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

A Novel Strategy to Identify Prognosis-Relevant Gene Sets in Cancers

Molecular prognosis markers hold promise for improved prediction of patient survival, and a pathway or gene set may add mechanistic interpretation to their prognostic prediction power. In this study, we demonstrated a novel strategy to identify prognosis-relevant gene sets in cancers. Our study consists of a first round of gene-level analyses and a second round of gene-set-level analyses, in which the Composite Gene Expression Score critically summarizes a surrogate expression value at gene set level and a permutation procedure is exerted to assess prognostic significance of gene sets. An optional differential coexpression module is appended to the two phases of survival analyses to corroborate and refine prognostic gene sets. Our strategy was demonstrated in 33 cancer types across 32,234 gene sets. We found oncogenic gene sets accounted for an increased proportion among the final gene sets, and genes involved in DNA replication and DNA repair have ubiquitous prognositic value for multiple cancer types. In summary, we carried out the largest gene set based prognosis study to date. Compared to previous similar studies, our approach offered multiple improvements in design and methodology implementation. Functionally relevant gene sets of ubiquitous prognostic significance in multiple cancer types were identified.

Systematic review of neighborhood socioeconomic indices studied across the cancer control continuum

BACKGROUND

There is extensive interest in understanding how neighborhood socioeconomic status (nSES) may affect cancer incidence or survival. However, variability regarding items included and approaches used to form a composite nSES index presents challenges in summarizing overall associations with cancer. Given recent calls for standardized measures of neighborhood sociodemographic effects in cancer disparity research, the objective of this systematic review was to identify and compare existing nSES indices studied across the cancer continuum (incidence, screening, diagnosis, treatment, survival/mortality) and summarize associations by race/ethnicity and cancer site to inform future cancer disparity studies.

METHODS

Using PRISMA guidelines, peer-reviewed articles published between 2010 and 2019 containing keywords related to nSES and cancer were identified in PubMed.

RESULTS

Twenty-four nSES indices were identified from 75 studies. In general, findings indicated a significant association between nSES and cancer outcomes (n = 64/75 studies; 85.33%), with 42/64 (65.63%) adjusting for highly-correlated individual SES factors (e.g., education). However, the direction of association differed by cancer site, race/ethnicity, and nSES index.

CONCLUSIONS

This review highlights several methodologic and conceptual issues surrounding nSES measurement and potential associations with cancer disparities. Recommendations pertaining to the selection of nSES measures are provided, which may help inform disparity-related disease processes and improve the identification of vulnerable populations in need of intervention.

Impact of racial disparities and insurance status in patients with bone sarcomas in the USA : a population-based cohort study

Aims

Socioeconomic and racial disparities have been recognized as impacting the care of patients with cancer, however there are a lack of data examining the impact of these disparities on patients with bone sarcoma. The purpose of this study was to examine socioeconomic and racial disparities that impact the oncological outcomes of patients with bone sarcoma.

Methods

We reviewed 4,739 patients diagnosed with primary bone sarcomas from the Surveillance, Epidemiology and End Results (SEER) registry between 2007 and 2015. We examined the impact of race and insurance status associated with the presence of metastatic disease at diagnosis, treatment outcome, and overall survival (OS).

Results

Patients with Medicaid (odds ratio (OR) 1.41; 95% confidence interval (CI) 1.15 to 1.72) and uninsured patients (OR 1.90; 95% CI 1.26 to 2.86) had higher risks of metastatic disease at diagnosis compared to patients with health insurance. Compared to White patients, Black (OR 0.63, 95% CI 0.47 to 0.85) and Asian/Pacific Islander (OR 0.65, 95% CI 0.46 to 0.91) were less likely to undergo surgery. In addition, Black patients were less likely to receive chemotherapy (OR 0.67, 95% CI 0.49 to 0.91) compared to White patients. In patients with chondrosarcoma, those with Medicaid had worse OS compared to patients with insurance (hazard ratio (HR) 1.65, 95% CI 1.06 to 2.56).

Conclusion

In patients with a bone sarcoma, the cancer stage at diagnosis varied based on insurance status, and racial disparities were identified in treatment. Further studies are needed to identify modifiable factors which can mitigate socioeconomic and racial disparities found in patients with bone sarcomas.

Cite this article: Bone Joint Res 2022;11(5):278–291.

Mediators of Racial Disparity in the Use of Prostate Magnetic Resonance Imaging Among Patients With Prostate Cancer

Importance

Racial disparity in the use of prostate magnetic resonance imaging (MRI) presents obstacles to closing gaps in prostate cancer diagnosis, treatment, and outcome.

Objective

To identify clinical, sociodemographic, and structural processes underlying racial disparity in the use of prostate MRI among men with a new diagnosis of prostate cancer.

Design, Setting, and Participants

This population-based cohort study used mediation analysis to assess claims in the US Surveillance, Epidemiology, and End Results (SEER)-Medicare database for prostate MRI among 39 534 patients with a diagnosis of localized prostate cancer from January 1, 2011, to December 31, 2015. Statistical analysis was performed from April 1, 2020, to September 1, 2021.

Exposure

Diagnosis of prostate cancer.

Main Outcomes and Measures

Claims for prostate MRI within 6 months before or after diagnosis of prostate cancer were assessed. Candidate clinical and sociodemographic meditators were identified based on their association with both race and prostate MRI, including the Index of Concentration at the Extremes (ICE), as specified to measure racialized residential segregation. Mediation analysis was performed using nonlinear multiple additive regression trees models to estimate the direct and indirect effects of mediators.

Results

A total of 39 534 eligible male patients (3979 Black patients [10.1%] and 32 585 White patients [82.4%]; mean [SD] age, 72.8 [5.3] years) were identified. Black patients with prostate cancer were less likely than White patients to receive a prostate MRI (6.3% vs 9.9%; unadjusted odds ratio, 0.62, 95% CI, 0.54-0.70). Approximately 24% (95% CI, 14%-32%) of the racial disparity in prostate MRI use between Black and White patients was attributable to geographic differences (SEER registry), 19% (95% CI, 11%-28%) was attributable to neighborhood-level socioeconomic status (residence in a high-poverty area), 19% (95% CI, 10%-29%) was attributable to racialized residential segregation (ICE quintile), and 11% (95% CI, 7%-16%) was attributable to a marker of individual-level socioeconomic status (dual eligibility for Medicare and Medicaid). Clinical and pathologic factors were not significant mediators. In this model, the identified mediators accounted for 81% (95% CI, 64%-98%) of the observed racial disparity in prostate MRI use between Black and White patients.

Conclusions and Relevance

In this this population-based cohort study of US adults, mediation analysis revealed that sociodemographic factors and manifestations of structural racism, including poverty and residential segregation, explained most of the racial disparity in the use of prostate MRI among older Black and White men with prostate cancer. These findings can be applied to develop targeted strategies to improve cancer care equity.

Cancer statistics for African American/Black People 2022

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

Disparities in Breast Cancer Screening Between Caucasian and Asian American Women

INTRODUCTION

Asian American women have lower breast cancer incidence and mortality than their non-Hispanic White (NHW) counterparts. We sought to determine whether differences in screening practices could explain, in part, the variation in breast cancer detection rate.

METHODS

The 2015 National Health Interview Survey, an annual survey that is representative of the civilian, noninstitutionalized American population, was used to determine whether mammography usage was different between Asian and NHW women. Women ≥40 y of age who identified as either Asian or NHW were included.

RESULTS

A total of 7990 women ≥40 y of age (6.12% Asian, 93.88% NHW), representing 53,275,420 women in the population, were included in our cohort of interest; 71.49% of Asian and 74.46% of NHW women reported having had a mammogram within the past 2 y (P = 0.324). Controlling for education, insurance, family income, marital status, and whether they were born in the United States, Asians were less likely to have had a mammogram within the past 2 y than their NHW counterparts (odds ratio = 0.68; 95% confidence interval: 0.46-0.99, P = 0.047). Of patients who had an abnormal mammogram, there was no difference in the biopsy rate (20.35% versus 25.97%, P = 0.4935) nor in the rate of cancer diagnosis among those who had a biopsy (7.70% versus 12.86%, P = 0.211) between Asian and NHW women, respectively.

CONCLUSIONS

Our findings suggest that the lower breast cancer incidence among the Asian population may, in part, be explained by a lower screening mammography rate in this population.

