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

Association of race and health insurance in treatment disparities of colon cancer: A retrospective analysis utilizing a national population database in the United States

BACKGROUND

Both health insurance status and race independently impact colon cancer (CC) care delivery and outcomes. The relative importance of these factors in explaining racial and insurance disparities is less clear, however. This study aimed to determine the association and interaction of race and insurance with CC treatment disparities.

STUDY SETTING

Retrospective cohort review of a prospective hospital-based database.

METHODS AND FINDINGS

In this cross-sectional study, patients diagnosed with stage I to III CC in the United States were identified from the National Cancer Database (NCDB; 2006 to 2016). Multivariable regression with generalized estimating equations (GEEs) were performed to evaluate the association of insurance and race/ethnicity with odds of receipt of surgery (stage I to III) and adjuvant chemotherapy (stage III), with an additional 2-way interaction term to evaluate for effect modification. Confounders included sex, age, median income, rurality, comorbidity, and nodes and margin status for the model for chemotherapy. Of 353,998 patients included, 73.8% (n = 261,349) were non-Hispanic White (NHW) and 11.7% (n = 41,511) were non-Hispanic Black (NHB). NHB patients were less likely to undergo resection [odds ratio (OR) 0.66, 95% confidence interval [CI] 0.61 to 0.72, p < 0.001] or to receive adjuvant chemotherapy [OR 0.83, 95% CI 0.78 to 0.87, p < 0.001] compared to NHW patients. NHB patients with private or Medicare insurance were less likely to undergo resection [OR 0.76, 95% CI 0.63 to 0.91, p = 0.004 (private insurance); OR 0.59, 95% CI 0.53 to 0.66, p < 0.001 (Medicare)] and to receive adjuvant chemotherapy [0.77, 95% CI 0.68 to 0.87, p < 0.001 (private insurance); OR 0.86, 95% CI 0.80 to 0.91, p < 0.001 (Medicare)] compared to similarly insured NHW patients. Although Hispanic patients with private and Medicare insurance were also less likely to undergo surgical resection, this was not the case with adjuvant chemotherapy. This study is mainly limited by the retrospective nature and by the variables provided in the dataset; granular details such as continuity or disruption of insurance coverage or specific chemotherapy agents or dosing cannot be assessed within NCDB.

CONCLUSIONS

This study suggests that racial disparities in receipt of treatment for CC persist even among patients with similar health insurance coverage and that different disparities exist for different racial/ethnic groups. Changes in health policy must therefore recognize that provision of insurance alone may not eliminate cancer treatment racial disparities.

Prospective Longitudinal Assessment of Health-related Quality of Life in Patients With Brain Metastases Undergoing Radiation Therapy

OBJECTIVE

We conducted a prospective clinical trial of patients receiving radiation (RT) for brain metastases to identify clinical predictors of pre-RT and post-RT health-related quality of life (hrQoL).

MATERIALS AND METHODS

Patients with brain metastases completed overall (European Organisation for Research and Treatment of Cancer QLQ C15-PAL) and brain tumor-specific (QLQ-BN20) hrQoL assessments pre-RT (n=127) and 1 (n=56) and 3 (n=45) months post-RT. Linear and proportional-odds models analyzed patient, disease, and treatment predictors of baseline, 1-, and 3-month hrQoL scores. Generalized estimating equations and repeated measures proportional-odds models assessed predictors of longitudinal hrQoL scores.

RESULTS

Most patients underwent stereotactic radiosurgery (SRS) (69.3%) and had non-small-cell lung (36.0%) metastases. Compared with SRS, receipt of whole brain RT was associated with a higher odds of appetite loss (baseline P=0.04, 1 mo P=0.02) and greater motor dysfunction (baseline P=0.01, 1 mo P=0.003, 3 mo P=0.02). Receipt of systemic therapy was associated with better emotional functioning after RT (1 mo P=0.03, 3 mo P=0.01). Compared with patients with breast cancer, patients with melanoma had higher odds of better global hrQoL (P=0.01) and less pain (P=0.048), while patients with lung cancer reported lower physical function (P=0.048) 3 months post-RT. Nonmarried patients had greater odds of higher global hrQoL (1 mo P=0.01), while male patients had lower odds of reporting more hair loss (baseline P=0.03, 3 mo P=0.045). Patients 60 years and above had lower odds of more drowsiness (P=0.04) and pain (P=0.049) over time.

CONCLUSIONS

Patients receiving SRS versus whole brain RT and systemic therapy reported better posttreatment hrQoL. In addition, melanoma metastases, nonmarried, male, and older patients with reported better hrQoL in various as well as domains after intracranial RT.

Health Disparities: Impact of Health Disparities and Treatment Decision-Making Biases on Cancer Adverse Effects Among Black Cancer Survivors

BACKGROUND

Health disparities affect cancer incidence, treatment decisions, and adverse effects. Oncology providers may hold biases in the decision-making process, which can perpetuate health disparities.

OBJECTIVES

The purpose of this article is to describe health disparities across treatment decisions and adverse effects, describe decision-making biases, and provide suggestions for nurses to mitigate adverse outcomes.

METHODS

A scoping review of the literature was conducted.

FINDINGS

Factors affecting health disparities stem, in part, from structural racism and decision-making biases, such as implicit bias, which occurs when individuals have unconscious negative thoughts or feelings toward a particular group. Other decision-making biases, seemingly unrelated to race, include default bias, delay discounting bias, and availability bias. Nurses and nurse navigators can mitigate health disparities by providing culturally appropriate care, assessing health literacy, providing education regarding adverse effects, serving as patient advocates, empowering patients, evaluating personal level of disease knowledge, and monitoring and managing cancer treatment adverse effects.

Associations between neighborhood disinvestment and breast cancer outcomes within a populous state registry

BACKGROUND

Breast cancer (BrCa) outcomes vary by social environmental factors, but the role of built-environment factors is understudied. The authors investigated associations between environmental physical disorder-indicators of residential disrepair and disinvestment-and BrCa tumor prognostic factors (stage at diagnosis, tumor grade, triple-negative [negative for estrogen receptor, progesterone receptor, and HER2 receptor] BrCa) and survival within a large state cancer registry linkage.

METHODS

Data on sociodemographic, tumor, and vital status were derived from adult women who had invasive BrCa diagnosed from 2008 to 2017 ascertained from the New Jersey State Cancer Registry. Physical disorder was assessed through virtual neighborhood audits of 23,276 locations across New Jersey, and a personalized measure for the residential address of each woman with BrCa was estimated using universal kriging. Continuous covariates were z scored (mean ± standard deviation [SD], 0 ± 1) to reduce collinearity. Logistic regression models of tumor factors and accelerated failure time models of survival time to BrCa-specific death were built to investigate associations with physical disorder adjusted for covariates (with follow-up through 2019).

RESULTS

There were 3637 BrCa-specific deaths among 40,963 women with a median follow-up of 5.3 years. In adjusted models, a 1-SD increase in physical disorder was associated with higher odds of late-stage BrCa (odds ratio, 1.09; 95% confidence interval, 1.02-1.15). Physical disorder was not associated with tumor grade or triple-negative tumors. A 1-SD increase in physical disorder was associated with a 10.5% shorter survival time (95% confidence interval, 6.1%-14.6%) only among women who had early stage BrCa.

CONCLUSIONS

Physical disorder is associated with worse tumor prognostic factors and survival among women who have BrCa diagnosed at an early stage.

The Impact of Racial Residential Segregation on Colorectal Cancer Outcomes and Treatment

OBJECTIVE

We sought to examine the impact of racial residential segregation on Black-White disparities in colorectal cancer diagnosis, surgical resection, and cancer-specific survival.

SUMMARY BACKGROUND DATA

There are clear Black-White disparities in colorectal cancer diagnosis and treatment with equally disparate explanations for these findings, including genetics, socioeconomic factors, and health behaviors.

METHODS

Data on Black and White patients with colorectal cancer were obtained from SEER between 2005 and 2015. The exposure of interest was the index of dissimilarity (IoD), a validated measure of segregation derived from 2010 Census data. Outcomes included advanced stage at diagnosis (AJCC stage IV), resection of localized disease (AJCC stage I-II), and cancer-specific survival. We used Poisson regression with robust error variance for the outcomes of interest and Cox proportional hazards were used to assess cancer-specific 5-year survival.

RESULTS

Black patients had a 41% increased risk of presenting at advanced stage per IoD [risk ratio (RR) 1.41, 95% confidence intervals (CI) 1.18, 1.69] and White patients saw a 17% increase (RR 1.17, 95%CI 1.04, 1.31). Black patients were 5% less likely to undergo surgical resection (RR 0.95, 95%CI 0.90, 0.99), whereas Whites were 5% more likely (RR 1.05, 95%CI 1.03, 1.07). Black patients had 43% increased hazards of cancer-specific mortality with increasing IoD (hazard ratio (HR) 1.43, 95%CI 1.17, 1.74).

CONCLUSIONS

Black patients with colorectal cancer living in more segregated counties are significantly more likely to present at advanced stage and have worse cancer-specific survival. Enduring structural racism in the form of residential segregation has strong impacts on the colorectal cancer outcomes.

