

Cancer mortality disparities among New York City's Upper Manhattan neighborhoods

The East Harlem (EH), Central Harlem (CH), and Upper East Side (UES) neighborhoods of New York City are geographically contiguous to tertiary medical care, but are characterized by cancer mortality rate disparities. This ecological study aims to disentangle the effects of race and neighborhood on cancer deaths. Mortality-to-incidence ratios were determined using neighborhood-specific data from the New York State Cancer Registry and Vital Records Office (2007-2011). Ecological data on modifiable cancer risk factors from the New York City Community Health Survey (2002-2006) were stratified by sex, age group, race/ethnicity, and neighborhood and modeled against stratified mortality rates to disentangle race/ethnicity and neighborhood using logistic regression. Significant gaps in mortality rates were observed between the UES and both CH and EH across all cancers, favoring UES. Mortality-to-incidence ratios of both CH and EH were similarly elevated in the range of 0.41-0.44 compared with UES (0.26-0.30). After covariate and multivariable adjustment, black race (odds ratio=1.68; 95% confidence interval: 1.46-1.93) and EH residence (odds ratio=1.20; 95% confidence interval: 1.07-1.35) remained significant risk factors in all cancers' combined mortality. Mortality disparities remain among EH, CH, and UES neighborhoods. Both neighborhood and race are significantly associated with cancer mortality, independent of each other. Multivariable adjusted models that include Community Health Survey risk factors show that this mortality gap may be avoidable through community-based public health interventions.

Brain Metastases in Newly Diagnosed Breast Cancer: A Population-Based Study

Importance

Population-based estimates of the incidence and prognosis of brain metastases at diagnosis of breast cancer are lacking.

Objective

To characterize the incidence proportions and median survivals of patients with breast cancer and brain metastases at the time of cancer diagnosis.

Design, Setting, and Participants

Patients with breast cancer and brain metastases at the time of diagnosis were identified using the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute. Data were stratified by subtype, age, sex, and race. Multivariable logistic and Cox regression were performed to identify predictors of the presence of brain metastases at diagnosis and factors associated with all-cause mortality, respectively. For incidence, we identified a population-based sample of 238 726 adult patients diagnosed as having invasive breast cancer between 2010 and 2013 for whom the presence or absence of brain metastases at diagnosis was known. Patients diagnosed at autopsy or with an unknown follow-up were excluded from the survival analysis, leaving 231 684 patients in this cohort.

Main Outcomes and Measures

Incidence proportion and median survival of patients with brain metastases and newly diagnosed breast cancer.

Results

We identified 968 patients with brain metastases at the time of diagnosis of breast cancer, representing 0.41% of the entire cohort and 7.56% of the subset with metastatic disease to any site. A total of 57 were 18 to 40 years old, 423 were 41 to 60 years old, 425 were 61-80 years old, and 63 were older than 80 years. Ten were male and 958 were female. Incidence proportions were highest among patients with hormone receptor (HR)-negative human epidermal growth factor receptor 2 (HER2)-positive (1.1% among entire cohort, 11.5% among patients with metastatic disease to any distant site) and triple-negative (0.7% among entire cohort, 11.4% among patients with metastatic disease to any distant site) subtypes. Median survival among the entire cohort with brain metastases was 10.0 months. Patients with HR-positive HER2-positive subtype displayed the longest median survival (21.0 months); patients with triple-negative subtype had the shortest median survival (6.0 months).

Conclusions and Relevance

The findings of this study provides population-based estimates of the incidence and prognosis for patients with brain metastases at time of diagnosis of breast cancer. The findings lend support to consideration of screening imaging of the brain for patients with HER2-positive or triple-negative subtypes and extracranial metastases.

A multidimensional view of racial differences in access to prostate cancer care

BACKGROUND

Racial disparities in prostate cancer treatment and outcomes are widespread and poorly understood. In the current study, the authors sought to determine whether access to care, measured across multiple dimensions, contributed to racial differences in prostate cancer.

METHODS

The Philadelphia Area Prostate Cancer Access Study (P² Access) included 2374 men diagnosed with localized prostate cancer between 2012 and 2014. Men were surveyed to assess their experiences accessing care (response rate of 51.1%). The authors determined appointment availability at 151 urology practices using simulated patient telephone calls and calculated travel distances using geospatial techniques. Multivariable logistic regression models were used to determine the association between 5 different domains of access (availability, accessibility, accommodation, affordability, and acceptability) and receipt of treatment, perceived quality of care, and physician-patient communication.