Evaluation of Racial Disparities in Quality of Care for Patients With Gastrointestinal Tract Cancer Treated With Surgery

IMPORTANCE

Racial disparities have been demonstrated in many facets of health care, but a comprehensive understanding of who is most at risk for substandard surgical care of gastrointestinal tract cancers is lacking.

OBJECTIVE

To examine racial disparities in quality of care of patients with gastrointestinal tract cancers.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of patients with gastrointestinal tract cancer included the US population as captured in the National Cancer Database with a diagnosis from January 1, 2004, to December 31, 2017. Participants included 565 124 adults who underwent surgical resection of gastrointestinal tract cancers. Data were analyzed from June 21 to December 23, 2021.

EXPOSURES

Race and site of cancer.

MAIN OUTCOMES AND MEASURES

Oncologic standard of care, as defined by negative resection margin, adequate lymphadenectomy, and receipt of indicated adjuvant chemotherapy and/or radiotherapy.

RESULTS

Among 565 124 adult patients who underwent surgical resection of a gastrointestinal tract cancer, 10.9% were Black patients, 83.5% were White patients, 54.7% were men, and 50.7% had Medicare coverage. The most common age range at diagnosis was 60 to 69 years (28.5%). Longer median survival was associated with negative resection margins (87.3 [IQR, 28.5-161.9] months vs 22.9 [IQR, 8.8-69.2] months; P < .001) and adequate lymphadenectomies (80.7 [IQR, 25.6 to not reached] months vs 57.6 [IQR, 17.7-153.8] months; P < .001). After adjustment for covariates, Black patients were less likely than White patients to have negative surgical margins overall (odds ratio [OR], 0.96 [95% CI, 0.93-0.98]) and after esophagectomy (OR, 0.71 [95% CI, 0.58-0.87]), proctectomy (OR, 0.71 [95% CI, 0.66-0.76]), and biliary resection (OR, 0.75 [95% CI, 0.61-0.91]). Black patients were also less likely to have adequate lymphadenectomy overall (OR, 0.89 [95% CI, 0.87-0.91]) and after colectomy (OR, 0.89 [95% CI, 0.87-0.92]), esophagectomy (OR, 0.72 [95% CI, 0.63-0.83]), pancreatectomy (OR, 0.90 [95% CI, 0.85-0.96]), proctectomy (OR, 0.93 [95% CI, 0.88-0.98]), proctocolectomy (OR, 0.90 [95% CI, 0.81-1.00]), and enterectomy (OR, 0.71 [95% CI, 0.65-0.79]). Black patients were more likely than White patients not to be recommended for chemotherapy (OR, 1.15 [95% CI, 1.10-1.21]) and radiotherapy (OR, 1.49 [95% CI, 1.35-1.64]) because of comorbidities and more likely not to receive recommended chemotherapy (OR, 1.68 [95% CI, 1.55-1.82]) and radiotherapy (OR, 2.18 [95% CI, 1.97-2.41]) for unknown reasons.

CONCLUSIONS AND RELEVANCE

These findings suggest that there are significant racial disparities in surgical care of gastrointestinal tract cancers. Black patients are less likely than White patients to receive standard of care with respect to negative surgical margins, adequate lymphadenectomies, and use of adjuvant therapies. Both system- and physician-level reforms are needed to eradicate these disparities in health care.

Structural Racism and Breast Cancer-specific Survival: Impact of Economic and Racial Residential Segregation

OBJECTIVE

To analyze the effect of economic and racial/ethnic residential segregation on breast cancer-specific survival (BCSS) in South Florida, a diverse metropolitan area that mirrors the projected demographics of many United States regions.

SUMMARY BACKGROUND DATA

Despite advances in diagnosis and treatment, racial and economic disparities in BCSS. This study evaluates these disparities through the lens of racial and economic residential segregation, which approximate the impact of structural racism.

METHODS

Retrospective cohort study of stage I to IV breast cancer patients treated at our institution from 2005 to 2017. Our exposures include index of concentration at the extremes, a measurement of economic and racial neighborhood segregation, which was computed at the census-tract level using American Community Survey data. The primary outcome was BCSS.

RESULTS

Random effects frailty models predicted that patients living in low-income neighborhoods had higher mortality compared to those living in high-income neighborhoods [hazard ratios (HR): 1.56, 95% confidence interval (CI): 1.23-2.00]. Patients living in low-income non-Hispanic Black and Hispanic neighborhoods had higher mortality compared to those living in high-income non-Hispanic White (NHW) neighborhoods (HR: 2.43, 95%CI: 1.72, 3.43) and (HR: 1.99, 95%CI: 1.39, 2.84), after controlling for patient characteristics, respectively. In adjusted race-stratified analysis, NHWs living in low-income non-Hispanic Black neighborhoods had higher mortality compared to NHWs living in high-income NHW neighborhoods (HR: 4.09, 95%CI: 2.34-7.06).

CONCLUSIONS

Extreme racial/ethnic and economic segregation were associated with lower BCSS. We add novel insight regarding NHW and Hispanics to a growing body of literature that demonstrate how the ecological effects of structural racism-expressed through poverty and residential segregation-shape cancer survival.

Understanding gastrointestinal cancer mortality disparities in a racially and geographically diverse population

BACKGROUND

Gastrointestinal (GI) cancers represent a diverse group of diseases. We assessed differences in geographic and racial disparities in cancer-specific mortality across subtypes, overall and by patient characteristics, in a geographically and racially diverse US population.

METHODS

Clinical, sociodemographic, and treatment characteristics for patients diagnosed during 2009-2014 with colorectal cancer (CRC), pancreatic cancer, hepatocellular carcinoma (HCC), or gastric cancer in Georgia were obtained from the Surveillance, Epidemiology, and End Results Program database. Patients were classified by geography (rural or urban county) and race and followed for cancer-specific death. Multivariable Cox proportional hazards models were used to calculate stratified hazard ratios (HR) and 95% confidence intervals (CIs) for associations between geography or race and cancer-specific mortality.

RESULTS

Overall, 77% of the study population resided in urban counties and 33% were non-Hispanic Black (NHB). For all subtypes, NHB patients were more likely to reside in urban counties than non-Hispanic White patients. Residing in a rural county was associated with an overall increased hazard of cancer-specific mortality for HCC (HR = 1.15, 95% CI = 1.02-1.31), pancreatic (HR = 1.11, 95% CI = 1.03-1.19), and gastric cancer (HR = 1.17, 95% CI = 1.03-1.32) but near-null for CRC. Overall racial disparities were observed for CRC (HR = 1.18, 95% CI = 1.11-1.25) and HCC (HR = 1.12, 95% CI = 1.01-1.24). Geographic disparities were most pronounced among HCC patients receiving surgery. Racial disparities were pronounced among CRC patients receiving any treatment.

CONCLUSION

Geographic disparities were observed for the rarer GI cancer subtypes, and racial disparities were pronounced for CRC. Treatment factors appear to largely drive both disparities.

Competing risk of the specific mortality among Asian-American patients with prostate cancer: a surveillance, epidemiology, and end results analysis

Background

Adopted the competing-risk model to investigate the relevant factors affecting the prostate cancer (PCa)-specific mortality among Asian-American PCa patients based on the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

The information of 26,293 Asian-American patients diagnosed with PCa between 2004 and 2015 were extracted from the SEER 18 database. Subjects were divided into three groups: died of PCa, died of other causes, survival based on the outcomes at the end of 155 months’ follow-up. Multivariate analysis was performed by the Fine-gray proportional model. Meanwhile, subgroup analyses were conducted risk stratification by race and age.

Results

Age ≥ 65 years [Hazard ratio (HR) = 1.509, 95% confidence interval (CI) 1.299–1.754], race (HR = 1.220, 95% CI 1.028–1.448), marital status (unmarried, single or widowed, HR = 1.264, 95% CI 1.098–1.454), tumor grade II (HR = 3.520, 95% CI 2.915–4.250), the American Joint Committee on Cancer (AJCC) stage (T3: HR = 1.597, 95% CI 1.286–1.984; T4: HR = 2.446, 95% CI 1.796–3.331; N1: HR = 1.504, 95% CI 1.176–1.924; M1: HR = 9.875, 95% CI 8.204–11.887) at diagnosis, radiotherapy (HR = 1.892, 95% CI 1.365–2.623), regional nodes positive (HR = 2.498, 95% CI 1.906–3.274) increased risk of PCa-specific mortality for Asian-American PCa patients, while surgical (HR = 0.716, 95% CI 0.586–0.874) reduced the risk.