Disentangling Racial, Ethnic, and Socioeconomic Disparities in Treatment for Colorectal Cancer

BACKGROUND

Colorectal cancer is curable if diagnosed early and treated properly. Black and Hispanic patients with colorectal cancer are more likely to experience treatment delays and/or receive lower standards of care. Socioeconomic deprivation may contribute to these disparities, but this has not been extensively quantified. We studied the interrelationship between patient race/ethnicity and neighborhood socioeconomic status (nSES) on receipt of timely appropriate treatment among patients with colorectal cancer in California.

METHODS

White, Black, and Hispanic patients (26,870) diagnosed with stage I-III colorectal cancer (2009-2013) in the California Cancer Registry were included. Logistic regression models were used to examine the association of race/ethnicity and nSES with three outcomes: undertreatment, >60-day treatment delay, and >90-day treatment delay. Joint effect models and mediation analysis were used to explore the interrelationships between race/ethnicity and nSES.

RESULTS

Hispanics and Blacks were at increased risk for undertreatment [Black OR = 1.39; 95% confidence interval (CI) = 1.23-1.57; Hispanic OR = 1.17; 95% CI = 1.08-1.27] and treatment delay (Black/60-day OR = 1.78; 95% CI = 1.57-2.02; Hispanic/60-day OR = 1.50; 95% CI = 1.38-1.64) compared with Whites. Of the total effect (OR = 1.15; 95% CI = 1.07-1.24) of non-white race on undertreatment, 45.71% was explained by nSES.

CONCLUSIONS

Lower nSES patients of any race were at substantially higher risk for undertreatment and treatment delay, and racial/ethnic disparities are reduced or eliminated among non-white patients living in the highest SES neighborhoods. Racial and ethnic disparities persisted after accounting for neighborhood socioeconomic status, and between the two, race/ethnicity explained a larger portion of the total effects.

IMPACT

This research improves our understanding of how socioeconomic deprivation contributes to racial/ethnic disparities in colorectal cancer.

Racial and Socioeconomic Disparities in Breast Cancer Outcomes within the AJCC Pathologic Prognostic Staging System

BACKGROUND

Non-Hispanic black (NHB) women and those of lower socioeconomic status (SES) have inferior breast cancer outcomes compared with non-Hispanic white (NHW) women and those of higher SES. We examined racial and SES disparities in breast cancer survival within the AJCC 8th edition pathologic prognostic staging system.

METHODS

Using the Surveillance, Epidemiology and End Results Program, we identified patients diagnosed with invasive breast cancer from 2010 to 2015, with follow-up through 2016. Census tract-level SES (cSES) data were available as a composite index and analyzed in quintiles. Cox proportional-hazards survival analyses adjusted for age, race, cSES, insurance, marital status, histology, pathologic prognostic stage, and treatment were used to estimate disease-specific survival (DSS).

RESULTS

A total of 259,852 patients were included: 176,369 (67.9%) NHW; 28,510 (11.0%) NHB; 29,737 (11.4%) Hispanic; and 22,887 (8.8%) Asian. NHB race and lower cSES were associated with increased incidence of triple-negative disease compared with NHW (p < 0.01). NHB race, lower cSES, public insurance, lower education, and increased poverty were associated with lower DSS. Survival analyses adjusting for cSES, tumor, and treatment characteristics demonstrated that NHB patients had inferior DSS within each AJCC pathologic prognostic stage (hazard ratio [HR] 1.25, 95% confidence interval [CI] 1.20-1.30) compared with NHW patients. Fully adjusted models also showed patients residing in lower SES counties had inferior DSS.

CONCLUSIONS

Racial and cSES disparities in breast cancer-specific mortality were evident across all stages, even within the pathologic prognostic staging system which incorporates tumor biology. Future efforts should assess the biological, behavioral, social, and environmental determinants that underlie racial and SES inequities in outcomes.

Disparities in Cancer-Specific Survival Between Māori and Non-Māori New Zealanders, 2007-2016

PURPOSE

While cancer survival is improving across most developed nations, those improvements are not shared equally within their population. Using high-quality national data, we have reviewed the extent to which cancer survival inequities are persisting for indigenous Māori compared with non-Māori New Zealanders and the extent to which these disparities are driven by deprivation, comorbidity, and stage of disease.

METHODS

Incident cases of cancer (2007-2016) were extracted from the New Zealand Cancer Registry and linked to mortality and hospitalization data. Descriptive, Kaplan-Meier, and Cox regression methods were used to compare survival outcomes between Māori and non-Māori.

RESULTS

Māori continue to have poorer survival than non-Māori for 23 of the 24 most common causes of Māori cancer death, with the extent of this disparity ranging from 12% to 156%. The magnitude of these disparities varies according to deprivation, comorbidity, and stage. Of note, there was a tendency for survival disparities to be largest among those with no comorbidity.

CONCLUSION

Māori continue to experience substantial cancer survival inequities. These observations are in keeping with reports from previous decades, which suggest that these disparities persist despite heightened attention. Reduction of the cancer burden on Māori and achievement of equitable survival outcomes require us to prevent cancer for Māori where we can, diagnose Māori patients early when we cannot, and once diagnosed, deliver equitable care to Māori patients at each step along the treatment path.

Association between disparities in intergenerational economic mobility and cause-specific mortality among Black and White persons in the United States

BACKGROUND

Evidence about the association between structural racism and mortality in the United States is limited. We examined the association between ongoing structural racism, measured as inequalities in adulthood income between White and Black children with similar parental household income (economic mobility gap) in a recent birth cohort, and Black-White disparities in death rates (mortality gap) overall and for major causes.

METHODS

Sex-, race/ethnicity-, and county-specific data were used to examine sex-specific associations between economic mobility and mortality gaps for all causes combined, heart diseases, cerebrovascular diseases, chronic obstructive pulmonary disease (COPD), injury/violence, all malignant cancers, and 14 cancer types. Economic mobility data for 1978-1983 birth cohorts and death rates during 2011-2018 were obtained from the Opportunity Atlas and National Center for Health Statistics, respectively. Data from 471 counties were included in analyses of all-cause mortality at ages 30-39 years during 2011-2018 (corresponding to partially overlapping 1978-1983 birth cohorts); and from 1,572 and 1,248 counties in analyses of all-cause and cause-specific mortality in all ages combined, respectively.

RESULTS

In ages 30-39 years, a one percentile increase in the economic mobility gap was associated with a 6.8 % (95 % confidence interval 1.8 %-11.8 %) increase in the Black-White mortality gap among males and a 13.5 % (8.9 %-18.1 %) increase among females, based on data from 471 counties. In all ages combined, the corresponding percentages based on data from 1,572 counties were 10.2 % (7.2 %-13.2 %) among males and 14.8 % (11.4 %-18.2 %) among females, equivalent to an increase of 18.4 and 14.0 deaths per 100,000 in the mortality gap, respectively. Similarly, strong associations between economic mobility gap and mortality gap in all ages were found for major causes of death, notably for potentially preventable conditions, including COPD, injury/violence, and cancers of the lung, liver, and cervix.

CONCLUSIONS

Economic mobility gap conditional on parental income in a recent birth cohort as a marker of ongoing structural racism is strongly associated with Black-White disparities in all-cause mortality and mortality from several causes.

Impact of Socioeconomic Status on Paranasal Sinus Cancer Disease-Specific and Conditional Survival

OBJECTIVE

Socioeconomic status (SES) is often used to quantify social determinants of health. This study uses the National Cancer Institute SES index to examine the effect of SES on disease-specific survival and 5-year conditional disease-specific survival (CDSS; the change in life expectancy with increasing survivorship) in paranasal sinus cancer.

STUDY DESIGN

Cross-sectional analysis.

SETTING

National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) program.

METHODS

A study of adults with sinus cancer between 1973 and 2015 was performed. The Yost index, a census tract-level composite score of SES, was used to categorize patients. Kaplan-Meier analysis and Cox regression for disease-specific survival were stratified by SES. CDSS was calculated with simplified models. Logistic regression was conducted to identify risk factors for advanced stage at diagnosis, multimodal therapy, and diagnosis of squamous cell carcinoma.

RESULTS

There were 3437 patients analyzed. In Cox models adjusting for patient-specific factors, the lowest SES tertile exhibited worse mortality (hazard ratio, 1.22; 95% CI, 1.07-1.39; P < .01). After addition of treatment and pathology, SES was not significant (P = .07). The lowest SES tertile was more often diagnosed at later stages (odds ratio [OR], 1.52; 95% CI, 1.12-2.06; P < .01). For those with regional/distant disease, the middle tertile (OR, 0.75; 95% CI, 0.63-0.90; P < .01) and lowest tertile (OR, 0.75; 95% CI, 0.62-0.91; P < .01) were less likely to receive multimodal therapy. SES tertiles primarily affected 5-year CDSS for regional/distant disease. CDSS for all stages converged over time.

CONCLUSION

Lower SES is associated with worse outcomes in paranasal sinus cancer. Research should be devoted toward understanding factors that contribute to such disparities, including tumor pathology and treatment course.