RESULTS

There were 1907 non-Hispanic white and 394 black men in the study cohort. Overall, approximately 85% of the men received definitive treatment with no differences noted by race. Black men were less likely to report a high quality of care (69% vs 81%; P<.001) and good physician-patient communication (60% vs 71%; P<.001) compared with white men. In adjusted models, none of the 5 domains of access were found to be associated with definitive treatment overall or with radical prostatectomy. All access domains were associated with perceived quality of care and communication, although these domains did not mediate racial disparities.

CONCLUSIONS

To the authors' knowledge, the current study presents the first comprehensive assessment of prostate cancer care access, treatment, and patient experience, demonstrating that although access was related to overall perceived quality of care and better physician-patient communication, it did not appear to explain observed racial differences. Cancer 2017;123:4449-57. © 2017 American Cancer Society.

Racial Differences in Prostate Cancer Treatment: The Role of Socioeconomic Status

OBJECTIVE

This study examines whether socioeconomic status (SES), measured at both the individual and neighborhood levels, is associated with receipt of definitive treatment for localized prostate cancer and whether these associations mediate racial differences in treatment between non-Hispanic White and non-Hispanic Black men.

DESIGN

The Philadelphia Area Prostate Cancer Access Study (P² Access) is a mailed, cross-sectional survey of men sampled from the Pennsylvania Cancer Registry, combined with neighborhood Census data.

SETTING

Eight counties in southeastern Pennsylvania.

PARTICIPANTS

2,386 men with prostate adenocarcinoma.

MAIN MEASURES

Receipt of definitive treatment, race, self-reported income, education, employment status, and neighborhood SES.

RESULTS

Overall, Black and White men were equally likely to receive definitive treatment. Men living in neighborhoods with higher SES were more likely to receive definitive treatment (OR 1.57, 95%CI 1.01, 2.42). Among men who received definitive treatment, Black men were significantly less likely to receive radical prostatectomy compared with White men (OR .71, 95% CI .52, .98), as were men with some college education compared with those with a high school education or less (OR .66, 95% CI .47, .94). SES does not mediate racial differences in receipt of definitive treatment or the type of definitive treatment received, and associations with income or employment status were not significant.

CONCLUSIONS

These results stress the importance of examining racial disparities within geographic areas and highlight the unique associations that different measures of SES, particularly neighborhood SES and education, may have with prostate cancer treatment.

Telomeres and telomerase in prostate cancer development and therapy

Aberrations in telomere biology are among the earliest events in prostate cancer tumorigenesis and continue during tumour progression. Substantial telomere shortening occurs in prostate cancer cells and high-grade prostatic intraepithelial neoplasia. Not all mechanisms of telomere shortening are understood, but oxidative stress from local inflammation might accelerate prostatic telomere loss. Critically short telomeres can drive the accumulation of tumour-promoting genomic alterations; however, continued telomere erosion is unsustainable and must be mitigated to ensure cancer cell survival and unlimited replication potential. Prostate cancers predominantly maintain telomeres by activating telomerase, but alternative mechanisms of telomere extension can occur in metastatic disease. Telomerase activity and telomere length assessment might be useful in prostate cancer diagnosis and prognosis. Telomere shortening in normal stromal cells has been associated with prostate cancer, whereas variable telomere lengths in prostate cancer cells and telomere shortening in cancer-associated stromal cells correlated with lethal disease. Single-agent telomerase-targeted treatments for solid cancers were ineffective in clinical trials but have not been investigated in prostate cancer and might be useful in combination with established regimens. Telomere-directed strategies have not been explored as extensively. Telomere deprotection strategies have the advantage of being effective in both telomerase-dependent and telomerase-independent cancers. Disruption of androgen receptor function in prostate cancer cells results in telomere dysfunction, indicating telomeres and telomerase as potential therapeutic targets in prostate cancer.

Sequential matched analysis of racial disparities in breast cancer hospitalization outcomes among African American and White patients

BACKGROUND

The purpose of this study is to determine if racial disparities in inpatient outcomes persist among hospitalized patients comparing African American and White breast cancer patients matched on demographics, presentation and treatment.

METHODS

A total of 136,211 African American and White breast cancer patients from the Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS) database, matched on demographics alone, demographics and presentation or demographics, presentation and treatment were studied. Conditional logistic regression was conducted to evaluate post-surgical complications, length of stay and in-hospital mortality outcomes. Analysis was further stratified by age (≤65 years and >65years) to evaluate whether disparities were larger in younger or older patients. All analysis was conducted using SAS 9.3.