Conclusion

The study findings showed that age, race, marital status, tumor grade (II), AJCC stages (T3, T4, N1, M1) at diagnosis, radiotherapy, regional nodes positive and surgery was associated with the specific mortality of PCa patients among Asian-Americans.

Prognostic Analysis and Comparison of the 2014 and 2018 International Federation of Gynecology and Obstetrics Staging System on Overall Survival in Patients with Stage IIB-IVA Cervix Carcinoma

Purpose

This study aimed to assess the prognostic factors of overall survival (OS) in patients with stage IIB–IVA cervix carcinoma (CC) who underwent external beam radiation therapy (EBRT) and brachytherapy (BRT) and to compare the prognostic accuracy of the 2014 and 2018 International Federation of Gynecology and Obstetrics (FIGO) staging system using the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

Patients with a histopathological diagnosis of CC between 2004 and 2016 were included. The primary endpoint was OS. The prognostic significance for OS was analyzed by the Cox regression model. Prognostic accuracy in evaluating 3- and 5-year OS in different staging systems was evaluated using time-dependent receiver operating characteristic (tdROC) curves.

Results

A total of 2585 patients with stage IIB–IVA CC, staged according to the 2014 FIGO staging system, were included in the study. The 3- and 5-year OS rates were 63.9% and 56.6%, respectively, with a median OS of 98 months. Independent variables, such as older age at diagnosis, histological grades apart from well or moderately differentiated, large tumor size, advanced tumor stages classified according to the 2014 and 2018 FIGO staging systems and treatment without chemotherapy or unknown were associated with a worse OS. A tdROC analysis conducted using DeLong’s tests revealed no significant difference in the prediction of 3- and 5-year OS between the 2014 and 2018 FIGO staging systems (P = 0.912 and 0.863, respectively).

Conclusion

Both 2014 and 2018 FIGO staging systems were strong prognostic factors for OS. No significant risk classification was observed for stage IIIC1 disease in the revised 2018 FIGO staging system for patients who underwent EBRT and BRT.

Geospatial Disparities in the Treatment of Curable Breast Cancer Across the US

IMPORTANCE

Patient factors help explain disparities in breast cancer treatments and outcomes.

OBJECTIVE

To determine the extent to which geospatial variation in initial breast cancer care can be attributed to region vs patient factors with the aim of guiding quality improvement efforts.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective population-based cohort study from January 1, 2007, through December 31, 2016, using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database that included 31 571 patients diagnosed with stage I to III breast cancer from 2007 through 2013. Five metrics of care delivery were defined: stage I at diagnosis, chemotherapy receipt, radiation therapy receipt, endocrine therapy (ET) initiation (year 1), and ET continuation (years 3-5). Data analysis was performed from January to June 2021.

EXPOSURES

Stage I diagnosis and treatment with chemotherapy, radiation therapy, or ET.

MAIN OUTCOMES AND MEASURES

For each metric, total variance was attributed proportionally to 4 domains-random, patient factors (eg, age, race and ethnicity, socioeconomic status), region (health service area [HSA]), and unexplained-using hierarchical multivariable modeling.

RESULTS

Of 31 571 total patients (median [IQR] age, 71 [68-75] years), 19 391 (61.4%) had stage I disease at diagnosis. Among eligible patients, 17 297 of 21 190 (81.6%) received radiation therapy, 7204 of 9903 (72.8%) received chemotherapy, 13 115 of 26 855 (48.8%) initiated ET, and 13 944 of 26 855 (52.1%) continued ET. Geospatial density (ie, heat) maps highlight regional performance patterns. For all 5 metrics, region/HSA explained more observed variation (24%-48%) than patient factors (1%-4%); the largest share of variation was unexplained (35%-54%). The metrics with the largest proportion of total variance attributed to region/HSA were ET initiation and continuation (28% and 39%, respectively).

CONCLUSIONS AND RELEVANCE

In this cohort study, there was substantial unexplained geospatial variation in initial breast cancer care. The variance attributed to region/HSA was multifold larger than that explained by patient factors. The importance of patient factors such as race and ethnicity notwithstanding, future quality improvement efforts should focus on reducing unwarranted geospatial variation, especially including optimizing the delivery of ET in low-performing regions.

The Impact of Income and Social Mobility on Colorectal Cancer Outcomes and Treatment: A Cross-sectional Study

OBJECTIVE

To determine the impact of income mobility on racial disparities in colorectal cancer.

BACKGROUND

There are well-documented disparities in colorectal cancer treatment and outcomes between Black and White patients. Socioeconomic status, insurance, and other patient-level factors have been shown important, but little has been done to show the discriminatory factors that lead to these outcomes.

METHODS

Data were obtained from the Surveillance Epidemiology and End-Results database for Black and White patients with colorectal cancer between 2005 and 2015. County level measures of Black (BIM) and White income mobility (WIM) were obtained from the Opportunity Atlas as a measure of intergenerational poverty and social mobility. Regression models were created to assess the relative risk of advanced stage at diagnosis (Stage IV), surgery for localized disease (Stage I/II), and cancer-specific mortality.

RESULTS

There was no significant association of BIM or WIM on advanced stage at diagnosis in Black or White patients. An increase of $10,000 of BIM was associated with a 9% decrease in hazards of death for both Black (hazard ratio 0.91, 95% confidence interval 0.86,0.95) and White (0.91, 95%CI 0.90,0.93) patients, while the same increase in WIM was associated with no significant difference in hazards among Black patients (hazard ratio 0.99, 95% confidence interval 0.97,1.02). There were no predicted racial differences in hazards of death at high levels of BIM.

CONCLUSIONS

Increased Black income mobility significantly improves survival for both Black and White patients. Interventions aimed at increasing economic and social mobility could significantly decrease mortality in both Black and White patients while alleviating disparities in outcomes.

Healthcare Disparities and Colorectal Cancer

Health care disparities are defined as health differences between groups that are avoidable, unnecessary, and unjust. Racial disparities in colorectal cancer mortality, particularly for Black patients, are well-described. Disparities in preventative measures, early detection, effective treatment, and posttreatment services contribute to these differences. Underlying these issues are patient, provider, health care system, and policy-level factors that lead to these disparities. Multilevel interventions designed to address each level of care can provide an effective means to mitigate these disparities.

Applying Latent Class Analysis on Cancer Registry Data to Identify and Compare Health Disparity Profiles in Colorectal Cancer Surgical Treatment Delay

CONTEXT

Colorectal cancer (CRC) surgical treatment delay (TD) has been associated with mortality and morbidity; however, disparities by TD profiles are unknown.

OBJECTIVES

This study aimed to identify CRC patient profiles of surgical TD while accounting for differences in sociodemographic, health insurance, and geographic characteristics.

DESIGN

We used latent class analysis (LCA) on 2005-2015 Tennessee Cancer Registry data of CRC patients and observed indicators that included sex/gender, age at diagnosis, marital status (single/married/divorced/widowed), race (White/Black/other), health insurance type, and geographic residence (non-Appalachian/Appalachian).

SETTING

The state of Tennessee in the United States that included both Appalachian and non-Appalachian counties.

PARTICIPANTS

Adult (18 years or older) CRC patients (N = 35 412) who were diagnosed and surgically treated for in situ (n = 1286) and malignant CRC (n = 34 126).

MAIN OUTCOME MEASURE

The distal outcome of TD was categorized as 30 days or less and more than 30 days from diagnosis to surgical treatment.

RESULTS

Our LCA identified a 4-class solution and a 3-class solution for in situ and malignant profiles, respectively. The highest in situ CRC patient risk profile was female, White, aged 75 to 84 years, widowed, and used public health insurance when compared with respective profiles. The highest malignant CRC patient risk profile was male, Black, both single/never married and divorced/separated, resided in non-Appalachian county, and used public health insurance when compared with respective profiles. The highest risk profiles of in situ and malignant patients had a TD likelihood of 19.3% and 29.4%, respectively.

CONCLUSIONS

While our findings are not meant for diagnostic purposes, we found that Blacks had lower TD with in situ CRC. The opposite was found in the malignant profiles where Blacks had the highest TD. Although TD is not a definitive marker of survival, we observed that non-Appalachian underserved/underrepresented groups were overrepresented in the highest TD profiles. The observed disparities could be indicative of intervenable risk.

