Socioeconomic, Rural-Urban, and Racial Inequalities in US Cancer Mortality: Part I-All Cancers and Lung Cancer and Part II-Colorectal, Prostate, Breast, and Cervical Cancers

Socioeconomic disparities in childhood cancer survival in Switzerland

In this study, we investigated whether childhood cancer survival in Switzerland is influenced by socioeconomic status (SES), and if disparities vary by type of cancer and definition of SES (parental education, living condition, area-based SES). Using Cox proportional hazards models, we analyzed 5-year cumulative mortality in all patients registered in the Swiss Childhood Cancer Registry diagnosed 1991-2006 below 16 years. Information on SES was extracted from the Swiss census by probabilistic record linkage. The study included 1602 children (33% with leukemia, 20% with lymphoma, 22% with central nervous system (CNS) tumors); with an overall 5-year survival of 77% (95%CI 75-79%). Higher SES, particularly parents' education, was associated with a lower 5-year cumulative mortality. Results varied by type of cancer with no association for leukemia and particularly strong effects for CNS tumor patients, where mortality hazard ratios for the different SES indicators, comparing the highest with the lowest group, ranged from 0.48 (95%CI: 0.28-0.81) to 0.71 (95%CI: 0.44-1.15). We conclude that even in Switzerland with a high quality health care system and mandatory health insurance, socioeconomic differences in childhood cancer survival persist. Factors causing these survival differences have to be further explored, to facilitate universal access to optimal treatment and finally eliminate social inequalities in childhood cancer survival.

Association of Financial Strain With Symptom Burden and Quality of Life for Patients With Lung or Colorectal Cancer

PURPOSE

To measure the association between patient financial strain and symptom burden and quality of life (QOL) for patients with new diagnoses of lung or colorectal cancer.

PATIENTS AND METHODS

Patients participating in the Cancer Care Outcomes Research and Surveillance study were interviewed about their financial reserves, QOL, and symptom burden at 4 months of diagnosis and, for survivors, at 12 months of diagnosis. We assessed the association of patient-reported financial reserves with patient-reported outcomes including the Brief Pain Inventory, symptom burden on the basis of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30, and QOL on the basis of the EuroQoL-5 Dimension scale. Multivariable linear regression models were fit for each outcome and cancer type, adjusting for age, race/ethnicity, sex, income, insurance, stage at diagnosis, and comorbidity.

RESULTS

Among patients with lung and colorectal cancer, 40% and 33%, respectively, reported limited financial reserves (≤ 2 months). Relative to patients with more than 12 months of financial reserves, those with limited financial reserves reported significantly increased pain (adjusted mean difference, 5.03 [95% CI, 3.29 to 7.22] and 3.45 [95% CI, 1.25 to 5.66], respectively, for lung and colorectal), greater symptom burden (5.25 [95% CI, 3.29 to .22] and 5.31 [95% CI, 3.58 to 7.04]), and poorer QOL (4.70 [95% CI, 2.82 to 6.58] and 5.22 [95% CI, 3.61 to 6.82]). With decreasing financial reserves, a clear dose-response relationship was present across all measures of well-being. These associations were also manifest for survivors reporting outcomes again at 1 year and persisted after adjustment for stage, comorbidity, insurance, and other clinical attributes.

CONCLUSION

Patients with cancer and limited financial reserves are more likely to have higher symptom burden and decreased QOL. Assessment of financial reserves may help identify patients who need intensive support.

Colorectal cancer survival in Jamaica

Objective

To determine the intermediate and long-term survival of patients diagnosed with colorectal cancer (CRC) and to determine factors that affect survival.

Method

Patients were identified from a prospectively maintained colonoscopy database. All patients who underwent colonoscopy during the period January 2008 to December 2012 and had histologically confirmed invasive carcinoma were included. These patients were contacted at the end of 2013 to determine their survival status. In addition to demographics, variables analyzed included presenting complaint and tumor site and stage at presentation.

Results

Of 1757 patients being subjected to colonoscopy, 118 had endoscopic and histologic documentation of invasive CRC. Of these the survival status of 102 was determined as of December 2013 and they formed the basis of our study. The mean age of the group was 62 years with approximately 20% of the group being age 50 years or younger. Females (54%) slightly outnumbered males. Anemia or overt rectal bleeding was a dominant indication (44%) and 65% of the tumours were left sided. There were 58 (57%) deaths and the median overall survival time was two years post diagnosis. Log rank tests for equality of survivorship looking at age, gender, tumor site and presentation revealed that only presenting complaint was a predictor of survivorship (p < 0.001). Patients presenting with bleeding or anemia have the best survival.

Conclusions

Long-term survival from colorectal cancer remains poor with only about 33% of patients being alive five years after their diagnosis.

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This manuscript documents the poor intermediate and long-term survival from colorectal cancer in Jamaica.

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Mean survival was 24 months and only 33% of patients were alive five years after their diagnosis.

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Patients presenting with anemia or bleeding had a better outcome.

Sociodemographic disparities in survival from colorectal cancer in South Australia: a population-wide data linkage study

BACKGROUND

Inequalities in survival from colorectal cancer (CRC) across socioeconomic groups and by area of residence have been described in various health care settings. Few population-wide datasets which include clinical and treatment information are available in Australia to investigate disparities. This study examines socio-demographic differences in survival for CRC patients in South Australia (SA), using a population-wide database derived via linkage of administrative and surveillance datasets.