Disparities in Surgical Oncology: Management of Advanced Cancer

Significant variations in the patterns of care, incidence, and mortality rates of several common cancers have been noted. These disparities have been attributed to a complex interplay of factors, including genetic, environmental, and healthcare-related components. Within this review, primarily focusing on commonly occurring cancers (breast, lung, colorectal), we initially summarize the burden of these disparities with regard to incidence and screening patterns. We then explore the interaction between several proven genetic, epigenetic, and environmental influences that are known to contribute to these disparities.

Clinical Course of Breast Cancer Patients with Local-Regional Progression During Neoadjuvant Systemic Therapy

BACKGROUND

Neoadjuvant systemic therapy (NST) is standard for locally advanced breast cancer and is now frequently considered for those with early-stage and node-positive disease. We aimed to evaluate the treatment course and outcomes in patients with disease progression during NST.

METHODS

Patients diagnosed with unilateral stage I-III breast cancer between 2005 and 2015 with documented local-regional progression while receiving NST, by clinical examination and/or imaging after two or more cycles of chemotherapy, were identified from a prospective database, stratified by receipt of surgery and outcomes analyzed.

RESULTS

Of 6362 patients treated with NST during the study period, 124 (1.9%) developed disease progression. At a median live follow-up of 71 months, 23.4% were alive without disease and 70.2% had died from breast cancer. Median overall survival (OS) time for patients with progression was 26 months and median distant disease-free survival (DFS) was 14 months. Triple-negative breast cancer was associated with a higher likelihood of death (p < 0.001) and development of distant metastasis (p = 0.002). Among patients who had surgery (104, 89.3%), 40 (38.5%) developed local-regional recurrence, 67 (64.4%) developed distant metastasis, and 69 (66.3%) died from breast cancer. Median OS and median distant DFS in this subgroup was 31 and 16 months, respectively.

CONCLUSIONS

High rates of local-regional and distant failure were seen following disease progression while receiving NST. This suggests aggressive tumor biology and the need to study novel systemic therapies. Poor survival outcomes despite surgical management highlight the importance of careful patient selection when considering operative intervention after progression while receiving NST.

Evaluation of Racial/Ethnic Differences in Treatment and Mortality Among Women With Triple-Negative Breast Cancer

Importance

To our knowledge, there is no consensus regarding differences in treatment and mortality between non-Hispanic African American and non-Hispanic White women with triple-negative breast cancer (TNBC). Little is known about whether racial disparities vary by sociodemographic, clinical, and neighborhood factors.

Objective

To examine the differences in clinical treatment and outcomes between African American and White women in a nationally representative cohort of patients with TNBC and further examine the contributions of sociodemographic, clinical, and neighborhood factors to TNBC outcome disparities.

Design, Setting, and Participants

This population-based, retrospective cohort study included 23 123 women who received a diagnosis of nonmetastatic TNBC between January 1, 2010, and December 31, 2015, followed up through December 31, 2016, and identified from the Surveillance, Epidemiology, and End Results data set. The study was conducted from July 2019 to November 2020. The analyses were performed from July 2019 to June 2020.

Exposures

Race and ethnicity, including non-Hispanic African American and non-Hispanic White race.

Main Outcomes and Measures

Using logistic regression analysis and competing risk regression analysis, we estimated odds ratios (ORs) of receipt of treatment and hazard ratios (HRs) of breast cancer mortality in African American patients compared with White patients.

Results

Of 23 213 participants, 5881 (25.3%) were African American women and 17 332 (74.7%) were White women. Compared with White patients, African American patients had lower odds of receiving surgery (OR, 0.69; 95% CI, 0.60-0.79) and chemotherapy (OR, 0.89; 95% CI, 0.81-0.99) after adjustment for sociodemographic, clinicopathologic, and county-level factors. During a 43-month follow-up, 3276 patients (14.2%) died of breast cancer. The HR of breast cancer mortality was 1.28 (95% CI, 1.18-1.38) for African American individuals after adjustment for sociodemographic and county-level factors. Further adjustment for clinicopathological and treatment factors reduced the HR to 1.16 (95% CI, 1.06-1.25). This association was observed in patients living in socioeconomically less deprived counties (HR, 1.26; 95% CI, 1.14-1.39), urban patients (HR, 1.21; 95% CI, 1.11-1.32), patients having stage II (HR, 1.19; 95% CI, 1.02-1.39) or III (HR, 1.15; 95% CI, 1.01-1.31) tumors that were treated with chemotherapy, and patients younger than 65 years (HR, 1.24; 95% CI, 1.12-1.37).

Conclusions and Relevance

In this retrospective cohort study, African American women with nonmetastatic TNBC had a significantly higher risk of breast cancer mortality compared with their White counterparts, which was partially explained by their disparities in receipt of surgery and chemotherapy.

Racial Disparities in Treatment for Rectal Cancer at Minority-Serving Hospitals

BACKGROUND

Racial disparities exist in patients with rectal cancer with respect to both treatment and survival. Minority-serving hospitals (MSHs) provide healthcare to a disproportionately large percent of minority patients in the USA. We examined the effects of rectal cancer treatment at MSH to understand drivers of these disparities.

METHODS

The NCDB was queried (2004-2015), and patients diagnosed with stage II or III rectal adenocarcinoma were identified. Racial case mix distribution was calculated at the institutional level, and MSHs were defined as those within the top decile of Black and Hispanic patients. Logistic regression was used to identify predictors of receipt of standard of care treatment. Survival was assessed using the Kaplan-Meier method, and Cox proportional hazards models were used to evaluate adjusted risk of death. Analyses were clustered by facility.

RESULTS

A total of 68,842 patients met the inclusion criteria. Of these patients, 63,242 (91.9%) were treated at non-MSH, and 5600 (8.1%) were treated at MSH. In multivariable analysis, treatment at MSH (OR 0.70 95%CI 0.61-0.80 p < 0.001) and Black race (OR 0.75 95%CI 0.70-0.81 p < 0.001) were associated with significantly lower odds of receiving standard of care. In adjusted analysis, Black patients had a significantly higher risk of mortality (HR 1.20 95%CI 1.14-1.26 p < 0.001).

CONCLUSIONS

Treatment at MSH institutions and Black race were associated with significantly decreased odds of receipt of recommended standard therapy for locally advanced rectal adenocarcinoma. Survival was worse for Black patients compared to White patients despite adjustment for receipt of standard of care.

Pentz R. Prostate Cancer: Community Education and Disparities in Diagnosis and Treatment

Prostate cancer remains the leading diagnosed cancer and the second leading cause of death among American men. Despite improvements in screening modalities, diagnostics, and treatment, disparities exist among Black men in this country. The primary objective of this systematic review is to describe the reported disparities in screening, diagnostics, and treatments as well as efforts to alleviate these disparities through community and educational outreach efforts. Critical review took place of retrospective, prospective, and socially descriptive data of English language publications in the PubMed database. Despite more advanced presentation, lower rates of screening and diagnostic procedures, and low rates of trial inclusion, subanalyses have shown that various modalities of therapy are quite effective in Black populations. Moreover, patients treated on prospective clinical trials and within equal-access care environments have shown similar outcomes regardless of race. Additional prospective studies and enhanced participation in screening, diagnostic and genetic testing, clinical trials, and community-based educational endeavors are important to ensure equitable progress in prostate cancer for all patients. IMPLICATIONS FOR PRACTICE: Notable progress has been made with therapeutic advances for prostate cancer, but racial disparities continue to exist. Differing rates in screening and utility in diagnostic procedures play a role in these disparities. Black patients often present with more advanced disease, higher prostate-specific antigen, and other adverse factors, but outcomes can be attenuated in trials or in equal-access care environments. Recent data have shown that multiple modalities of therapy are quite effective in Black populations. Novel and bold hypotheses to increase inclusion in clinical trial, enhance decentralized trial efforts, and enact successful models of patient navigation and community partnership are vital to ensure continued progress in prostate cancer disparities.

Impact of Race and Socioeconomics Disparities on Survival in Young-Onset Colorectal Adenocarcinoma-A SEER Registry Analysis

Simple Summary

The results of this study show the effects of socio-economic determinants, such as higher income levels, high school education, private insurance, and married marital status, have favorable survival in patients with young-onset colorectal cancer (YoCRC). Moreover, most of the positive social factors are often interrelated. The inclusion of these factors could further prognosticate and help with healthcare resource allocation for successful interventions through public health measures. Colorectal cancer awareness, knowledge, and even utilization of medical services would differ with the education and health literacy.