Accountable care in oncology: Where do we go from here?

The study by Erfani et al. confirms that ACOs did not achieve the promise of cancer care cost reduction, but leaves open important questions about the impacts of accountable care on the quality, coordination, and equity of cancer care delivery. While the inability of ACOs to deliver cost reductions for patients with cancer may feel like a step backwards for accountable care in oncology, the work of Erfani et al. actually represents an important step forward in the field, settling the important cost question in order to open a broader conversation on the goals of ACOs and value-based care delivery models in oncology, the means to evaluate them in a comprehensive, patient-centered manner, and the urgency of incorporating the needs and voices of diverse populations in the important work of cancer care delivery reform.

The study by Erfani et al. confirms that ACOs did not achieve the promise of cancer care cost reduction, but leaves open important questions about the impacts of accountable care on the quality, coordination, and equity of cancer care delivery.

The association of health insurance and race with treatment and survival in patients with metastatic colorectal cancer

Background

Black patients and underinsured patients with colorectal cancer (CRC) present with more advanced disease and experience worse outcomes. The study aim was to evaluate the interaction of health insurance status and race with treatment and survival in metastatic CRC.

Materials and methods

Patients diagnosed with metastatic CRC within NCDB from 2006–2016 were included. Primary outcomes included receipt of chemotherapy and 3-year all-cause mortality. Multivariable logistic regression and Cox-regression (MVR) including a two-way interaction term of race and insurance were performed to evaluate the differential association of race and insurance with receipt of chemotherapy and mortality, respectively.

Results

128,031 patients were identified; 70.6% White, 14.4% Black, 5.7% Hispanic, and 9.3% Other race. Chemotherapy use was higher among White compared to Black patients. 3-year mortality rate was higher for Blacks and lower for Hispanics, in comparison with White patients. By MVR, Black patients were less likely to receive chemotherapy. When stratified by insurance status, Black patients with private and Medicare insurance were less likely to receive chemotherapy than White patients. All-cause mortality was higher in Black patients and lower in Hispanic patients, and these differences persisted after controlling for insurance and receipt of chemotherapy.

Conclusion

Black patients and uninsured or under-insured patients with metastatic CRC are less likely to receive chemotherapy and have increased mortality. The effect of health insurance among Blacks and Whites differs, however, and improving insurance alone does not appear to fully mitigate racial disparities in treatment and outcomes.

Impacts of Neighborhood Characteristics and Surgical Treatment Disparities on Overall Mortality in Stage I Renal Cell Carcinoma Patients

Racial/ethnic minority groups in the United States have high renal cell carcinoma (RCC) mortality rates. This study assessed surgical treatment disparities across racial/ethnic groups and impacts of neighborhood socioeconomic characteristics on surgical treatments and overall mortality. Stage I RCC patients diagnosed between 2004 and 2016 from National Cancer Database were included (n = 238,141). We assessed differences in associations between race/ethnicity and treatment patterns using logistic regression and between race/ethnicity and overall mortality using Cox regression with and without neighborhood characteristics in the regression models. When compared to non-Hispanic Whites (NHWs), American Indians/Alaska Natives and non-Hispanic Blacks (NHBs) were more likely not to receive surgical care and all racial/ethnic minority groups had significantly increased odds of undergoing radical rather than partial nephrectomy, even after adjusting for neighborhood characteristics. Including surgical treatment and neighborhood factors in the models slightly attenuated the association, but NHBs had a significantly increased risk of overall mortality. NHBs who underwent radical nephrectomy had an increased risk of mortality (HR 1.15, 95% CI: 1.08-1.23), but not for NHBs who underwent partial nephrectomy (HR 0.92, 95% CI: 0.84-1.02). Neighborhood factors were associated with surgical treatment patterns and overall mortality in both NHBs and NHWs. Neighborhood socioeconomic factors may only partly explain RCC disparities.

The impact of race and ethnicity in breast cancer-disparities and implications for precision oncology

Breast cancer is the most commonly diagnosed cancer worldwide and is one of the leading causes of cancer death. The incidence, pathological features, and clinical outcomes in breast cancer differ by geographical distribution and across racial and ethnic populations. Importantly, racial and ethnic diversity in breast cancer clinical trials is lacking, with both Blacks and Hispanics underrepresented. In this forum article, breast cancer researchers from across the globe discuss the factors contributing to racial and ethnic breast cancer disparities and highlight specific implications of precision oncology approaches for equitable provision of breast cancer care to improve outcomes and address disparities.

Disparities in Lung Cancer Treatment

PURPOSE OF REVIEW

Despite an overall reduction in lung cancer incidence and mortality rates worldwide, Blacks still have higher mortality rates compared to Whites. There are many factors that contribute to this difference. This review seeks to highlight racial disparities in treatment and the possible reasons for these disparities.

RECENT FINDINGS

Factors attributing to racial disparities in lung cancer treatment include social determinants of health, differences in the administration of guideline-concordant therapy as well as molecular testing that is essential for most NSCLC patients. One way to circumvent disparities in lung cancer survivorship is to ensure equal representation of race in research at all levels that will provide insight on interventions that will address social determinants of health, differences in treatment patterns, molecular testing, and clinical trial involvement.

Healthcare Utilization Disparities Among Lung Cancer Patients in US Hospitals During 2010–2014: Evidence from the US Hispanic Population’s Hospital Charges and Length of Stay

Purpose

There is a lack of research focused on understanding the differences in the healthcare utilization of lung cancer patients between ethnic groups. This study aims to characterize disparities in healthcare utilization for Hispanic lung cancer patients compared to non-Hispanic patients.

Methods

National Inpatient Sample was used to identify nationwide lung cancer patients (n=141,675, weighted n=702,878) from 2010 to 2014. We examined the characteristics of the study sample by race (Hispanic vs non-Hispanic) and its association with healthcare utilization, measured by discounted hospital charges and length of stay. Multivariate survey regression models were used to identify predictors by racial groups.

Results

Among 702,878 lung cancer patients, 5.1% were Hispanic. Descriptive statistics showed that Hispanics have higher hospital charges and length of stay. Survey regression results also suggested that Hispanic lung cancer patients were associated with higher hospital charges (26.6%) and length of stay (3.5%) than non-Hispanic lung cancer patients. Subgroup analysis displayed a similar trend to the full model.

Conclusion

Healthcare utilization disparities may exist for lung cancer Hispanic patients due to insurance status and early detection. Thus, our findings support providing financial assistance and targeted programs for minority patients. Future health policy consideration should be given to those vulnerable populations where limited healthcare resources are available.

Contributions of Social Factors to Disparities in Prostate Cancer Risk Profiles among Black Men and Non-Hispanic White Men with Prostate Cancer in California

BACKGROUND

Black men are more likely than Non-Hispanic White (NHW) men to be diagnosed with high-risk prostate cancer. We examined the extent to which social factors were associated with differences in prostate cancer risk profiles between Black men and NHW men [using a modification to the original D'Amico risk groups based on prostate specific antigen (PSA), Gleason score (GS), and TNM stage (stage)], based on individual and combined clinicopathologic characteristics.

METHODS

We conducted a cross-sectional population-based study of 23,555 Black men and 146,889 NHW men diagnosed with prostate cancer in the California Cancer Registry from 2004 to 2017. We conducted multivariable logistic regression to examine the association of year of diagnosis, block group-level neighborhood socioeconomic status (nSES), marital status, and insurance type on differences in prostate cancer risk profiles between Black and NHW men.

RESULTS

High PSA (>20 ng/mL), GS, stage, individually and combined prostate cancer risk profiles were more common among Black men versus NHW men. In fully adjusted models, relative to NHW men, we observed a persistent 67% increased odds of high PSA among Black men. nSES was the factor most strongly associated with racial disparity in high PSA, accounting for 25% of the difference. Marital status was the factor that was second most associated with a racial disparity.

CONCLUSIONS

nSES was the factor most strongly associated with racial disparities in high PSA prostate cancer.

IMPACT

The influence of nSES on racial disparities in PSA, GS, stage, and prostate cancer risk profiles warrants further consideration.