METHODS

The study population comprised all cases of CRC diagnosed in 2003-2008 among SA residents aged 50-79 yrs in the SA Central Cancer Registry. Measures of socioeconomic status (area level), geographical remoteness, clinical characteristics, comorbid conditions, treatments and outcomes were derived through record linkage of central cancer registry, hospital-based clinical registries, hospital separations, and radiotherapy services data sources. Socio-demographic disparities in CRC survival were examined using competing risk regression analysis.

RESULTS

Four thousand six hundred and forty one eligible cases were followed for an average of 4.7 yrs, during which time 1525 died from CRC and 416 died from other causes. Results of competing risk regression indicated higher risk of CRC death with higher grade (HR high v low =2.25, 95% CI 1.32-3.84), later stage (HR C v A = 7.74, 95% CI 5.75-10.4), severe comorbidity (HR severe v none =1.21, 95% CI 1.02-1.44) and receiving radiotherapy (HR = 1.41, 95% CI 1.18-1.68). Patients from the most socioeconomically advantaged areas had significantly better outcomes than those from the least advantaged areas (HR =0.75, 95% 0.62-0.91). Patients residing in remote locations had significantly worse outcomes than metropolitan residents, though this was only evident for stages A-C (HR = 1.35, 95 % CI 1.01-1.80). These disparities were not explained by differences in stage at diagnosis between socioeconomic groups or area of residence. Nor were they explained by differences in patient factors, other tumour characteristics, comorbidity, or treatment modalities.

CONCLUSIONS

Socio-economic and regional disparities in survival following CRC are evident in SA, despite having a universal health care system. Of particular concern is the poorer survival for patients from remote areas with potentially curable CRC. Reasons for these disparities require further exploration to identify factors that can be addressed to improve outcomes.

Breast cancer screening utilization and understanding of current guidelines among rural U.S. women with private insurance

Women living in rural areas of the U.S. face disparities in screening mammography and breast cancer outcomes. We sought to evaluate utilization of mammography, awareness of screening guidelines, and attitudes towards screening among rural insured U.S. women. We conducted a cross-sectional self-administered anonymous survey among 2000 women aged 40-64 insured by the National Rural Electric Cooperative Association, a non-profit insurer for electrical utility workers in predominantly rural areas across the U.S. Outcomes included mammographic screening in the past year, screening interval, awareness of guidelines, and perceived barriers to screening. 1588 women responded to the survey (response rate 79.4 %). 74 % of respondents lived in a rural area. Among women aged 40-49, 66.5 % reported mammographic screening in the past year. 46 % received annual screening, 32 % biennial screening, and 22 % rare/no screening. Among women aged 50-64, 77.1 % reported screening in the past year. 63 % received annual screening, 25 % biennial screening, and 12 % rare/no screening. The majority of women (98 %) believed that the mammography can find breast cancer early and save lives. Less than 1 % of younger women, and only 14 % of women over age 50 identified the recommendations of the U.S. Preventative Services Screening Task Force as the current expert recommendations for screening. Screening practices tended to follow perceived guideline recommendations. When rural U.S. women over age 40 have insurance, most receive breast cancer screening. The screening guidelines of cancer advocacy groups and specialty societies appear more influential and widely recognized than those of the U.S. preventative services taskforce.

Lung cancer care: the impact of facilities and area measures

Lung cancer is the leading cause of cancer related mortality in the US, and while treatment disparities by race and class have been well described in the literature, the impact of social determinates of health, and specific characteristics of the treatment centers have been less well characterized. As the treatment of lung cancer relies more upon a precision and personalized medicine approach, where patients obtain treatment has an impact on outcomes and could be a major factor in treatment disparities. The purpose of this manuscript is to discuss the manner in which lung cancer care can be impacted by poor access to high quality treatment centers, and how the built environment can be a mitigating factor in the pursuit of treatment equity.

Cancer death rates in US congressional districts

Knowledge of the cancer burden is important for informing and advocating cancer prevention and control. Mortality data are readily available for states and counties, but not for congressional districts, from which representatives are elected and which may be more influential in compelling legislation and policy. The authors calculated average annual cancer death rates during 2002 to 2011 for each of the 435 congressional districts using mortality data from the National Center for Health Statistics and population estimates from the US Census Bureau. Age-standardized death rates were mapped for all sites combined and separately for cancers of the lung and bronchus, colorectum, breast, and prostate by race/ethnicity and sex. Overall cancer death rates vary by almost 2-fold and are generally lowest in Mountain states and highest in Appalachia and areas of the South. The distribution is similar for lung and colorectal cancers, with the lowest rates consistently noted in districts in Utah. However, for breast and prostate cancers, while the highest rates are again scattered throughout the South, the geographic pattern is less clear and the lowest rates are in Hawaii and southern Texas and Florida. Within-state heterogeneity is limited, particularly for men, with the exceptions of Texas, Georgia, and Florida. Patterns also vary by race/ethnicity. For example, the highest prostate cancer death rates are in the West and north central United States among non-Hispanic whites, but in the deep South among African Americans. Hispanics have the lowest rates except for colorectal cancer in Wyoming, eastern Colorado, and northern New Mexico. These data can facilitate cancer control and stimulate conversation about the relationship between cancer and policies that influence access to health care and the prevalence of behavioral and environmental risk factors.