Abstract

Introduction: We aimed to assess the impact of socio-economic determinants of health (SEDH) on survival disparities within and between the ethnic groups of young-onset (<50 years age) colorectal adenocarcinoma patients. Patients and Methods: Surveillance, epidemiology, and end results (SEER) registry was used to identify colorectal adenocarcinoma patients aged between 25–49 years from 2012 and 2016. Survival analysis was performed using the Kaplan–Meir method. Cox proportional hazards model was used to determine the hazard effect of SEDH. American community survey (ACS) data 2012–2016 were used to analyze the impact of high school education, immigration status, poverty, household income, employment, marital status, and insurance type. Results: A total of 17,145 young-onset colorectal adenocarcinoma patients were studied. Hispanic (H) = 2874, Non-Hispanic American Indian/Alaskan Native (NHAIAN) = 164, Non-Hispanic Asian Pacific Islander (NHAPI) = 1676, Non-Hispanic black (NHB) = 2305, Non-Hispanic white (NHW) = 10,126. Overall cancer-specific survival was, at 5 years, 69 m. NHB (65.58 m) and NHAIAN (65.67 m) experienced worse survival compared with NHW (70.11 m), NHAPI (68.7), and H (68.31). High school education conferred improved cancer-specific survival significantly with NHAPI, NHB, and NHW but not with H and NHAIAN. Poverty lowered and high school education improved cancer-specific survival (CSS) in NHB, NHW, and NHAPI. Unemployment was associated with lowered CSS in H and NAPI. Lower income below the median negatively impacted survival among H, NHAPI NHB, and NHW. Recent immigration within the last 12 months lowered CSS survival in NHW. Commercial health insurance compared with government insurance conferred improved CSS in all groups. Conclusions: Survival disparities were found among all races with young-onset colorectal adenocarcinoma. The pattern of SEDH influencing survival was unique to each race. Overall higher income levels, high school education, private insurance, and marital status appeared to be independent factors conferring favorable survival found on multivariate analysis.

Genetic Variants in COX2 and ALOX Genes and Breast Cancer Risk in White and Black Women

COX and ALOX genes are involved in inflammatory processes and that may be related to breast cancer risk differentially between White and Black women. We evaluated distributions of genetic variants involved in COX2 and ALOX-related pathways and examined their associations with breast cancer risk among 1,275 White and 1,299 Black cases and controls who participated in the Women’s Circle of Health Study. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using multivariable-adjusted logistic regression models. Our results showed differential associations of certain genetic variants with breast cancer according to menopausal and ER status in either White or Black women. In White women, an increased risk of breast cancer was observed for COX2-rs689470 (OR: 2.02, P = 0.01) in the dominant model, and was strongest among postmenopausal women (OR: 2.72, P = 0.02) and for estrogen receptor positive (ER+) breast cancers (OR: 2.60, P = 0.001). A reduced risk was observed for ALOX5-rs7099874 (OR: 0.75, P = 0.01) in the dominant model, and was stronger among postmenopausal women (OR: 0.68, P = 0.03) and for ER+ cancer (OR: 0.66, P = 0.001). Four SNPs (rs3840880, rs1126667, rs434473, rs1042357) in the ALOX12 gene were found in high LD (r² >0.98) in White women and were similarly associated with reduced risk of breast cancer, with a stronger association among postmenopausal women and for ER− cancer. Among Black women, increased risk was observed for ALOX5-rs1369214 (OR: 1.44, P = 0.003) in the recessive model and was stronger among premenopausal women (OR: 1.57, P = 0.03) and for ER+ cancer (OR: 1.53, P = 0.003). Our study suggests that genetic variants of COX2 and ALOX genes are associated with breast cancer, and that these associations and genotype distributions differ in subgroups defined by menopausal and ER status between White and Black women. Findings may provide insights into the etiology of breast cancer and areas for further research into reasons for breast cancer differences between races.

Bias Issues in Colorectal Cancer Management: A Review

Based on census data, over one-third of the US population identifies as a racial or ethnic minority. This group of racial and ethnic minorities is more likely to develop cancer and die from it when compared with the general population of the USA. These disparities are most pronounced in the African American community. Despite overall CRC rates decreasing nationally and within certain racial and ethnic minorities in the USA, there continue to be disparities in incidence and mortality when compared with non-Hispanic Whites. The disparities in CRC incidence and mortality are related to systematic racism and bias inherent in healthcare systems and society. Disparities in CRC management will continue to exist until specific interventions are implemented in the context of each racial and ethnic group. This review's primary aim is to highlight the disparities in CRC among African Americans in the USA. For surgeons, understanding these disparities is formative to creating change and improving the quality of care, centering equity for all patients.

Using the health belief model to assess racial/ethnic disparities in cancer-related behaviors in an NCI-designated comprehensive cancer center catchment area

BACKGROUND

Racial and ethnic minorities experience well-documented disparities across the cancer trajectory. However, factors underlying these disparities may vary regionally. The Health Belief Model (HBM) was developed to explain and predict health-related prevention and early detection behaviors, particularly uptake of health services. Our goal was to use the HBM to guide an exploration of factors that contribute to racial/ethnic health disparities in the catchment area of a large National Cancer Institute-designated Comprehensive Cancer Center in the Southeastern United States.

METHODS

We conducted a secondary analysis of data collected by the cancer center for its triennial Community Health Needs Assessment, which sampled adults from the center's 15-county catchment area. White non-Hispanics (WNHs; n = 887), Black non-Hispanics (BNHs; n = 78), Hispanics/Latinxs (H/Ls; n = 185), and those identifying as another race/ethnicity ("Others"; n = 39) were compared across key HBM variables, including demographic/psychosocial information, perceived benefits and barriers to preventive health behaviors, risk perception, and health behavior outcomes.

RESULTS

Controlling for annual household income, relationship status, and age (for certain screening behaviors), significant differences were seen in information-seeking behaviors, risk perception, community attributes, discrimination, and distress. Non-WNH groups reported worse community attributes, higher everyday discrimination, lower health literacy, less confidence in their ability to get health information, and lower perceived risk of cancer.

CONCLUSION

This analysis presents a better understanding of how HBM factors may influence health disparities in the cancer center's catchment area. Results describe the needs of community members from racial and ethnic minority groups, which will inform future research, education, outreach, and service activities.

Cancer Outcomes Among Medicare Beneficiaries And Their Younger Uninsured Counterparts

Proposals for expanding Medicare insurance coverage to uninsured Americans approaching the Medicare eligibility age of sixty-five has been the subject of intense debate. We undertook this study to assess cancer survival differences between uninsured patients younger than age sixty-five and older Medicare beneficiaries by using data from the National Cancer Database from the period 2004-16. The main outcomes were survival at one, two, and five years for sixteen cancer types in 1,206,821 patients. We found that uninsured patients ages 60-64 were nearly twice as likely to present with late-stage disease and were significantly less likely to receive surgery, chemotherapy, or radiotherapy than Medicare beneficiaries ages 66-69, despite lower comorbidity among younger patients. Compared with older Medicare patients, younger uninsured patients had strikingly lower five-year survival across cancer types. For instance, five-year survival in younger uninsured patients with late-stage breast or prostate cancer was 5-17 percent lower than that among older Medicare patients. We conclude that survival after a diagnosis of cancer is considerably lower in younger uninsured patients than in older Medicare patients. Expanding comprehensive health insurance coverage to people approaching Medicare age eligibility may improve cancer outcomes in the US.

Racial Disparity and Social Determinants in Receiving Timely Surgery Among Stage I-IIIA Non-small Cell Lung Cancer Patients in a U.S. Southern State

Delayed surgery is associated with worse lung cancer outcomes. Social determinants can influence health disparities. This study aimed to examine the potential racial disparity and the effects from social determinants on receipt of timely surgery among lung cancer patients in Louisiana, a southern state in the U.S. White and black stage I-IIIA non-small cell lung cancer patients diagnosed in Louisiana between 2004 and 2016, receiving surgical lobectomy or a more extensive surgery, were selected. Diagnosis-to-surgery interval >6 weeks were considered as delayed surgery. Social determinants included marital status, insurance, census tract level poverty, and census tract level urbanicity. Multivariable logistic regression and generalized multiple mediation analysis were conducted. A total of 3,616 white (78.9%) and black (21.1%) patients were identified. The median time interval from diagnosis to surgery was 27 days in whites and 42 days in blacks (P < 0.0001). About 28.7% of white and 48.4% of black patients received delayed surgery (P < 0.0001). Black patients had almost two-fold odds of receiving delayed surgery than white patients (adjusted odds ratio: 1.91; 95% confidence interval: 1.59-2.30). Social determinants explained about 26% of the racial disparity in receiving delayed surgery. Having social support, private insurance, and living in census tracts with lower poverty level were associated with improved access to timely surgery. The census tract level poverty level a stronger effect on delayed surgery in black patients than in white patients. Tailored interventions to improve the timely treatment in NSCLC patients, especially black patients, are needed in the future.

A narrative review of sociodemographic risk and disparities in screening, diagnosis, treatment, and outcomes of the most common extrathoracic malignancies in the United States

There is a well-established association between multiple sociodemographic risk factors and disparities in cancer care. These risk factors include minority race and ethnicity, low socioeconomic status (SES) including low income and education level, non-English primary language, immigrant status, and residential segregation, and distance to facilities that deliver cancer care. As cancer care advances, existing disparities in screening, treatment, and outcomes have become more evident. Lung cancer remains the most common and fatal malignancy in the United States, with breast, colorectal, and prostate cancer being the three most common and deadly extrathoracic malignancies. Achieving the best outcomes for patients with these malignancies relies on strong physician-patient relationships leading to robust screening, early diagnosis, and early referral to facilities that can deliver multidisciplinary care and multimodal therapy. It is likely that challenges experienced in developing patient trust and understanding, providing access to screening, and building referral pipelines for definitive therapy in lung cancer care to vulnerable populations are paralleled by those in extrathoracic malignancies. Likewise, progress made in delivering optimal care to all patients across sociodemographic and geographic barriers can serve as a roadmap. Therefore, we provide a narrative review of current disparities in screening, treatment, and outcomes for patients with breast, prostate, and colorectal malignancies.