Promoting informed prostate cancer screening decision-making for African American men in a community-based setting

PURPOSE

Current screening guidelines for prostate cancer (PCa) encourage men to make individual screening decisions after consulting with their primary care provider to weigh the risks and benefits of undergoing prostate specific antigen (PSA) testing, but many men at high risk of PCa diagnosis (notably African American men) are more likely to be uninsured and lack a primary care provider. An academic-community partnership redesigned its community-based screening program to ensure access to services for African American men, incorporating a session with a trained clinical educator in community settings, designed to increase knowledge and promote informed decision-making regarding PSA testing. This study evaluated effects of the intervention on decision-making outcomes.

METHODS

To evaluate program efficacy, 88 men completed pre- and post-test surveys assessing outcomes of interest.

RESULTS

Participants' knowledge, beliefs, attitudes, anxiety levels, and self-efficacy all improved from pre- to post-test at a statistically significant level. Most notably participants' awareness that PCa is often not life-threatening, and watchful waiting is a reasonable treatment option increased after the encounter. More than half of the study sample felt they had received enough knowledge to make an informed decision about whether the PSA test was right for them.

CONCLUSION

Our findings show the program had positive effects on men's ability to make informed decisions about PCa screening and demonstrate that educational outreach programs with an emphasis on informed decision-making can effectively balance screening guidelines with the needs of underserved populations in community settings to improve outcomes.

Racial disparities in colon cancer survival: A propensity score matched analysis in the United States

BACKGROUND

Black patients are disproportionally impacted by colorectal cancer, both with respect to incidence and mortality. Studies accounting for patient- and community-level factors that contribute to such disparities are lacking. Our objective is to determine if Black compared to White race is associated with worse survival in colon cancer, while accounting for socioeconomic and clinical factors.

METHODS

A retrospective analysis was performed of Black or White patients with nonmetastatic colon cancer in the Surveillance, Epidemiology, and End Results cancer registry between 2008 and 2016. Multivariable Cox regression analysis and propensity-score matching was performed.

RESULTS

A total of 100,083 patients were identified, 15,155 Black patients and 84,928 White patients. Median follow-up was 38 months (interquartile range: 15-67). Black patients were more likely to lack health insurance and reside in counties with low household income, high unemployment, and lower high school completion rates. Black race was associated with poorer unadjusted 5-year cancer-specific survival (79.4% vs 82.4%, P < .001). After multivariable adjustment, Black race was associated with greater 5-year cancer-specific mortality (hazard ratio: 1.19, 95% confidence interval: 1.13-1.25, P < .001) and overall mortality (hazard ratio: 1.12, 95% confidence interval: 1.08-1.16, P < .001). Mortality was higher for Black patients across stages: stage I (hazard ratio: 1.08, 95% confidence interval: 1.08-1.09), stage II (hazard ratio: 1.06, 95% confidence interval: 1.06-1.07), stage III (1.03, 95% confidence interval: 1.03-1.04). Propensity-score matching identified 27,640 patients; Black race was associated with worse 5-year overall survival (67.5% vs 70.2%, P = .003) and cancer-specific survival (79.4% vs 82.3%, P < .001).

CONCLUSIONS

This US population-based analysis confirms poorer overall survival and cancer-specific survival in Black patients undergoing surgery for nonmetastatic colon cancer despite accounting for trans-sectoral factors that have been implicated in structural racism.

#ColonCancer: Social Media Discussions About Colorectal Cancer During the COVID-19 Pandemic

PURPOSE

Colorectal cancer (CRC) is the second leading cause of cancer-related mortality worldwide. Social media platforms such as Twitter are extensively used to communicate about cancer care, yet little is known about the role of these online platforms in promoting early detection or sharing the lived experiences of patients with CRC. This study tracked Twitter discussions about CRC and characterized participating users to better understand public communication and perceptions of CRC during the COVID-19 pandemic.

METHODS

Tweets containing references to CRC were collected from January 2020 to April 2021 using Twitter's Application Programming Interface. Account metadata was used to predict user demographic information and classify users as either organizations, individuals, clinicians, or influencers. We compared the number of impressions across users and analyzed the content of tweets using natural language processing models to identify prominent topics of discussion.

RESULTS

There were 72,229 unique CRC-related tweets by 31,170 users. Most users were male (66%) and older than 40 years (57%). Individuals accounted for most users (44%); organizations (35%); clinicians (19%); and influencers (2%). Influencers made the most median impressions (35,853). Organizations made the most overall impressions (1,067,189,613). Tweets contained the following topics: bereavement (20%), appeals for early detection (20%), research (17%), National Colorectal Cancer Awareness Month (15%), screening access (14%), and risk factors (14%).

CONCLUSION

Discussions about CRC largely focused on bereavement and early detection. Online coverage of National Colorectal Cancer Awareness Month and personal experiences with CRC effectively stimulated goal-oriented tweets about early detection. Our findings suggest that although Twitter is commonly used for communicating about CRC, partnering with influencers may be an effective strategy for improving communication of future public health recommendations related to CRC.

Nonverbal Synchrony: An Indicator of Clinical Communication Quality in Racially-Concordant and Racially-Discordant Oncology Interactions

Objectives

The aim of this cross-sectional study was to apply a novel software to measure and compare levels of nonverbal synchrony, as a potential indicator of communication quality, in video recordings of racially-concordant and racially-discordant oncology interactions. Predictions include that the levels of nonverbal synchrony will be greater during racially-concordant interactions than racially-discordant interactions, and that levels of nonverbal synchrony will be associated with traditional measures of communication quality in both racially-concordant and racially-discordant interactions.

Design

This is a secondary observational analysis of video-recorded oncology treatment discussions collected from 2 previous studies.

Setting

Two National Cancer Institute-designated Comprehensive Cancer Centers and another large urban cancer center.

Participants

Participants from Study 1 include 161 White patients with cancer and 11 White medical oncologists. Participants from Study 2 include 66 Black/African-American patients with cancer and 17 non-Black medical oncologists. In both studies inclusion criteria for patients was a recent cancer diagnosis; in Study 2 inclusion criteria was identifying as Black/African American.

Main outcome measures

Nonverbal synchrony and communication quality.

Results

Greater levels of nonverbal synchrony were observed in racially-discordant interactions than in racially-concordant interactions. Levels of nonverbal synchrony were associated with indicators of communication quality, and these associations were more consistently found in racially-discordant interactions.

Conclusion

This study advances clinical communication and disparities research by successfully applying a novel approach capturing the unconscious nature of communication, and revealing differences in communication in racially-discordant and racially-concordant oncology interactions. This study highlights the need for further exploration of nonverbal aspects relevant to patient-physician interactions.

Racial and ethnic disparities in cancer caregiver burden and potential sociocultural mediators

PURPOSE

Black and Hispanic cancer patients experience many worse care quality and health outcomes than non-Hispanic White patients, yet less is known about disparities in caregiving responsibilities and burden among cancer caregivers.

METHODS

We analyzed cross-sectional data from Cancer Care Outcomes Research and Surveillance consortium, a large multi-regional, population-based study of colorectal and lung cancer patients and their caregivers. Bivariate and multivariable regression models assessed differences by racial and ethnic groups in caregiving responsibilities and social/emotional, financial, and health burdens. Structural equation models estimated whether sociocultural resources (social support, caregiving preparedness, caregiver-patient communication) mediated racial and ethnic differences in caregiver burden.

RESULTS

Compared with non-Hispanic White caregivers (N = 1,169), Black (N = 220) and Hispanic (N = 84) caregivers spent more time caregiving (18 vs. 26 vs. 26 h/week; P < 0.001), completed more tasks (6.8 vs. 7.6 vs. 8.7; P < 0.05), and reported greater financial burden (P = 0.02). Yet, compared to non-Hispanic Whites, Hispanic caregivers reported similar social/emotional and health burdens, while Black caregivers reported lower levels (P < 0.01). In adjusted models, disparities in financial burden disappeared, and Hispanic caregivers had less health burden than non-Hispanic White caregivers (P = 0.01). Social support and/or caregiving preparedness partially mediated the Black-White gap for all three types of burdens.

CONCLUSIONS

Black and Hispanic cancer caregivers perform more caregiving and report greater financial burden than non-Hispanic White caregivers, but experience lower or equivalent social/emotional and health burdens. Racial differences in caregivers' social support and caregiving preparedness levels partially explain Black-White burden differences. Research and policy should address Black and Hispanic caregivers' increased financial burden.