Where can colorectal cancer screening interventions have the most impact?

BACKGROUND

Although colorectal cancer death rates in the United States have declined by half since 1970, large geographic disparities persist. Spatial identification of high-risk areas can facilitate targeted screening interventions to close this gap.

METHODS

We used the Getis-Ord Gi* statistic within ArcGIS to identify contemporary colorectal cancer "hotspots" (spatial clusters of counties with high rates) based on county-level mortality data from the national vital statistics system. Hotspots were compared with the remaining aggregated counties (non-hotspot United States) by plotting trends from 1970 to 2011 and calculating rate ratios (RR). Trends were quantified using joinpoint regression.

RESULTS

Spatial mapping identified three distinct hotspots in the contemporary United States where colorectal cancer death rates were elevated. The highest rates were in the largest hotspot, which encompassed 94 counties in the Lower Mississippi Delta [Arkansas (17), Illinois (16), Kentucky (3), Louisiana (6), Mississippi (27), Missouri (15), and Tennessee (10)]. During 2009 to 2011, rates here were 40% higher than the non-hotspot United States [RR, 1.40; 95% confidence interval (CI), 1.34-1.46], despite being 18% lower during 1970 to 1972 (RR, 0.82; 95% CI, 0.78-0.86). The elevated risk was similar in blacks and whites. Notably, rates among black men in the Delta increased steadily by 3.5% per year from 1970 to 1990, and have since remained unchanged. Rates in hotspots in west central Appalachia and eastern Virginia/North Carolina were 18% and 9% higher, respectively, than the non-hotspot United States during 2009 to 2011.

CONCLUSIONS

Advanced spatial analysis revealed large pockets of the United States with excessive colorectal cancer death rates.

IMPACT

These well-defined areas warrant prioritized screening intervention.

Lung cancer and urbanization level in a region of Southern Europe: influence of socio-economic and environmental factors

BACKGROUND

This study analysed the distribution of lung cancer deaths in areas with different urbanization levels in the Madrid Region and whether such differences persisted when deprivation and air pollution were considered.

METHODS

This was a population-based cross-sectional study covering lung cancer deaths (2001-07). The exposure indicators were: a deprivation index based on 2001 census data; and the daily mean NO2 measurement (2002-07), both at the census tract level. Analysis was stratified by sex and age group and the Poisson regression models were applied to obtain rate ratios (RRs).

RESULTS

After adjustment for age, deprivation index and NO2, mortality was similar in the city and Greater Madrid areas and lower in the rural area for the over-64 age group (RR: 0.84 in men and RR: 0.66 in women, with respect to the city of Madrid), and significantly lower in the Greater Madrid area (RR: 0.84 in men and RR: 0.74 in women) and in the rural area (RR: 0.73 in men and RR: 0.51 in women) with respect to the city of Madrid for the under-65 age group.

CONCLUSIONS

The most urbanized areas of the Madrid Region are characterized by higher lung cancer mortality.

Rural-Urban Differences in Late-Stage Breast Cancer: Do Associations Differ by Rural-Urban Classification System?

INTRODUCTION

Rural residence is associated with later stage of breast cancer diagnosis in some but not all prior studies. The lack of a standardized definition of rural residence may contribute to these mixed findings. We characterize and compare multiple definitions of rural vs. non-rural residence to provide guidance regarding choice of measures and to further elucidate rural disparities in breast cancer stage at diagnosis.

METHODS

We used Texas Cancer Registry data of 120,738 female breast cancer patients ≥50 years old diagnosed between 1995-2009. We defined rural vs. non-rural residence using 7 different measures and examined their agreement using Kappa statistics. Measures were defined at various geographic levels: county, ZIP code, census tract, and census block group. Late-stage was defined as regional or distant disease. For each measure, we tested the association of rural residence and late-stage cancer with unadjusted and adjusted logistic regression. Covariates included: age; patient race/ethnicity; diagnosis year; census block group-level mammography capacity; and census tract-level percent poverty, percent Hispanic, and percent Black.

RESULTS

We found moderate to high levels of agreement between measures of rural vs. non-rural residence. For 72.9% of all patients, all 7 definitions agreed as to rural vs. non-rural residence. Overall, 6 of 7 definitions demonstrated an adverse association between rural residence and late-stage disease in unadjusted and adjusted models (Adjusted OR Range = 1.09-1.14).

DISCUSSION

Our results document a clear rural disadvantage in late-stage breast cancer. We contribute to the heterogeneous literature by comparing varied measures of rural residence. We recommend use of the census tract-level Rural Urban Commuting Area Codes in future cancer outcomes research where small area data are available.

Widening Socioeconomic and Racial Disparities in Cardiovascular Disease Mortality in the United States, 1969-2013

OBJECTIVES

This study examined trends and socioeconomic and racial/ethnic disparities in cardiovascular disease (CVD) mortality in the United States between 1969 and 2013.

METHODS

National vital statistics data and the National Longitudinal Mortality Study were used to estimate racial/ethnic and area- and individual-level socioeconomic disparities in CVD mortality over time. Rate ratios and log-linear regression were used to model mortality trends and differentials.