Sociodemographic disparities in the management of advanced lung cancer: a narrative review

Treatment of advanced non-small cell lung cancer (NSCLC) has markedly changed in the past decade with the integration of biomarker testing, targeted therapies, immunotherapy, and palliative care. These advancements have led to significant improvements in quality of life and overall survival. Despite these improvements, racial and socioeconomic disparities in lung cancer mortality persist. This narrative review aims to assess and synthesize the literature on sociodemographic disparities in the management of advanced NSCLC. A narrative overview of the literature was conducted using PubMed and Scopus and was narrowed to articles published from January 1, 2010, until July 22, 2020. Articles relevant to sociodemographic variation in (I) chemoradiation for stage III NSCLC, (II) molecular biomarker testing, (III) systemic treatment, including chemotherapy, targeted therapy, and immunotherapy, and (IV) palliative and end of life care were included in this review. Twenty-two studies were included. Sociodemographic disparities in the management of advanced NSCLC varied, but recurring findings emerged. Across most treatment domains, Black patients, the uninsured, and patients with Medicaid were less likely to receive recommended lung cancer care. However, some of the literature was limited due to incomplete data to adequately assess appropriateness of care, and several studies were out of date with current practice guidelines. Sociodemographic disparities in the management of advanced lung cancer are evident. Given the rapidly evolving treatment paradigm for advanced NSCLC, updated research is needed. Research on interventions to address disparities in advanced NSCLC is also needed.

Access to Cancer Care Resources in a Federally Qualified Health Center: a Mixed Methods Study to Increase the Understanding of Met and Unmet Needs of Cancer Survivors

Assessing the met and unmet needs of cancer survivors is critical in optimizing access to cancer services especially in underserved populations. The purpose of this study is to expand our understanding of the priority needs for cancer survivorship within racial/ethnic and underserved populations that speak either English or Spanish and seek health care in a federally qualified health center (FQHC). A convergent mixed methods design integrating survey and focus group data was utilized for this study. A total of 17 participants were enrolled in the study. The meta-inferences were drawn by looking across the top ten matched survey and focus group met and unmet needs including psychological, informational, and health system as well as patient care and support. The preferred languages of participants were Spanish 53% (n = 9) and English 47% (n = 8), and the survival breakdown was 65% (n = 11) within 0-5 years with 17.5% (n = 3), 6-10 years and 17.5% (n = 3), and 17.5% (n = 3) > 11 years. The most frequently met needs included health care providers and hospital staff being attentive to their physical and emotional needs and feeling they were treated with respect. Unmet needs were often related to physical and daily living needs such as pain, fatigue, sadness, depression, and not being able to work. Providing a needs-based approach of cancer health services in a FQHC or similar community-based health center is critical to meet the needs of cancer survivors to improve health outcomes and quality of life.

Race and ethnicity representation in clinical trials: findings from a literature review of Phase I oncology trials

Aim: To provide an assessment of published literature on the demographic representation in Phase I trials of biopharmaceutical oncology agents. Materials & methods: We conducted a rapid evidence assessment to identify demographic representation reported in Phase I clinical trials for biopharmaceutical oncology agents published in 2019. Results: Globally, the population was predominantly White/Caucasian (62.2%). In the USA, the distribution was heavily skewed toward White/Caucasian (84.2%), with minimal representation of Blacks/African-Americans (7.3%), Asians (3.4%), Hispanics/Latinos (2.8%) or other race/ethnicity groups. Conclusion: Our data highlight that Phase I oncology trials do not reflect the population at large, which may perpetuate health disparities. Further research is needed to understand and address barriers to participation, particularly among under-represented groups.

Racial/Ethnic Disparities Across Indicators of Cigarette Smoking in the Era of Increased Tobacco Control, 1992-2019

INTRODUCTION

This study compared tobacco use and cessation for African Americans (AA), Asians/Pacific Islanders (API), Hispanics/Latinos (H/L), American Indian/Alaskan Natives (AI/AN), and non-Hispanic Whites (NHW) in the United States to California (CA), the state with the longest continually funded tobacco control program. The purpose of this study was to identify tobacco use disparities across racial/ethnic groups across time.

METHODS

Cigarette use prevalence (uptake and current use), consumption (mean number of cigarettes smoked per day [CPD]), and quit ratios were calculated across survey years, and trends were examined within each race/ethnic group and comparing between CA and the United States, utilizing the 1992-2019 Tobacco Use Supplements to the Current Population Survey.

RESULTS

Prevalence decreased for all race/ethnic groups. Current use among CA NHW showed significant decline compared with US counterparts, whereas US H/L showed greater decline than CA counterparts. CPD decreased by approximately 30% across race/ethnic groups, with CA groups having lower numbers. The greatest decrease occurred among AA in CA (average 10.3 CPD [95% confidence interval (CI): 10.3, 12.6] in 1992/1993 to 3 CPD [95% CI: 2.4, 3.7] in 2018/2019). Quit ratios increased from 1992/1993 to 2018/2019 for CA H/L 52.4% (95% CI: 49.8, 53.0) to 59.3 (95% CI: 55.8, 62.5) and CA NHWs 61.5% (95% CI: 60.7, 61.9) to 63.8% (95% CI: 63.9, 66.9).

CONCLUSIONS

Although overall prevalence decreased over time for each racial/ethnic group, declines in CA outpaced the United States only for NHWs. Reductions in CPD were encouraging but the quit ratio points to the need to increase tobacco control efforts toward cessation.

IMPLICATIONS

The successes in reduced cigarette use uptake and prevalence across time for both California and the rest of the United States were observed largely among non-Hispanic White populations. Although reductions in the number of cigarettes smoked per day are a notable success, particularly among the Californian African Americans, efforts to support quitting across racial/ethnic groups, especially marginalized groups, need to be prioritized.

Racial disparities in mortality for patients with prostate cancer after radical prostatectomy

BACKGROUND

Although racial disparities in prostate cancer survival are well documented, the relative importance of contributing factors remains unclear. Few studies have examined the disparity between Whites and Hispanics or between Whites and Asian Americans and Pacific Islanders (AAPIs).

METHODS

Using data from the National Cancer Database for 526,690 patients with prostate cancer who underwent radical prostatectomy between 2004 and 2014, this study systematically evaluated the impact of clinical characteristics and factors related to access to care on survival by race. Included in the analysis were 432,640 White patients (82.1%), 63,602 Black patients (12.1%), 8990 AAPI patients (1.7%), and 21,458 Hispanic patients (4.1%). Multivariable Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals to measure racial survival disparities. Inverse probability weighting was used to adjust for imbalances of prognostic factors.

RESULTS

When adjustments were made for age and year of diagnosis only, Blacks had 51% higher mortality, AAPIs had 22% lower mortality, and Hispanics had 6% lower mortality than Whites. Overall, with adjustments for all clinical factors and nonclinical factors, the Black-White survival disparity narrowed to 20%, whereas the AAPI-White disparity increased to 35%. Among the controlled-for factors, education, median household income, and insurance status contributed the most to the racial disparity.

CONCLUSIONS

The overall survival disparity among men undergoing radical prostatectomy was significantly decreased, but not eliminated, for Blacks and significantly increased for AAPIs in comparison with Whites after adjustments for a number of clinical factors and factors related to access to care.

Neighborhood archetypes and breast cancer survival in California

PURPOSE

Previous studies on neighborhoods and breast cancer survival examined neighborhood variables as unidimensional measures (e.g. walkability or deprivation) individually and thus cannot inform how the multitude of highly correlated neighborhood domains interact to impact breast cancer survival. Neighborhood archetypes were developed that consider interactions among a broad range of neighborhood social and built environment attributes and examine their associations with breast cancer survival.

METHODS

Archetypes were measured using latent class analysis (LCA) fit to California census tract-level data. Thirty-nine social and built environment attributes relevant to eight neighborhood domains (socioeconomic status (SES), urbanicity, demographics, housing, land use, commuting and traffic, residential mobility, and food environment) were included.  The archetypes were linked to cancer registry data on breast cancer cases (diagnosed 1996-2005 with follow-up through Dec 31, 2017) to evaluate their associations with overall and breast cancer-specific survival using Cox proportional hazards models. Analyses were stratified by race/ethnicity.

RESULTS

California neighborhoods were best described by nine archetypal patterns that were differentially associated with overall and breast cancer-specific survival. The lowest risk of overall death was observed in the upper middle class suburb (reference) and high status neighborhoods, while the highest was observed among inner city residents with a 39% greater risk of death (95% CI = 1.35 to 1.44). Results were similar for breast cancer-specific survival. Stratified analyses indicated that differences in survival by neighborhood archetypes varied according to individuals' race/ethnicity.