Impact of Race, Ethnicity, and Socioeconomic Status on Nasopharyngeal Carcinoma Disease-Specific and Conditional Survival

Introduction  Race, ethnicity, and socioeconomic status (SES) are complex, interconnected social determinants of health outcomes. This study uses multivariable analysis on a combination of large national datasets to examine the effects of these factors on 5-year disease-specific survival (DSS) and conditional DSS (CDSS) for nasopharyngeal carcinoma (NPC). Methods  A retrospective study of adults with NPC between 2000 and 2017 from the Surveillance, Epidemiology, End Results (SEER) registry was performed, using the National Cancer Institute Yost Index, a census tract-level composite score of SES to categorize patients. Kaplan-Meier analysis and Cox's regression for DSS and CDSS were stratified by SES. Logistic regression was conducted to identify risk factors for advanced cancer stage at time of diagnosis and receiving multimodal therapy. Results  Our analysis included 5,632 patients. DSS was significantly associated with race and SES ( p  < 0.01). Asian/Pacific Islander patients exhibited increased survival when controlling for other variables (hazard ratio [HR] = 0.73, p  < 0.01). Although Black patients were more likely to be diagnosed with advanced disease (Black odds ratio [OR] = 1.47, p  < 0.01), Black patients were also less likely to receive multimodal therapy; however, this relationship lost statistical significance once SES was incorporated into the multivariable analysis. DSS was decreased among the lowest (first) and middle (second) tertiles of SES (first HR = 1.34, p  < 0.01; second HR = 1.20, p  < 0.01) compared with the highest (third). Conclusion  Our results indicate that race, ethnicity, and SES significantly affect survival, stage at diagnosis, and treatment of NPC. An interplay of tumor biology and inequalities in access to care likely drives these disparities.

Immune response and inflammation in cancer health disparities

Cancer death rates vary among population groups. Underserved populations continue to experience an excessive burden of lethal cancers that is largely explained by health-care disparities. However, the prominent role of advanced-stage disease as a driver of cancer survival disparities may indicate that some cancers are more aggressive in certain population groups than others. The tumor mutational burden can show large differences among patients with similar-stage disease but differences in race/ethnicity or residence. These dissimilarities may result from environmental or chronic inflammatory exposures, altering tumor biology and the immune response. We discuss the evidence that inflammation and immune response dissimilarities among population groups contribute to cancer disparities and how they can be targeted to reduce these disparities.

Inequity in Cardio-Oncology: Identifying Disparities in Cardiotoxicity and Links to Cardiac and Cancer Outcomes

Minority and underresourced communities experience disproportionately high rates of fatal cancer and cardiovascular disease. The intersection of these disparities within the multidisciplinary field of cardio‐oncology is in critical need of examination, given the risk of perpetuating health inequities in the growing vulnerable population of patients with cancer and cardiovascular disease. This review identifies 13 cohort studies and 2 meta‐analyses investigating disparate outcomes in treatment‐associated cardiotoxicity and situates these data within the context of oncologic disparities, preexisting cardiovascular disparities, and potential system‐level inequities. Black survivors of breast cancer have elevated risks of cardiotoxicity morbidity and mortality compared with White counterparts. Adolescent and young adult survivors of cancer with lower socioeconomic status experience worsened cardiovascular outcomes compared with those of higher socioeconomic status. Female patients treated with anthracyclines or radiation have higher risks of cardiotoxicity compared with male patients. Given the paucity of data, our understanding of these racial and ethnic, socioeconomic, and sex and gender disparities remains limited and large‐scale studies are needed for elucidation. Prioritizing this research while addressing clinical trial inclusion and access to specialist care is paramount to reducing health inequity.

Race-Specific Genetic Profiles of Homologous Recombination Deficiency in Multiple Cancers

Homologous recombination deficiency (HRD) has been used to predict both cancer prognosis and the response to DNA-damaging therapies in many cancer types. HRD has diverse manifestations in different cancers and even in different populations. Many screening strategies have been designed for detecting the sensitivity of a patient's HRD status to targeted therapies. However, these approaches suffer from low sensitivity, and are not specific to each cancer type and population group. Therefore, identifying race-specific and targetable HRD-related genes is of clinical importance. Here, we conducted analyses using genomic sequencing data that was generated by the Pan-Cancer Atlas. Collapsing non-synonymous variants with functional damage to HRD-related genes, we analyzed the association between these genes and race within cancer types using the optimal sequencing kernel association test (SKAT-O). We have identified race-specific mutational patterns of curated HRD-related genes across cancers. Overall, more significant mutation sites were found in ATM, BRCA2, POLE, and TOP2B in both the 'White' and 'Asian' populations, whereas PTEN, EGFG, and RIF1 mutations were observed in both the 'White' and 'African American/Black' populations. Furthermore, supported by pathogenic tendency databases and previous reports, in the 'African American/Black' population, several associations, including BLM with breast invasive carcinoma, ERCC5 with ovarian serous cystadenocarcinoma, as well as PTEN with stomach adenocarcinoma, were newly described here. Although several HRD-related genes are common across cancers, many of them were found to be specific to race. Further studies, using a larger cohort of diverse populations, are necessary to identify HRD-related genes that are specific to race, for guiding gene testing methods.

Naïve Bayesian network-based contribution analysis of tumor biology and healthcare factors to racial disparity in breast cancer stage-at-diagnosis

BACKGROUND

Variation in breast cancer stage at initial diagnosis (including racial disparities) is driven both by tumor biology and healthcare factors.

METHODS

We studied women age 67-74 with initial diagnosis of breast cancer from 2006 through 2014 in the SEER-Medicare database. We extracted variables related to tumor biology (histologic grade and hormone receptor status) and healthcare factors (screening mammography [SM] utilization and time delay from mammography to diagnostic biopsy). We used naïve Bayesian networks (NBNs) to illustrate the relationships among patient-specific factors and stage-at-diagnosis for African American (AA) and white patients separately. After identifying and controlling confounders, we conducted counterfactual inference through the NBN, resulting in an unbiased evaluation of the causal effects of individual factors on the expected utility of stage-at-diagnosis. An NBN-based decomposition mechanism was developed to evaluate the contributions of each patient-specific factor to an actual racial disparity in stage-at-diagnosis. 2000 bootstrap samples from our training patients were used to compute the 95% confidence intervals (CIs) of these contributions.

RESULTS

Using a causal-effect contribution analysis, the relative contributions of each patient-specific factor to the actual racial disparity in stage-at-diagnosis were as follows: tumor grade, 45.1% (95% CI: 44.5%, 45.8%); hormone receptor status, 5.0% (4.5%, 5.4%); mammography utilization, 23.1% (22.4%, 24.0%); and biopsy delay 26.8% (26.1%, 27.3%).

CONCLUSION

The modifiable mechanisms of mammography utilization and biopsy delay drive about 49.9% of racial difference in stage-at-diagnosis, potentially guiding more targeted interventions to eliminate cancer outcome disparities.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13755-021-00165-5.

Epidemiology and Outcomes of Hospitalizations Due to Hepatocellular Carcinoma

Background Hepatocellular Carcinoma (HCC) is a severe complication of cirrhosis and the incidence of HCC has been increasing in the United States (US). We aim to describe the trends, characteristics, and outcomes of hospitalizations due to HCC across the last decade. Methods We derived a study cohort from the Nationwide Inpatient Sample (NIS) for the years 2008-2017. Adult hospitalizations due to HCC were identified using the International Classification of Diseases (9th/10th Editions) Clinical Modification diagnosis codes (ICD-9-CM/ICD-10-CM). Comorbidities were also identified by ICD-9/10-CM codes and Elixhauser Comorbidity Software (Agency for Healthcare Research and Quality, Rockville, Maryland, US). Our primary outcomes were in-hospital mortality and discharge to the facility. We then utilized the Cochran-Armitage trend test and multivariable survey logistic regression models to analyze the trends, outcomes, and predictors. Results A total of 155,436 adult hospitalizations occurred due to HCC from 2008-2017. The number of hospitalizations with HCC decreased from 16,754 in 2008 to 14,715 in 2017. Additionally, trends of in-hospital mortality declined over the study period but discharge to facilities remained stable. Furthermore, in multivariable regression analysis, predictors of increased mortality in HCC patients were advanced age (OR 1.1; 95%CI 1.0-1.2; p< 0.0001), African American (OR 1.3; 95%CI 1.1-1.4;p< 0.001), Rural/ non-teaching hospitals (OR 2.7; 95%CI 2.4-3.3; p< 0.001), uninsured (OR 1.9; CI 1.6-2.2; p< 0.0001) and complications like septicemia and pneumonia as well as comorbidities such as hypertension, diabetes mellitus, and renal failure. We observed similar trends in discharge to facilities. Conclusions In this nationally representative study, we observed a decrease in hospitalizations of patients with HCC along with in-hospital mortality; however, discharge to facilities remained stable over the last decade. We also identified multiple predictors significantly associated with increased mortality, some of which are potentially modifiable and can be points of interest for future studies.