RESULTS

Between 1969 and 2013, CVD mortality rates decreased by 2.66% per year for whites and 2.12% for blacks. Racial disparities and socioeconomic gradients in CVD mortality increased substantially during the study period. In 2013, blacks had 30% higher CVD mortality than whites and 113% higher mortality than Asians/Pacific Islanders. Compared to those in the most affluent group, individuals in the most deprived area group had 11% higher CVD mortality in 1969 but 40% higher mortality in 2007-2011. Education, income, and occupation were inversely associated with CVD mortality in both men and women. Men and women with low education and incomes had 46-76% higher CVD mortality risks than their counterparts with high education and income levels. Men in clerical, service, farming, craft, repair, construction, and transport occupations, and manual laborers had 30-58% higher CVD mortality risks than those employed in executive and managerial occupations.

CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS

Socioeconomic and racial disparities in CVD mortality are marked and have increased over time because of faster declines in mortality among the affluent and majority populations. Disparities in CVD mortality may reflect inequalities in the social environment, behavioral risk factors such as smoking, obesity, physical inactivity, disease prevalence, and healthcare access and treatment. With rising prevalence of many chronic disease risk factors, the global burden of cardiovascular diseases is expected to increase further, particularly in low- and middle-income countries where over 80% of all CVD deaths occur.

Widening Geographical Disparities in Cardiovascular Disease Mortality in the United States, 1969-2011

OBJECTIVES

This study examined trends in geographical disparities in cardiovascular-disease (CVD) mortality in the United States between 1969 and 2011.

METHODS

National vital statistics data and the National Longitudinal Mortality Study were used to estimate regional, state, and county-level disparities in CVD mortality over time. Log-linear, weighted least squares, and Cox regression were used to analyze mortality trends and differentials.

RESULTS

During 1969-2011, CVD mortality rates declined fastest in New England and Mid-Atlantic regions and slowest in the Southeast and Southwestern regions. In 1969, the mortality rate was 9% higher in the Southeast than in New England, but the differential increased to 48% in 2011. In 2011, Southeastern states, Mississippi and Alabama, had the highest CVD mortality rates, nearly twice the rates for Minnesota and Hawaii. Controlling for individual-level covariates reduced state differentials. State- and county-level differentials in CVD mortality rates widened over time as geographical disparity in CVD mortality increased by 50% between 1969 and 2011. Area deprivation, smoking, obesity, physical inactivity, diabetes prevalence, urbanization, lack of health insurance, and lower access to primary medical care were all significant predictors of county-level CVD mortality rates and accounted for 52.7% of the county variance.

CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS

Although CVD mortality has declined for all geographical areas in the United States, geographical disparity has widened over time as certain regions and states, particularly those in the South, have lagged behind in mortality reduction. Geographical disparities in CVD mortality reflect inequalities in socioeconomic conditions and behavioral risk factors. With the global CVD burden on the rise, monitoring geographical disparities, particularly in low- and middle-income countries, could indicate the extent to which reductions in CVD mortality are achievable and may help identify effective policy strategies for CVD prevention and control.

PROMOTING CANCER SCREENING AMONG RURAL AFRICAN AMERICANS: A SOCIAL NETWORK APPROACH

Obstacles that prevent rural African Americans (AAs) from regularly engaging in cancer screening were explored, and a theoretical approach was formulated utilizing social networks as a culturally sensitive form of health promotion. Disparities in cancer morbidity and mortality continue to exist between AAs and Caucasians in the United States. Often rural dwellers are further disadvantaged because of a potential lack of medical and financial resources and low health literacy. Social networks provide an existing framework where health concerns are discussed and health interventions in cancer screening can strengthen or encourage relevant health behaviors in rural AAs and other disadvantaged populations.

Informed consent for biobanking research: cancer patient recruitment from rural communities in Maine

Biobanking research seeks to improve the diversity, availability, and quality of human specimens critical for translational research, including biospecimen collections from disadvantaged minorities. American rural whites are seldom represented in such initiatives as geographic isolation makes obtaining informed consent challenging. We report a case series of 83 newly diagnosed cancer patients, attending a rural community medical center, who consented to participate in cancer research. To enable pooling with population studies, we created a BioGeoBank using 2007 NCI and ISBER Best Practices, after a protocol approval by Eastern Maine Medical Center (EMMC) IRB and OHP HRPO. Informed consent forms were at Flesch-Kincaid 8th Grade reading level, supplemented by NCI educational brochures. Of 108 patients identified, 85 were eligible. Of these, 83 patients (49 lung cancer, 21 breast cancer, and 13 other cancers) consented to donate data, blood, and tissue specimens for future research, and maintained eligibility. Two years later, we executed a legacy protocol to transfer specimens to NCI's biorepository. Of the 69 surviving patients, 9 patients could not be contacted. All those contacted (60) agreed to provide additional data on environmental risks, and consented to specimen transfer. Self-organizing map analyses showed no evidence that age, education, income, familial susceptibility, or lifestyle factors were associated with consent to donate data or biospecimens. Cancer cases reported 1-3 co-morbid chronic diseases (mostly cardiovascular), near lifetime smoking and/or alcohol consumption; familial cancer risks, and many had a prior cancer history. Anecdotally, willingness to consent was based on altruistic hopes that research would generate knowledge to reduce cancer incidence. Our study shows that cancer patients from disadvantaged white rural communities with health disparities associated with geographic isolation are motivated to consent to participate and support biobank research.