CONCLUSIONS

By describing neighborhood archetypes that differentiate survival following breast cancer diagnosis, the study provides direction for policy and clinical practice addressing contextually-rooted social determinants of health including SES, unhealthy food environments, and greenspace.

Racial disparities in supportive medication use among older patients with brain metastases: a population-based analysis

BACKGROUND

Brain metastases (BM) cause symptoms that supportive medications can alleviate. We assessed whether racial disparities exist in supportive medication utilization after BM diagnosis.

METHODS

Medicare-enrolled patients linked with the Surveillance, Epidemiology, and End Results program (SEER) who had diagnoses of BM between 2007 and 2016 were identified. Fourteen supportive medication classes were studied: non-opioid analgesics, opioids, anti-emetics, anti-epileptics, headache-targeting medications, steroids, cognitive aids, antidepressants, anxiolytics, antidelirium/antipsychotic agents, muscle relaxants, psychostimulants, sleep aids, and appetite stimulants. Drug administration ≤30 days following BM diagnosis was compared by race using multivariable logistic regression.

RESULTS

Among 17,957 patients, headache aids, antidepressants, and anxiolytics were prescribed less frequently to African Americans (odds ratio [95% CI] = 0.81 [0.73-0.90], P < 0.001; OR = 0.68 [0.57-0.80], P < 0.001; and OR = 0.68 [0.56-0.82], P < 0.001, respectively), Hispanics (OR = 0.83 [0.73-0.94], P = 0.004 OR = 0.78 [0.64-0.97], P = 0.02; and OR = 0.63 [0.49-0.81], P < 0.001, respectively), and Asians (OR = 0.81 [0.72-0.92], P = 0.001, OR = 0.67 [0.53-0.85], P = 0.001, and OR = 0.62 [0.48-0.80], P < 0.001, respectively) compared with non-Hispanic Whites. African Americans also received fewer anti-emetics (OR = 0.75 [0.68-0.83], P < 0.001), steroids (OR = 0.84 [0.76-0.93], P < 0.001), psychostimulants (OR = 0.14 [0.03-0.59], P = 0.007), sleep aids (OR = 0.71 [0.61-0.83], P < 0.001), and appetite stimulants (OR = 0.85 [0.77-0.94], P = 0.002) than Whites. Hispanic patients less frequently received antidelirium/antipsychotic drugs (OR = 0.57 [0.38-0.86], P = 0.008), sleep aids (OR = 0.78 [0.64-0.94, P = 0.01), and appetite stimulants (OR = 0.87 [0.76-0.99], P = 0.04). Asian patients received fewer opioids (OR = 0.86 [0.75-0.99], P = 0.04), anti-emetics (OR = 0.83 [0.73-0.94], P = 0.004), anti-epileptics (OR = 0.83 [0.71-0.97], P = 0.02), steroids (OR = 0.81 [0.72-0.92], P = 0.001), muscle relaxants (OR = 0.60 [0.41-0.89], P = 0.01), and appetite stimulants (OR = 0.87 [0.76-0.99], P = 0.03). No medication class was prescribed significantly less frequently to Whites.

CONCLUSIONS

Disparities in supportive medication prescription for non-White/Hispanic groups with BM exist; improved provider communication and engagement with at-risk patients is needed.

KEY POINTS

1. Patients with BM commonly experience neurologic symptoms.2. Supportive medications improve quality of life among patients with BM.3. Non-White patients with BM receive fewer supportive medications than White patients.

Defining self-disclosure of personal cancer coping experiences in oncology social workers' helping relationships: When cancer "hits home"

PURPOSE

Oncology social workers are increasingly finding themselves diagnosed with or caring for a loved one with cancer. Self-disclosure may be useful for building a therapeutic alliance. Yet, practice-informed guidelines for psychosocial oncology providers do not exist.

RESEARCH APPROACH

Twenty-three psychosocial oncology providers diagnosed with and/or providing care to someone with cancer completed semi-structured interviews eliciting attitudes and utilization regarding self-disclosure.

METHODOLOGICAL APPROACH

Interviews were digitally recorded and transcribed verbatim. Using grounded theory's constant comparative method, researchers conducted open and theoretical coding.

FINDINGS

Participants expressed consensus in defining, and reported a range of evolving practices regarding, self-disclosure. Recommendations for responsible self-disclosure included self-awareness, ongoing assessment, supervision, and enhanced educational programming.

INTERPRETATION AND IMPLICATION

Therapeutic tools must evolve as core features of psychosocial oncology care. A flexible and context-specific framework for clinician self-disclosure related to personal experiences with cancer can guide oncology social work practice.

Early colorectal cancer detection-Current and evolving challenges in evidence, guidelines, policy, and practices

The understanding at the beginning of the last century that colorectal cancer began as a localized disease that progressed and became systemic, and that most colorectal cancer arose from adenomatous polyps gave rise to aggressive attempts at curative treatment and eventually attempts to detect advanced lesions before they progressed to invasive disease. In the last four decades, steadily greater uptake of screening has led to reductions in colorectal cancer incidence and mortality. However, the fullest potential of screening is not being met due to the lack of organized screening, where a systems approach could lead to higher rates of screening of average and high risk groups, higher quality screening, and prompt followup of adults with positive screening tests. ABSTRACT: Since the beginning of the 20th century, there has been a general understanding that colorectal cancer is a clonal disease that progresses from a localized stage with a favorable prognosis through progressively more advanced stages which have progressively worse prognosis. That understanding led first to determined efforts to detect and treat early stage symptomatic disease, and then to detect pre-symptomatic colorectal cancer and precursor lesions, where there was hope that the natural history of the disease could be arrested and the incidence and premature mortality of colorectal cancer averted. Toward the end of the last century, guidelines for colorectal cancer screening, growth in the number of technical options for screening, and a steady increase in the proportion of the adult population who attended screening contributed to the beginning of a significant decline in colorectal cancer incidence and mortality. Despite this progress, colorectal cancer remains the third leading cause of death among men and women in the United States. Screening for early detection of precursor lesions and localized cancer offers the single most productive opportunity to further reduce the burden of disease, and yet nearly four in five deaths from colorectal cancer are associated with having never been screened, not recently screened, or not followed up for an abnormal screening test. This simple observation is a call to action in all communities to apply existing knowledge to fulfill the potential to prevent avertable incidence and mortality.

Association of Health-Care System with Prostate Cancer-Specific Mortality in African American and Non-Hispanic White Men

BACKGROUND

Disparities in prostate cancer-specific mortality (PCSM) between African American and non-Hispanic White (White) patients have been attributed to biological and systemic factors. We evaluated drivers of these disparities in the Surveillance, Epidemiology and End Results (SEER) national registry and an equal-access system, the Veterans Health Administration (VHA).

METHODS

We identified African American and White patients diagnosed with prostate cancer between 2004-2015 in SEER (N = 311,691) and the VHA (N = 90,749). We analyzed the association between race and metastatic disease at presentation using multivariable logistic regression adjusting for sociodemographic factors, and PCSM using sequential competing-risks regression adjusting for disease and sociodemographic factors.

RESULTS

The median follow-up was 5.3 years in SEER and 4.7 years in the VHA. African American men were more likely than White men to present with metastatic disease in SEER (adjusted odds ratio = 1.23, 95% confidence interval [CI] = 1.17-1.30), but not in the VHA (adjusted odds ratio = 1.07, 95% CI = 0.98-1.17). African American versus White race was associated with an increased risk of PCSM in SEER (subdistribution hazard ratio [SHR] = 1.32, 95% CI = 1.10-1.60), but not in the VHA (SHR = 1.00, 95% CI: 0.93-1.08). Adjusting for disease extent, PSA, and Gleason score eliminated the association between race and PCSM in SEER (aSHR 1.04, 95% CI 0.93-1.16).

CONCLUSIONS

Racial disparities in PCSM were present in a nationally representative registry, but not in an equal-access healthcare system, due to differences in advanced disease at presentation. Strategies to increase healthcare access may bridge the racial disparity in outcomes. Longer follow-up is needed to fully assess mortality outcomes.Disparities between African American and non-Hispanic White (White) patients in cancer-specific mortality have been described across numerous cancer types and healthcare systems[1-5]. The survival gap between African American and White patients with prostate cancer has been well-characterized, with two-fold higher prostate cancer-specific mortality (PCSM) rates among African American patients depending on the setting[1, 6-10]. This disparity has been attributed to differences in prostate cancer biology in African American men, in addition to systemic factors in mediating this disparity, such as differential access to healthcare, Prostate-Specific Antigen (PSA) screening, and distrust in the healthcare system[1, 11-16].The Veterans Health Administration (VHA) is a relatively equal-access healthcare system that treats a large, ethnically diverse population of veterans. The Surveillance, Epidemiology and End Results (SEER) program is a national cancer registry program that collects data from the general United States (US) population. The goals of the present investigation were to 1) Compare PCSM between African American and White men within SEER and the VHA and 2) Identify modifiable system-level contributors to these disparities. We hypothesized that PCSM would be comparable among African American and White men in an equal-access setting, the VHA, but not in a national registry, SEER, and that this disparity in SEER would be in part driven by more advanced disease at presentation.