Sociodemographic and Geographic Disparities of Prostate Cancer Treatment Delay in Tennessee: A Population-Based Study

The relationship of social determinants of health, Appalachian residence, and prostate cancer treatment delay among Tennessee adults is relatively unknown. We used multivariate logistic regression on 2005–2015 Tennessee Cancer Registry data of adults aged ≥18 diagnosed with prostate cancer. The outcome of treatment delay was more than 90 days without surgical or nonsurgical intervention from date of diagnosis. Social determinants in the population-based registry were race (White, Black, Other) and marital status (single, married, divorced/separated, widow/widower). Tennessee residence was classified as Appalachian versus non-Appalachian (urban/rural). Covariates include age at diagnosis (18–54, 54–69, ≥70), health insurance type (none, public, private), derived staging of cancer (localized, regional, distant), and treatment type (non-surgical/surgical). We found that Black and divorced/separated patients had 32% (95% confidence interval [CI]: 1.22–1.42) and 15% (95% CI: 1.01–1.31) increased odds to delay prostate cancer treatment. Patients were at decreased odds of treatment delay when living in an Appalachian county, both urban (odds ratio [OR] = 0.89, 95% CI: 0.82–0.95) and rural (OR = 0.83, 95% CI: 0.78–0.89), diagnosed at ≥70 (OR = 0.59, 95% CI: 0.53–0.66), and received surgical intervention (OR = 0.72, 95% CI: 0.68–0.76). Our study was among the first to comprehensively examine prostate cancer treatment delay in Tennessee, and while we do not make clinical recommendations, there is a critical need to further explore the unique factors that may propagate disparities. Prostate cancer treatment delay in Black patients may be indicative of ongoing health and access disparities in Tennessee, which may further affect quality of life and survivorship among this racial group. Divorced/separated patients may need tailored interventions to improve social support.

Socioeconomic disparities in colorectal cancer survival: contributions of prognostic factors in a large Australian cohort

Purpose

We quantified the contributions of prognostic factors to socioeconomic disparities in colorectal cancer survival in a large Australian cohort.

Methods

The sample comprised 45 and Up Study participants (recruited 2006–2009) who were subsequently diagnosed with colorectal cancer. Both individual (education attained) and neighbourhood socioeconomic measures were used. Questionnaire responses were linked with cancer registrations (to December 2013), records for hospital inpatient stays, emergency department presentations, death information (to December 2015), and Medicare and Pharmaceutical Benefits claims for subsidised procedures and medicines. Proportions of socioeconomic survival differences explained by prognostic factors were quantified using multiple Cox proportional hazards regression.

Results

1720 eligible participants were diagnosed with colorectal cancer after recruitment: 1174 colon and 546 rectal cancers. Significant colon cancer survival differences were only observed for neighbourhood socioeconomic measure (p = 0.033): HR = 1.55; 95% CI 1.09–2.19 for lowest versus highest quartile, and disease-related factors explained 95% of this difference. For rectal cancer, patient- and disease-related factors were the main drivers of neighbourhood survival differences (28–36%), while these factors and treatment-related factors explained 24–41% of individual socioeconomic differences. However, differences remained significant for rectal cancer after adjusting for all these factors.

Conclusion

In this large contemporary Australian cohort, we identified several drivers of socioeconomic disparities in colorectal cancer survival. Understanding of the role these contributors play remains incomplete, but these findings suggest that improving access to optimal care may significantly reduce these survival disparities.

Racial and Ethnic Disparities in Breast Cancer: A Collaboration Between the American College of Radiology Commissions on Women and Diversity and Breast Imaging

Since the 1980s, the mortality rate from breast cancer in the United States has dropped almost 40%. The quality of life and survival gains from early detection and improved treatment have not been shared equally by all ethnic groups, however. Many factors, including social determinants of health, unequal access to screening and oncologic care, and differences in incidence, tumor biology, and risk factors, have contributed to these unequal breast cancer outcomes. As breast radiologists approach their own patients, they must be aware that minority women are disproportionately affected by breast cancer at earlier ages and that non-Hispanic Black and Hispanic women are impacted by greater severity of disease than non-Hispanic White women. Guidelines that do not include women younger than 50 and/or have longer intervals between examinations could have a disproportionately negative impact on minority women. In addition, the COVID-19 pandemic could worsen existing disparities in breast cancer mortality. Increased awareness and targeted efforts to identify and mitigate all of the underlying causes of breast cancer disparities will be necessary to realize the maximum benefit of screening, diagnosis, and treatment and to optimize quality of life and mortality gains for all women. Breast radiologists, as leaders in breast cancer care, have the opportunity to address and reduce some of these disparities for their patients and communities.

Racial Disparities in the Management of Locoregional Colorectal Cancer

Racial disparities pervade nearly all aspects of management of locoregional colorectal cancer, including time to treatment, receipt of resection, adequacy of resection, postoperative complications, and receipt of neoadjuvant and adjuvant multimodality therapies. Disparate gaps in treatment translate into enduring effects on survivorship, recurrence, and mortality. Efforts to reduce these gaps in care must be undertaken on a multilevel basis and focus on modifiable factors that underlie racial disparity.

Patient-reported treatment toxicity and adverse events in Black and White women receiving chemotherapy for early breast cancer

PURPOSE

It is not known whether chemotherapy-related symptom experiences differ between Black and White women with early breast cancer (Stage I-III) receiving current chemotherapy regimens and, in turn, influences dose delay, dose reduction, early treatment discontinuation, or hospitalization.

METHODS

Patients self-reported their race and provided symptom reports for 17 major side effects throughout chemotherapy. Toxicity and adverse events were analyzed separately for anthracycline and non-anthracycline regimens. Fisher's exact tests and two-sample t-tests compared baseline patient characteristics. Modified Poisson regression estimated relative risks of moderate, severe, or very severe (MSVS) symptom severity, and chemotherapy-related adverse events.Please check and confirm that the authors and their respective affiliations have been correctly identified and amend if necessary.no changes RESULTS: In 294 patients accrued between 2014 and 2020, mean age was 58 (SD13) and 23% were Black. For anthracycline-based regimens, the only significant difference in MSVS symptoms was in lymphedema (41% Black vs 20% White, p = .04) after controlling for axillary surgery. For non-anthracycline regimens, the only significant difference was MSVS peripheral neuropathy (41% Blacks vs. 23% White) after controlling for taxane type (p = .05) and diabetes (p = .05). For all other symptoms, severity scores were similar. Dose reduction differed significantly for non-anthracycline regimens (49% Black vs. 25% White, p = .01), but not for anthracycline regimens or in dose delay, early treatment discontinuation, or hospitalization for either regimen.

CONCLUSION

Except for lymphedema and peripheral neuropathy, Black and White patients reported similar symptom severity during adjuvant chemotherapy. Dose reductions in Black patients were more common for non-anthracycline regimens. In this sample, there were minimal differences in patient-reported symptoms and other adverse outcomes in Black versus White patients.