Rural living as context: a study of disparities in long-term cancer survivors

PURPOSE/OBJECTIVES

To explore the impact of rurality on health-related quality-of-life (HRQOL) disparities in rural long-term cancer survivors.

DESIGN

Cross-sectional survey.

SETTING

Rural-Urban Continuum Codes (RUCC) 7, 8, and 9.

SAMPLE

91 adults at least five years post-treatment.

METHODS

Mailed surveys measured HRQOL, self-esteem, and social support. Regression models were estimated to isolate (from self-esteem and social support) the effect of level of rurality on HRQOL.

MAIN RESEARCH VARIABLES

HRQOL, self-esteem, social support, and rurality.

FINDINGS

No differences in demographic characteristics existed among RUCCs. Survivors residing in RUCCs 7 or 8 tended to be similar in several dimensions of HRQOL. Survivors living in RUCC 7 reported significantly lower social function and greater financial difficulty and number of symptoms compared to survivors in RUCC 9 (the most remote). Self-esteem and social support strongly correlated with HRQOL.

CONCLUSIONS

The significant impact of rurality on HRQOL beyond self-esteem and social support suggests its role in explaining cancer survivorship disparities and directing practice. Until additional exploration can identify mechanisms behind rurality's impact, consideration of level of rurality as a potential factor in evaluating survivors' HRQOL outcomes is reasonable.

IMPLICATIONS FOR NURSING

Survivor context (e.g., level of rurality) influences HRQOL outcomes. Context or culture-relevant risk minimization and HRQOL optimization nursing practices are indicated.

A registry study of the association of patient's residence and age with colorectal cancer survival

Because of limited literature from rural states of the United States like Nebraska, we evaluated the association of patient's age, Office of Management and Budget residence-county categories (rural-nonmetro, micropolitan-nonmetro, urban), and significant interactions between confounding-variables with colorectal cancer (CRC) survival. This retrospective 1998-2003 study of 6561 CRC patients from the Nebraska Cancer Registry showed median patient survival in colon and rectal cancer in urban, rural and micropolitan counties were 33, 36, and 46 months and 41, 47, 49 months, respectively. In Cox proportional-hazards analyses, after adjusting for significant demographics (age, race, marital status in colon cancer; age, insurance status in rectal cancer), cancer stage, surgery and radiation treatments; 1) no-chemotherapy urban colon cancer patients had significantly shorter survival (rural vs urban; adjusted hazard ratio, HR: 0.78 or urban vs rural HR: 1.28; micropolitan vs urban, HR: 0.78) and 2) no-surgery urban (vs rural, HR: 1.49); micropolitan (vs rural, HR: 2.01) rectal cancer patients had significantly shorter survival. Colon cancer (≥65 years) and rectal cancer (≥75 years) elderly each versus patients aged 19-64 years old had significantly shorter survival (all p < 0.01). The association of patients' age and treatment/residence-county interactions with CRC survival warrant decision-makers' attention.

Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study

BACKGROUND

Measures of socioeconomic disadvantage may enable improved targeting of programs to prevent rehospitalizations, but obtaining such information directly from patients can be difficult. Measures of U.S. neighborhood socioeconomic disadvantage are more readily available but are rarely used clinically.

OBJECTIVE

To evaluate the association between neighborhood socioeconomic disadvantage at the census block group level, as measured by the Singh validated area deprivation index (ADI), and 30-day rehospitalization.

DESIGN

Retrospective cohort study.

SETTING

United States.

PATIENTS

Random 5% national sample of Medicare patients discharged with congestive heart failure, pneumonia, or myocardial infarction between 2004 and 2009 (n = 255,744).

MEASUREMENTS

Medicare data were linked to 2000 census data to construct an ADI for each patient's census block group, which were then sorted into percentiles by increasing ADI. Relationships between neighborhood ADI grouping and 30-day rehospitalization were evaluated using multivariate logistic regression models, controlling for patient sociodemographic characteristics, comorbid conditions and severity, and index hospital characteristics.

RESULTS

The 30-day rehospitalization rate did not vary significantly across the least disadvantaged 85% of neighborhoods, which had an average rehospitalization rate of 21%. However, within the most disadvantaged 15% of neighborhoods, rehospitalization rates increased from 22% to 27% with worsening ADI. This relationship persisted after full adjustment, with the most disadvantaged neighborhoods having a rehospitalization risk (adjusted risk ratio, 1.09 [95% CI, 1.05 to 1.12]) similar to that of chronic pulmonary disease (adjusted risk ratio, 1.06 [CI, 1.04 to 1.08]) and greater than that of uncomplicated diabetes (adjusted risk ratio, 0.95 [CI, 0.94 to 0.97]).

LIMITATION

No direct markers of care quality or access.

CONCLUSION

Residence within a disadvantaged U.S. neighborhood is a rehospitalization predictor of magnitude similar to chronic pulmonary disease. Measures of neighborhood disadvantage, such as the ADI, could potentially be used to inform policy and care after hospital discharge.