Willingness of Latinx and African Americans to Participate in Nontherapeutic Trials: It Depends on Who Runs the Research

Background

Inclusion of racial/ethnic minorities in cancer-related research remains inadequate, continuing to impact disparate health outcomes. Data regarding enrollment of racial/ethnic minorities in nontherapeutic, health-related research is sparse, and even less is known about enrollment of those with a double disparity of racial/ethnic minorities in rural settings.

Objective

To examine perspectives of Latinx and African American (AA) healthy volunteers from rural and urban settings in five southern US states and Puerto Rico regarding their trust in research and their willingness to participate in nontherapeutic research trials based on who conducts the research.

Methods

This study was conducted in 2013 in rural and urban communities across Alabama, Florida, Georgia, Mississippi, Louisiana, and Puerto Rico. A 38-item questionnaire based on the Tuskegee Legacy Project Questionnaire assessed willingness, motivators, and barriers to participation in nontherapeutic cancer-related research. The sample was segmented into four subgroups by urban/rural location and race/ethnicity.

Results

Of 553 participants (rural Latinx=151, urban Latinx=158, rural AA=122, urban AA=122), more than 90% had never been asked to participate in research, yet 75% of those asked agreed to participate. Most had positive views regarding health-related research. Trust in who conducted research varied by subgroup. Personal doctors and university hospitals were most trusted by all subgroups; for-profit and tobacco companies were least trusted. Both Latinx subgroups trusted pharmaceutical companies more than AAs; local hospitals and for-profit businesses were more trusted by AAs. Both rural subgroups trusted research by insurance companies more than their urban counterparts.

Conclusions

If asked, rural and urban AA and Latinx healthy volunteers were willing to participate in health-related research, with personal doctors and university hospitals considered the most trusted sources to encourage/conduct research.

Predictors of respiratory cancer-related mortality for Jews and Arabs in Israel

Background

Respiratory cancers, including lung, tracheal and bronchus cancers, are a leading cause of cancer-related mortality in Israel; however, incidence can differ among demographic groups. Despite the importance of sociodemographic characteristics and the interactions between them to incidence and mortality, this topic is understudied. This study analyzes sociodemographic disparities by sex and ethnicity among Jews and Arabs to understand cancer outcome differences stratified by SES, marital status, and number of children as potential contextual factors.

Methods

This retrospective cohort study analyzed respiratory cancer-related mortality rates among Israelis born between 1940 and 1960 over 21-years. The follow up period was between January 1, 1996 and 12.31.2016. Mortality rates for Jews and Arabs were calculated. Using a Cox Regression, a multivariate model was constructed to determine the association between ethnicity and respiratory cancer mortality. The study population was then divided into four groups, by sex and ethnicity, to determine the association between marital status, number of children, and SES with respiratory cancer mortality for each subgroup.

Results

The overall mortality rate was 0.6%. Arabs had higher mortality rates compared to Jews, even after adjusting for demographic factors including age, sex and SES (Adjusted Hazard Ratio (AHR) = 1.442, 99% confidence intervals (CI) = 1.354,1.546). Among men, a higher mortality rate was found among Arabs (AHR = 1.383, 99%CI = 1.295,1.477), while among women, Arabs had lower mortality rates (AHR = 0.469, 99%CI = 0.398,0.552). Significant mortality rate differences were observed by ethnicity and sex for each sociodemographic variable.

Conclusions

This study highlights the importance and implications of understanding differences in respiratory cancer mortality between Jews and Arabs, a minority group in Israel, and is relevant for minority groups in general. There is a need to tailor interventions for these groups, based on differing underlying causes and contextual factors for these cancers. Cancer outcomes among these groups should also be studied separately, by sex, to better understand them.

•

This retrospective multivariable cohort study analyzed respiratory cancer mortality.

•

Data was collected for 26 years for 196,974 Arabs and 1,470,676 Jews in Israel.

•

A higher mortality rate was found among Arab men compared to Jewish men.

•

A lower mortality rate was found among Arab women compared to Jewish women.

•

Implications for predictive factors found for respiratory cancer-related mortality.

Patterns of overall mortality by race/ethnicity and socioeconomic status in insured cancer patients in Southern California

Purpose

We evaluated the influence of race/ethnicity and geocoded socioeconomic status (SES) on all-cause mortality in cancer patients with health insurance.

Methods

We identified adults diagnosed with eight common cancers from 2009 to 2014 from the California Cancer Registry and followed them through 2017 (8 years maximum). We calculated person-year mortality rates by race/ethnicity and SES. Adjusted hazard ratios for the association between overall mortality and race/ethnicity and SES were estimated using Cox proportional hazards models accounting for other demographics, stage at diagnosis, and cancer treatments.

Results

A total of 164,197 adults were diagnosed with cancer originating from breast, prostate, lung, colon, skin melanoma, uterus, kidney, and bladder. For all race/ethnic groups combined, the mortality rates from lowest to highest SES groups were 112.1/1000 PY (lowest); 100.2/1000 PY (lower-middle); 91.2/1000 PY (middle); 79.1/1000 PY (upper-middle); and 63.5/1000 PY (upper). These rates suggest that person with lowest SES have a markedly increased mortality risk after cancer diagnosis even if they have health insurance. In multivariable analyses, those in the lowest SES group had a 40–78% increased risk of all-cause mortality compared to those in the upper SES group across all race/ethnicities. For example, within African Americans, the adjusted mortality risk was up to 61% higher (HR 1.61, 95% CI 1.41–1.83) in the lowest SES group compared to the highest SES group.

Conclusion

This study suggests disparities in overall mortality risk after cancer diagnoses persist even in a cohort with health insurance, and that SES is an important driver of this disparity.

Neutrophil-to-Lymphocyte Ratio Is a Predictive Biomarker in Patients with Epidermal Growth Factor Receptor (EGFR) Mutated Advanced Non-Small Cell Lung Cancer (NSCLC) Treated with Tyrosine Kinase Inhibitor (TKI) Therapy

BACKGROUND

First-line treatment for patients with non-small cell lung cancer (NSCLC) with a sensitizing epidermal growth factor receptor (EGFR) mutation is a tyrosine kinase inhibitor (TKI). Despite higher response rates and prolonged progression free survival (PFS) compared with platinum doublet chemotherapy, a subset of these patients do not receive prolonged benefit from these agents. We investigate if the neutrophil-to-lymphocyte ratio (NLR) and other markers of cachexia and chronic inflammation correlate with worse outcomes in these patients.

METHODS

This study is a retrospective review of 137 patients with advanced EGFR-mutated NSCLC treated with TKIs at Rush University Medical Center and University of Chicago Medicine from August 2011 to July 2019, with outcomes followed through July 2020. The predictive value of NLR and body mass index (BMI) was assessed at the start of therapy, and after 6 and 12 weeks of treatment by univariable and multivariable analyses.

RESULTS

On univariable analysis, NLR ≥ 5 or higher NLR on a continuous scale were both associated with significantly worse PFS and overall survival (OS) at treatment initiation, and after 6 or 12 weeks of treatment. On multivariable analysis, NLR ≥ 5 was associated with increased risk of death at 12 weeks of therapy (HR 3.002, 95% CI 1.282-7.029, p = 0.011), as was higher NLR on a continuous scale (HR 1.231, 95% CI 1.063-1.425, p = 0.0054). There was no difference in PFS and OS and amongst BMI categories though number of disease sites and Eastern Cooperative Oncology Group (ECOG) performance status was associated with worse PFS and OS.

CONCLUSIONS

Patients with NLR ≥ 5 have a worse median PFS and median OS than patients with NLR < 5. NLR may have value as a predictive biomarker and may be useful for selecting patients for therapy intensification in the front-line setting either at diagnosis or after 12 weeks on therapy. NLR needs to be validated prospectively.

Development of an Actionable Framework to Address Cancer Care Disparities in Medically Underserved Populations in the United States: Expert Roundtable Recommendations

PURPOSE

Cancer disparities persist among medically underserved populations despite widespread efforts to address them. We describe the development of a framework for addressing cancer care disparities across the cancer care continuum (CCC), guided by the CCC domains established by the Institute of Medicine/National Academies of Sciences, Engineering, and Medicine (IOM/NAS).

MATERIALS AND METHODS

An environmental scan was conducted to identify strategies and associated experts who are providing or have successfully provided community- and/or patient-centric IOM/NAS-defined domain standards to our target populations. A multistakeholder expert roundtable working group was convened for framework development. A premeeting survey informed agenda development, documented expert practices for target populations, and identified priority areas for meeting focus.

RESULTS

The environmental scan identified 84 unique experts across 8 stakeholder groups and 44 patient organizations; 50 were invited to the roundtable and 33 participated. They broadly represented disease sites, geography, and experience with target populations and all CCC domains. The premeeting survey (16 responses) identified coordination of care or patient navigation (66.7%), community engagement (60.0%), and healthcare system changes (53.3%) as priority focus areas. The experts identified access and treatment barriers or gaps within and between CCC domains, specified key notable practices to address these, and developed an actionable framework and recommendations for each priority focus area.

CONCLUSION

The framework and recommendations are intended to guide researchers, healthcare leaders, advocates, community- and patient-focused service organizations, and policy leaders to address and promote health equity in cancer care access and treatment outcomes.