RESULTS

White women had significantly shorter hospital length of stay when matched on demographics (β=-0.87, p-value=<0.0001), demographics and presentation (β=-0.63, p-value=<0.0001), and demographics, presentation and treatment (β=-0.51, p-value=<0.0001) compared with African Americans. White women also had lower odds of mortality compared with African American women when matched on demographics (OR: 0.72, 95% CI: 0.65-0.79), demographics and presentation (OR: 0.77, 95% CI: 0.71-0.85), or matched on demographics, presentation and treatment (OR: 0.80, 95% CI: 0.73-0.88). The racial difference observed in length of stay and mortality was larger in the age group ≤65 years compared with >65years CONCLUSION: African American women experienced higher odds of inpatient mortality and longer length of stay compared with White women even after accounting for differences in demographics, presentation and treatment characteristics.

Racial Differences in Cancer Susceptibility and Survival: More Than the Color of the Skin?

Epidemiological studies point to race as a determining factor in cancer susceptibility. In US registries recording cancer incidence and survival by race (distinguishing 'black versus white'), individuals of African ancestry have a globally increased risk of malignancies compared with Caucasians and Asian Americans. Differences in socioeconomic status and health-care access play a key role. However, the lesser disease susceptibility of Hispanic populations with comparable lifestyles and socioeconomic status as African Americans (Hispanic paradox) points to the concomitant importance of genetic determinants. Here, we overview the molecular basis of racial disparity in cancer susceptibility ranging from genetic polymorphisms and cancer-driver gene mutations to obesity, chronic inflammation, and immune responses. We discuss implications for race-adapted cancer screening programs and clinical trials to reduce disparities in cancer burden.

Insurance Status and Racial Disparities in Cancer-Specific Mortality in the United States: A Population-Based Analysis

Background: Cancer-specific mortality (CSM) is known to be higher among blacks and lower among Hispanics compared with whites. Private insurance confers CSM benefit, but few studies have examined the relationship between insurance status and racial disparities. We sought to determine differences in CSM between races within insurance subgroups.Methods: A population-based cohort of 577,716 patients age 18 to 64 years diagnosed with one of the 10 solid malignancies causing the greatest mortality over 2007 to 2012 were obtained from Surveillance, Epidemiology, and End Results. A Cox proportional hazards model for CSM was constructed to adjust for known prognostic factors, and interaction analysis between race and insurance was performed to generate stratum-specific HRs.Results: Blacks had similar CSM to whites among the uninsured [HR = 1.01; 95% confidence interval (CI), 0.96-1.05], but higher CSM among the Medicaid (HR = 1.04; 95% CI, 0.01-1.07) and non-Medicaid (HR = 1.14; 95% CI, 1.12-1.16) strata. Hispanics had lower CSM compared with whites among uninsured (HR = 0.80; 95% CI, 0.76-0.85) and Medicaid (HR = 0.88; 95% CI, 0.85-0.91) patients, but there was no difference among non-Medicaid patients (HR = 0.99; 95% CI, 0.97-1.01). Asians had lower CSM compared with whites among all insurance types: uninsured (HR = 0.80; 95% CI, 0.76-0.85), Medicaid (HR = 0.81; 95% CI, 0.77-0.85), and non-Medicaid (HR = 0.85; 95% CI, 0.83-0.87).Conclusions: The disparity between blacks and whites was largest, and the advantage of Hispanic race was absent within the non-Medicaid subgroup.Impact: These findings suggest that whites derive greater benefit from private insurance than blacks and Hispanics. Further research is necessary to determine why this differential exists and how disparities can be improved. Cancer Epidemiol Biomarkers Prev; 26(6); 869-75. ©2017 AACR.

Implementation of evidence-based patient navigation programs

BACKGROUND

Patient navigation refers to a direct patient care role that links patients with clinical providers and their support system and provides individualized support during cancer care, ensuring that patients have access to the knowledge and resources necessary to complete recommended treatment. While most reports have studied the role of patient navigators during the cancer screening or diagnostic process, emerging evidence indicates the benefits of patient navigation during active cancer treatment.

DISCUSSION

Reports in the literature are conflicting on the impact of patient navigation during cancer care and on the benefits to timely or quality care in all populations. Recent sub-analyses of the Patient Navigation Research Program data demonstrated specifically the benefits of targeting patient navigation to the most vulnerable populations, including those with low educational attainment, low income and unstable housing, less social support, multiple comorbidities, and minority race/ethnicity.

CONCLUSION

The implications of the Patient Navigation Research Program are that this resource is best utilized when directed to support the care of patients at locations with known challenges to timely care and for specific patients with risk factors for delays in care, including comorbidities, low educational attainment and low income. Implementation of patient navigation programs requires the following processes: needs assessment, selection of a navigator to meet the community and care needs, supervision and integration of the navigator into clinical processes, and systems support to facilitate the identification and tracking of those patients requiring patient navigation. There is a need for ongoing research on methods to fund and sustain patient navigation programs.