PRIMARY FUNDING SOURCE

National Institute on Aging and University of Wisconsin School of Medicine and Public Health's Institute for Clinical and Translational Research and Health Innovation Program.

A protocol for a discrete choice experiment: understanding preferences of patients with cancer towards their cancer care across metropolitan and rural regions in Australia

INTRODUCTION

Medical decision-making in oncology is a complicated process and to date there are few studies examining how patients with cancer make choices with respect to different features of their care. It is also unknown whether patient choices vary by geographical location and how location could account for observed rural and metropolitan cancer differences. This paper describes an ongoing study that aims to (1) examine patient and healthcare-related factors that influence choices of patients with cancer; (2) measure and quantify preferences of patients with cancer towards cancer care using a discrete choice experiment (DCE) and (3) explore preference heterogeneity between metropolitan and rural locations.

METHODS AND ANALYSIS

A DCE is being conducted to understand how patients with cancer choose between two clinical scenarios accounting for different patient and healthcare-related factors (and levels). Preliminary qualitative research was undertaken to guide the development of an appropriate DCE design including characteristics that are important and relevant to patients with cancer. A fractional factorial design using the D-efficiency criteria was used to estimate interactions among attributes. Multinomial logistic regression will be used for the primary DCE analysis and to control for sociodemographic and clinical characteristics.

ETHICS AND DISSEMINATION

The Barwon Health Human Research Ethics Committee approved the study. Findings from the study will be presented in national/international conferences and peer-reviewed journals. Our results will form the basis of a feasibility study to inform the development of a larger scale study into preferences of patients with cancer and their association with cancer outcomes.

Cross-sectional study to assess the association of population density with predicted breast cancer risk

The Gail and CARE models estimate breast cancer risk for white and African-American (AA) women, respectively. The aims of this study were to compare metropolitan and nonmetropolitan women with respect to predicted breast cancer risks based on known risk factors, and to determine if population density was an independent risk factor for breast cancer risk. A cross-sectional survey was completed by 15,582 women between 35 and 85 years of age with no history of breast cancer. Metropolitan and nonmetropolitan women were compared with respect to risk factors, and breast cancer risk estimates, using general linear models adjusted for age. For both white and AA women, tisk factors used to estimate breast cancer risk included age at menarche, history of breast biopsies, and family history. For white women, age at first childbirth was an additional risk factor. In comparison to their nonmetropolitan counterparts, metropolitan white women were more likely to report having a breast biopsy, have family history of breast cancer, and delay childbirth. Among white metropolitan and nonmetropolitan women, mean estimated 5-year risks were 1.44% and 1.32% (p < 0.001), and lifetime risks of breast cancer were 10.81% and 10.01% (p < 0.001), respectively. AA metropolitan residents were more likely than those from nonmetropolitan areas to have had a breast biopsy. Among AA metropolitan and nonmetropolitan women, mean estimated 5-year risks were 1.16% and 1.12% (p = 0.039) and lifetime risks were 8.94%, and 8.85% (p = 0.344). Metropolitan residence was associated with higher predicted breast cancer risks for white women. Among AA women, metropolitan residence was associated with a higher predicted breast cancer risk at 5 years, but not over a lifetime. Population density was not an independent risk factor for breast cancer.

Assessing environmental support for better health: active living opportunity audits in rural communities in the southern United States

OBJECTIVE

Leisure-time physical activity in the United States is lower rural areas and the South and has been linked to socioeconomic and environmental aspects of where people live. The purpose of this study is to assess the built environment and policies for physical activity in rural communities.

METHODS

Eight rural communities in Alabama and Mississippi were assessed in 2011 using the Rural Active Living Assessment (RALA) street segment (SSA), town-wide (TWA), and town program and policies (PPA) assessment tools. Community Health Advisors Trained as Research Partners (CHARPS) and local staff conducted the assessments. The TWA and PPA were scored by domain and total scores. Data were analyzed using descriptive and nonparametric statistics.

RESULTS

117 segments were assessed in 22 towns in 8 counties. Built environmental barriers existed in all communities. Sidewalks were available in only 10-40% of the segments. TWA identified parks and playgrounds as the most available community feature. PPA scores indicated few policies for physical activity outside of school settings with mean scores higher in Mississippi compared to Alabama (61 vs. 49, respectively).

CONCLUSIONS

Multiple components of rural communities can be successfully assessed by CHARPs using RALA tools, providing information about resources and barriers for physical activity.

Differences in response to a dietary intervention between the general population and first-degree relatives of colorectal cancer patients

OBJECTIVE

To determine whether response to a dietary intervention is greater among people with family history of colorectal cancer (CRC) compared with a general population.

DESIGN

Cohort study examining participants from 2 related studies.

SETTING

Rural Virginia.

PARTICIPANTS

Seventy people with first-degree relatives with CRC and 113 participants from the intervention arm of a trial in the general population.

INTERVENTION

Both studies implemented a low-intensity intervention delivered via telephone and mail, including low-literacy self-help booklets and personalized dietary feedback.

MAIN OUTCOME MEASURES

Fat, fiber, and fruit and vegetable behavior.

ANALYSIS

Propensity score matching controlled for confounders. Mixed-model ANOVAs compared samples; mediation by perceived cancer risk was assessed.