Multilevel social factors and NICU quality of care in California

OBJECTIVE

Our objective was to incorporate social and built environment factors into a compendium of multilevel factors among a cohort of very low birth weight infants to understand their contributions to inequities in NICU quality of care and support providers and NICUs in addressing these inequities via development of a health equity dashboard.

STUDY DESIGN

We examined bivariate associations between NICU patient pool and NICU catchment area characteristics and NICU quality of care with data from a cohort of 15,901 infants from 119 NICUs in California, born 2008-2011.

RESULT

NICUs with higher proportion of minority racial/ethnic patients and lower SES patients had lower quality scores. NICUs with catchment areas of lower SES, higher composition of minority residents, and more household crowding had lower quality scores.

CONCLUSION

Multilevel social factors impact quality of care in the NICU. Their incorporation into a health equity dashboard can inform providers of their patients' potential resource needs.

Association of Living in Urban Food Deserts with Mortality from Breast and Colorectal Cancer

BACKGROUND

Food deserts are neighborhoods with low access to healthy foods and are associated with poor health metrics. We investigated association of food desert residence and cancer outcomes.

METHODS

In this population-based study, data from the 2000-2012 California Cancer Registry was used to identify patients with stage II/III breast or colorectal cancer. Patient residence at time of diagnosis was linked by census tract to food desert using the USDA Food Access Research Atlas. Treatment and outcomes were compared by food desert residential status.

RESULTS

Among 64,987 female breast cancer patients identified, 66.8% were < 65 years old, and 5.7% resided in food deserts. Five-year survival for food desert residents was 78% compared with 80% for non-desert residents (p < 0.0001). Among 48,666 colorectal cancer patients identified, 50.4% were female, 39% were > 65 years old, and 6.4% resided in food deserts. Five-year survival for food desert residents was 60% compared with 64% for non-desert residents (p < 0.001). Living in food deserts was significantly associated with diabetes, tobacco use, poor insurance coverage, and low socioeconomic status (p < 0.05) for both cancers. There was no significant difference in rates of surgery or chemotherapy by food desert residential status for either diagnosis. Multivariable analyses showed that food desert residence was associated with higher mortality.

CONCLUSION

Survival, despite treatment for stage II/III breast and colorectal cancers was worse for those living in food deserts. This association remained significant without differences in use of surgery or chemotherapy, suggesting factors other than differential care access may link food desert residence and cancer outcomes.

Understanding Racial Disparities in Gastrointestinal Cancer Outcomes: Lack of Surgery Contributes to Lower Survival in African American Patients

BACKGROUND

Race/ethnicity-related differences in rates of cancer surgery and cancer mortality have been observed for gastrointestinal (GI) cancers. This study aims to estimate the extent to which differences in receipt of surgery explain racial/ethnic disparities in cancer survival.

METHODS

The National Cancer Database was used to obtain data for patients diagnosed with stage I-III mid-esophageal, distal esophagus/gastric cardia (DEGC), noncardia gastric, pancreatic, and colorectal cancer in years 2004-2015. Mediation analysis was used to identify variables influencing the relationship between race/ethnicity and mortality, including surgery.

RESULTS

A total of 600,063 patients were included in the study: 3.5% mid-esophageal, 12.4% DEGC, 4.9% noncardia gastric, 17.0% pancreatic, 40.1% colon, and 22.0% rectal cancers. The operative rates for Black patients were low relative to White patients, with absolute differences of 21.0%, 19.9%, 2.3%, 8.3%, 1.6%, and 7.7%. Adjustment for age, stage, and comorbidities revealed even lower odds of receiving surgery for Black patients compared with White patients. The observed HRs for Black patients compared with White patients ranged from 1.01 to 1.42. Mediation analysis showed that receipt of surgery and socioeconomic factors had greatest influence on the survival disparity.

CONCLUSIONS

The results of this study indicate that Black patients appear to be undertreated compared with White patients for GI cancers. The disproportionately low operative rates contribute to the known survival disparity between Black and White patients.

IMPACT

Interventions to reduce barriers to surgery for Black patients should be promoted to reduce disparities in GI cancer outcomes.See related commentary by Hébert, p. 438.

Early-Stage Non-Small Cell Lung Cancer Stereotactic Body Radiation Therapy (SBRT) Outcomes in an Equal Access Military Setting

Introduction Lung stereotactic body radiation therapy (SBRT) is a first-line treatment for early-stage lung cancer in non-surgical candidates or those who refuse surgery. We compared our institutional outcomes from a unique patient population with decreased barriers to care with a recently published prospective series. Materials and methods  We retrospectively reviewed all patients who received definitive lung SBRT at the Walter Reed National Military Medical Center from 2015 to 2020. All patients underwent a positron emission tomography-computed tomography (PET-CT) and all were presented at a multidisciplinary tumor board. Patients were treated on a Trubeam linear accelerator (LINAC)-based system with daily cone-beam CT. The results were qualitatively compared to outcomes from prospective studies including RTOG 0236 and RTOG 0618. Results A total of 105 patients with 114 lesions were included. Median age was 77 years and 54.7% had ≥ 40-pack year smoking history. 36.8% did not have pathologic confirmation. With a median follow-up of 24 months, three-year local control (LC), disease-free survival (DFS) and overall survival (OS) rates were 92.4%, 81.0%, and 80.0%, respectively. Rates of Grade 1 and 2 toxicity were 21.9% and 6.7% and no patients experienced Grade ≥ 3 toxicity. Conclusions In our military setting with universal coverage and routine multidisciplinary care, lung SBRT provides outcomes comparable to prospective studies conducted at high-volume academic centers. More than one-third of patients were treated empirically without pathologic confirmation of disease, demonstrating a difference between clinical trials and community practice. Further investigation is warranted to integrate multidisciplinary management and achieve equal access to care to bridge existing health disparities in the community setting.

An overview of cancer health disparities: new approaches and insights and why they matter

Cancer health disparities remain stubbornly entrenched in the US health care system. The Affordable Care Act was legislation to target these disparities in health outcomes. Expanded access to health care, reduction in tobacco use, uptake of other preventive measures and cancer screening, and improved cancer therapies greatly reduced cancer mortality among women and men and underserved communities in this country. Yet, disparities in cancer outcomes remain. Underserved populations continue to experience an excessive cancer burden. This burden is largely explained by health care disparities, lifestyle factors, cultural barriers, and disparate exposures to carcinogens and pathogens, as exemplified by the COVID-19 epidemic. However, research also shows that comorbidities, social stress, ancestral and immunobiological factors, and the microbiome, may contribute to health disparities in cancer risk and survival. Recent studies revealed that comorbid conditions can induce an adverse tumor biology, leading to a more aggressive disease and decreased patient survival. In this review, we will discuss unanswered questions and new opportunities in cancer health disparity research related to comorbid chronic diseases, stress signaling, the immune response, and the microbiome, and what contribution these factors may have as causes of cancer health disparities.

The Effect of Payer Status on Survival of Patients With Prostate Cancer

Background

Disparities in access to care and proper treatment can have significant implications in patient survival outcome and mortality. This retrospective study of prostate cancer patients from the National Cancer Database (NCDB) between the years 2004 and 2014 and follow-up to the end of 2015 analyzed such effects that variation in payer status might have on outcome.

Methods

This study used the data of 696,321 diagnosed prostate cancer patients from the NCDB for the years 2004 to 2014 and follow-up to the end of 2015 to analyze the effect that payer status would have on prostate cancer survival. Multivariable cox regression was used to study the hazard ratios (HRs) of payer status and other variables along with the Charlson Comorbidity Index to analyze their associated increased risk of death. Statistical software SAS 9.4 for Windows was used to analyze the overall survival (OS) of patients on different insurance plans along with variations in prostate-specific antigen (PSA) levels and treatment type.

Results

When looking at OS, those with private insurance had the greatest overall survivability while those on Medicare were the only ones who reached the median OS. In contrast to those who had private insurance, those who had Medicare, the uninsured, and those with Medicaid demonstrated significantly greater risks of death at 43%, 58%, and 69% increased risk of death, respectively. In addition to payer status, other variables were also significant predictors of OS, including demographic factors (age, race), comorbidities, socioeconomic status (income, education), distance traveled to facility, type of facility, treatment delay, treatment modality, PSA levels at diagnosis, and cancer stage at diagnosis.

Conclusion

Payer status is intricately linked to a number of other variables that might affect survival. Even after adjustment for a number of these factors, insurance status was shown to have a significant effect on prostate cancer survivorship. In contrast to those who had private insurance, those who had Medicare, the uninsured, and those with Medicaid demonstrated significantly greater risks of death at 43%, 58%, and 69% increased risk of death, respectively. Studies have suggested that those without insurance or on Medicaid are less likely to undergo screening and have worse health-related quality of life, while those on Medicare may be deterred from continuing treatment due to high out-of-pocket costs. However, the complete mechanism behind the improved survivorship of those on private insurance is unclear. The effect of payer status on quality of life may be an interest that needs to be further studied. Further research will be required to provide definite reasons for these observations and mediation analysis of other factors could prove to be valuable.