Cancer statistics for the US Hispanic/Latino population, 2021

The Hispanic/Latino population is the second largest racial/ethnic group in the continental United States and Hawaii, accounting for 18% (60.6 million) of the total population. An additional 3 million Hispanic Americans live in Puerto Rico. Every 3 years, the American Cancer Society reports on cancer occurrence, risk factors, and screening for Hispanic individuals in the United States using the most recent population-based data. An estimated 176,600 new cancer cases and 46,500 cancer deaths will occur among Hispanic individuals in the continental United States and Hawaii in 2021. Compared to non-Hispanic Whites (NHWs), Hispanic men and women had 25%-30% lower incidence (2014-2018) and mortality (2015-2019) rates for all cancers combined and lower rates for the most common cancers, although this gap is diminishing. For example, the colorectal cancer (CRC) incidence rate ratio for Hispanic compared with NHW individuals narrowed from 0.75 (95% CI, 0.73-0.78) in 1995 to 0.91 (95% CI, 0.89-0.93) in 2018, reflecting delayed declines in CRC rates among Hispanic individuals in part because of slower uptake of screening. In contrast, Hispanic individuals have higher rates of infection-related cancers, including approximately two-fold higher incidence of liver and stomach cancer. Cervical cancer incidence is 32% higher among Hispanic women in the continental US and Hawaii and 78% higher among women in Puerto Rico compared to NHW women, yet is largely preventable through screening. Less access to care may be similarly reflected in the low prevalence of localized-stage breast cancer among Hispanic women, 59% versus 67% among NHW women. Evidence-based strategies for decreasing the cancer burden among the Hispanic population include the use of culturally appropriate lay health advisors and patient navigators and targeted, community-based intervention programs to facilitate access to screening and promote healthy behaviors. In addition, the impact of the COVID-19 pandemic on cancer trends and disparities in the Hispanic population should be closely monitored.

A transdisciplinary approach to understand the epigenetic basis of race/ethnicity health disparities

Health disparities correspond to differences in disease burden and mortality among socially defined population groups. Such disparities may emerge according to race/ethnicity, socioeconomic status and a variety of other social contexts, and are documented for a wide range of diseases. Here, we provide a transdisciplinary perspective on the contribution of epigenetics to the understanding of health disparities, with a special emphasis on disparities across socially defined racial/ethnic groups. Scientists in the fields of biological anthropology, bioinformatics and molecular epidemiology provide a summary of theoretical, statistical and practical considerations for conducting epigenetic health disparities research, and provide examples of successful applications from cancer research using this approach.

The role of patient navigators in ambulatory care: overview of systematic reviews

BACKGROUND

Patient navigators have been introduced across various countries to enable timely access to healthcare services and to ensure completion of diagnosis and follow-up of care. There is an increasing evidence on the the role of patient navigation for patients and healthcare systems. The aim of this study was to analyse the evidence on patient navigation interventions in ambulatory care and to evaluate their effects on individuals and health system outcomes.

METHODS

An overview of reviews was conducted, following a prespecified protocol. All patients in ambulatory care or transitional care setting were included in this review as long as it was related to the role of patient navigators. The study analysed patient navigators covering a wide range of health professionals such as physicians, nurses, pharmacists, social workers and lay health workers or community-based workers with no or very limited training. Studies including patient-related measures and health system-related outcomes were eligible for inclusion. A rigorous search was performed in multiple data bases. After reaching a high inter-rater agreement of 0.86, title and abstract screening was independently performed. Of an initial 14,248 search results and an additional 62 articles identified through the snowballing approach, a total of 7159 hits were eligible for title/abstract screening. 679  articles were included for full-text screening.

RESULTS

Eleven systematic reviews were included covering various patient navigation intervention in cancer care, disease screening, transitional care and for various chronic conditions and multimorbidity. Nine systematic reviews primarily tailored services to ethnic minorities or other disadvantaged groups. Patient navigators performed tasks such as providing education and counselling, translations, home visits, outreach, scheduling of appointments and follow-up. Eight reviews identified positive outcomes in expanding access to care, in particular for vulnerable patient groups. Two reviews on patient navigation in transitional care reported improved patient outcomes, hospital readmission rates and mixed evidence on quality of life and emergency department visits. Two reviews demonstrated improved patient outcomes for persons with various chronic conditions and multimorbidity.

CONCLUSIONS

Patient navigators were shown to expand access to screenings and health services for vulnerable patients or population groups with chronic conditions who tend to underuse health services.

Redlining, structural racism, and lung cancer screening disparities

OBJECTIVE

The objective of this study was to understand the effect of historical redlining (preclusion from home loans and wealth-building for Black Americans) and its downstream factors on the completion of lung cancer screening in Boston.

METHODS

Patients within our institution were identified as eligible for lung cancer screening on the basis of the United State Preventive Service Task Force criteria and patient charts were reviewed to determine if patients completed low-dose computed tomography screening. Individual addresses were geocoded and overlayed with original 1930 Home Owner Loan Corporation redlining vector files. Structural equation models were used to estimate the odds of screening for Black and White patients, interacted with sex, in redlined and nonredlined areas.

RESULTS

Black patients had a 44% lower odds of screening compared with White (odds ratio [OR], 0.66; 95% CI, 0.52-0.85). With race as a mediator, Black patients in redlined areas were 61% less likely to undergo screening than White patients (OR, 0.39; 95% CI, 0.24-0.64). Similarly, in redlined areas Black women had 61% (OR, 0.39; 95% CI, 0.21-0.73) and Black men 47% (OR, 0.53; 95% CI, 0.29-0.98) lower odds of screening compared with White men in redlined areas.

CONCLUSIONS

Despite higher rates of lung cancer screening in redlined areas, Black race mediated worse screening rates in these areas, suggesting racist structural factors contributing to the disparities in lung cancer screening completion among Black and White patients. Furthermore, these disparities were more apparent in Black women, suggesting that racial and gender intersectional discrimination are important in lung cancer screening completion.

Psychometric Properties and Analysis of the Masculinity Barriers to Medical Care Scale Among Black, Indigenous, and White Men

Non-Hispanic (NH) Black, American Indian/Alaska Native (Indigenous), and NH-White men have the highest colorectal cancer (CRC) mortality rates among all other racial/ethnic groups. Contributing factors are multifaceted, yet no studies have examined the psychometric properties of a comprehensive survey examining potential masculinity barriers to CRC screening behaviors among these populations. This study assessed the psychometric properties of our Masculinity Barriers to Medical Care (MBMC) Scale among NH-Black, Indigenous, and NH-White men who completed our web-based MBMC, Psychosocial Factors, and CRC Screening Uptake & Intention Survey. We conducted exploratory factor analysis on a sample of 254 men and multivariate analysis of variance (MANOVA) on a separate sample of 637 men nationally representative by age and state of residence. After psychometric assessment, the MBMC scale was reduced from 24 to 18 items and from six to four subscales. NH-Black men’s mean scores were lowest on three of four subscales (Being Strong, Negative and Positive Attitudes) and highest on the Acknowledging Emotions subscale. Compared with both Indigenous and NH-White men, NH-Black men had significantly lower Negative Attitudes subscale scores and significantly higher scores on the Acknowledging Emotions subscale. Compared with both Indigenous and NH-Black men, NH-White men had significantly higher Being Strong and Positive Attitudes subscales scores. This study expands on previous research indicating that, among racialized populations of men, endorsement of traditional masculine ideologies influences engagement in preventive health behaviors. Our scale can be tailored to assess attitudes to screening for other cancers and diseases that disproportionately burden medically underserved populations.

Ethnic Differences in Survival Among Lung Cancer Patients: A Systematic Review

Background

Despite a substantially worse risk factor profile, Hispanics in the United States experience lower incidence of many diseases and longer survival than non-Hispanic Whites (NHWs), an epidemiological phenomenon known as the Hispanic Health Paradox (HHP). This systematic review evaluated the published longitudinal literature to address whether this pattern extends to lung cancer survival.

Methods

Searches of Medline, PubMed, Embase, Web of Science, and the Cochrane Library were conducted for publications dated from January 1, 2000, to July 18, 2018. Records were restricted to articles written in English, employing a longitudinal design, and reporting a direct survival comparison (overall survival [OS], cancer-specific survival [CSS]) between NHW and Hispanic lung cancer patients.

Results

A final sample of 29 full-text articles were included, with 28 fully adjusted models of OS and 21 of CSS included. Overall, 26 (92.9%) OS models and 20 (95.2%) CSS models documented either no difference (OS = 16, CSS = 11) or a Hispanic survival advantage (OS = 10, CSS = 9). Both larger studies and those including foreign-born Hispanics were more likely to show a Hispanic survival advantage, and 2 studies of exclusively no-smokers showed a survival disadvantage. A number of reporting gaps were identified including Hispanic background and sociodemographic characteristics.

Conclusions

Hispanics exhibit similar or better survival in the context of lung cancer relative to NHWs despite a considerably worse risk factor profile. These findings support the HHP in the context of lung cancer. Further research is needed to understand the potential mechanisms of the HHP as it relates to lung cancer.