RESULTS

Participants in both groups significantly improved fat, fiber, and fruit and vegetable behavior at 1-month follow-up; there was significantly greater improvement in the general population sample. Cancer risk perception did not mediate the relationship between study sample and dietary change.

CONCLUSIONS AND IMPLICATIONS

Contrary to expectations, first-degree relatives of CRC patients did not respond better to a dietary intervention than the general population, nor was risk perception related to dietary change. Given the role of diet in CRC risk, additional research should investigate targeted strategies to improve dietary intakes of people at higher cancer risk.

Use of autologous hematopoietic cell transplantation as initial therapy in multiple myeloma and the impact of socio-geo-demographic factors in the era of novel agents

Very effective combination chemotherapy using novel agents has become available in multiple myeloma (MM). Its impact on the use of high-dose chemotherapy and autologous hematopoietic stem cell transplantation (AHCT) as part of initial therapy is unknown. Using the National Cancer Data Base, we studied the rate of upfront AHCT use among 137,409 newly diagnosed MM patients from 1998 to 2010 in the United States and determined whether disparity exists among various sociodemographic as well as geographic subgroups. Overall, 12,378 (9.0%) patients received AHCT as part of initial treatment. The use of upfront AHCT increased steadily from 5.2% in 1998 to 12.1% in 2010 (trend test, P < 0.001), with no sign of plateau. This was seen across all socio-geo-demographic subgroups except among patients treated in the Northeast where the rate fell from 8.7% in 1998 to 6.6% in 2010. In multivariable analysis, patients with the following characteristics were the least likely to receive AHCT (odds ratio): year of diagnosis from 1998 to 2003 before the era of novel agents (0.67), older age (0.35), Black race (0.58), Hispanic ethnicity (0.78), low level of education or annual household income (0.55), residence in a metro area (0.66), no or unknown medical insurance (0.30), treatment at a community cancer center (0.16), and treatment facility located in the Northeast region (0.54). Even after the introduction of novel agents, the rate of upfront AHCT in MM continues to increase annually. Significant disparities exist dependent on demographic, social, and geographic factors.

Physical and mental health among cancer survivors: considerations for long-term care and quality of life

The physical and mental health of cancer patients needs to be addressed not only during active treatment but also throughout the continuum of survivorship care. This commentary provides an overview of issues pertinent to cancer survivors, with an emphasis on mental health issues and recommendations for annual clinical screening and monitoring using recently published guidelines from the American Society of Clinical Oncology.

At the intersection of sexual orientation, race/ethnicity, and cervical cancer screening: assessing Pap test use disparities by sex of sexual partners among black, Latina, and white U.S. women

Understanding how various dimensions of social inequality shape the health of individuals and populations poses a key challenge for public health. Guided by ecosocial theory and intersectionality, we used data from the 2006-2010 National Survey of Family Growth, a national probability sample, to investigate how one dimension of sexual orientation, sex of sexual partners, and race/ethnicity jointly influence Pap test use among black, Latina and white U.S. women aged 21-44 years (N = 8840). We tested for an interaction between sex of sexual partners and race/ethnicity (p = 0.015) and estimated multivariable logistic regression models for each racial/ethnic group, adjusting for socio-demographic factors. The adjusted odds of Pap test use for women with only female sexual partners in the past year were significantly lower than for women with only male sexual partners in the past year among white women (odds ratio [OR] = 0.25, 95% confidence interval [CI]: 0.12,0.52) and may be lower among black women (OR = 0.32, 95% CI: 0.07,1.52); no difference was apparent among Latina women (OR = 1.54, 95% CI: 0.31,7.73). Further, the adjusted odds of Pap test use for women with no sexual partners in the past year were significantly lower than for women with only male sexual partners in the past year among white (OR = 0.30, 95% CI: 0.22,0.41) and black (OR = 0.23, 95% CI: 0.15,0.37) women and marginally lower among Latina women (OR = 0.63, 95% CI: 0.38,1.03). Adding health care indicators to the models completely explained Pap test use disparities for women with only female vs. only male sexual partners among white women and for women with no vs. only male sexual partners among Latina women. Ecosocial theory and intersectionality can be used in tandem to conceptually and operationally elucidate previously unanalyzed health disparities by multiple dimensions of social inequality.

The relationship between area poverty rate and site-specific cancer incidence in the United States

BACKGROUND

The relationship between socioeconomic status and cancer incidence in the United States has not traditionally been a focus of population-based cancer surveillance systems.

METHODS

Nearly 3 million tumors diagnosed between 2005 and 2009 from 16 states plus Los Angeles were assigned into 1 of 4 groupings based on the poverty rate of the residential census tract at time of diagnosis. The sex-specific risk ratio of the highest-to-lowest poverty category was measured using Poisson regression, adjusting for age and race, for 39 cancer sites.

RESULTS

For all sites combined, there was a negligible association between cancer incidence and poverty; however, 32 of 39 cancer sites showed a significant association with poverty (14 positively associated and 18 negatively associated). Nineteen of these sites had monotonic increases or decreases in risk across all 4 poverty categories. The sites most strongly associated with higher poverty were Kaposi sarcoma, larynx, cervix, penis, and liver; those most strongly associated with lower poverty were melanoma, thyroid, other nonepithelial skin, and testis. Sites associated with higher poverty had lower incidence and higher mortality than those associated with lower poverty.

CONCLUSIONS

These findings demonstrate the importance and relevance of including a measure of socioeconomic status in national cancer surveillance. Cancer 2014;120:2191–2198. © 2014 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.

A majority of cancer sites exhibit significant associations with area poverty rates. Those associated with higher poverty had lower incidence but higher mortality than those associated with lower poverty.

Improving outcomes in breast cancer: where should we target our efforts?

Rural-urban differences in health outcomes, including breast cancer, in the US have been studied for decades, but often with inconsistent findings. Possible reasons include methodological differences, lack of prospective investigations, small number of studies overall, and the tendency to measure rurality as a simple patient-level predictor variable. Studies have tended to assume that the same racial/ethnic cancer disparities found in the general population exist in rural regions, but this conclusion may not always be warranted. Needed are better definitions of rurality; the capability to define important predictor variables such as race, ethnicity, education, and income with greater precision than at present; and data revealing the patient's own perspective regarding care decisions. Future studies should examine whether the impact of rurality status on outcomes varies with geographic location by including the appropriate interaction terms in the outcome prediction models, as well as patient-reported reasons that might explain the outcomes observed.

Time trends in liver cancer mortality, incidence, and risk factors by unemployment level and race/ethnicity, United States, 1969-2011

This study examined unemployment and racial/ethnic disparities in liver cancer mortality, incidence, survival, and risk factors in the United States between 1969 and 2011. Census-based unemployment rates were linked to 1969-2009 county-level mortality and incidence data, whereas 2006-2011 National Health Interview Surveys were used to examine variations in hepatitis infection and alcohol consumption. Age-adjusted mortality rates, risk-ratios, and rate-differences were calculated by year, sex, race, and county-unemployment level. Log-linear, Poisson, and logistic regression and disparity indices were used to model trends and differentials. Although liver-cancer mortality rose markedly for all groups during 1969-2011, higher unemployment levels were associated with increased mortality and incidence rates in each time period. Both absolute and relative inequalities in liver cancer mortality according to unemployment level increased over time for both males and females and for those aged 25-64 years. Compared to the lowest-unemployment group, those aged 25-64 in the highest-unemployment group had 56 and 115 % higher liver-cancer mortality in 1969-1971 and 2005-2009, respectively. Regardless of unemployment levels, Asian/Pacific Islanders and Hispanics had the highest mortality and incidence rates. The adjusted odds of hepatitis infection and heavy drinking were 38-39 % higher among the unemployed than employed. Liver-cancer mortality and incidence have risen steadily among all racial/ethnic, sex, and socioeconomic groups. Faster increases in mortality among the highest-unemployment group have led to a widening gap in mortality over time. Disparities in mortality and incidence are consistent with similar inequalities in hepatitis infection and alcohol consumption.

Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969-2009

This study examined trends in rural-urban disparities in all-cause and cause-specific mortality in the USA between 1969 and 2009. A rural-urban continuum measure was linked to county-level mortality data. Age-adjusted death rates were calculated by sex, race, cause-of-death, area-poverty, and urbanization level for 13 time periods between 1969 and 2009. Cause-of-death decomposition and log-linear and Poisson regression were used to analyze rural-urban differentials. Mortality rates increased with increasing levels of rurality overall and for non-Hispanic whites, blacks, and American Indians/Alaska Natives. Despite the declining mortality trends, mortality risks for both males and females and for blacks and whites have been increasingly higher in non-metropolitan than metropolitan areas, particularly since 1990. In 2005-2009, mortality rates varied from 391.9 per 100,000 population for Asians/Pacific Islanders in rural areas to 1,063.2 for blacks in small-urban towns. Poverty gradients were steeper in rural areas, which maintained higher mortality than urban areas after adjustment for poverty level. Poor blacks in non-metropolitan areas experienced two to three times higher all-cause and premature mortality risks than affluent blacks and whites in metropolitan areas. Disparities widened over time; excess mortality from all causes combined and from several major causes of death in non-metropolitan areas was greater in 2005-2009 than in 1990-1992. Causes of death contributing most to the increasing rural-urban disparity and higher rural mortality include heart disease, unintentional injuries, COPD, lung cancer, stroke, suicide, diabetes, nephritis, pneumonia/influenza, cirrhosis, and Alzheimer's disease. Residents in metropolitan areas experienced larger mortality reductions during the past four decades than non-metropolitan residents, contributing to the widening gap.

Widening rural-urban disparities in life expectancy, U.S., 1969-2009

BACKGROUND

There is limited research on rural-urban disparities in U.S. life expectancy.

PURPOSE

This study examined trends in rural-urban disparities in life expectancy at birth in the U.S. between 1969 and 2009.

METHODS

The 1969-2009 U.S. county-level mortality data linked to a rural-urban continuum measure were analyzed. Life expectancies were calculated by age, gender, and race for 3-year time periods between 1969 and 2004 and for 2005-2009 using standard life-table methodology. Differences in life expectancy were decomposed by age and cause of death.

RESULTS

Life expectancy was inversely related to levels of rurality. In 2005-2009, those in large metropolitan areas had a life expectancy of 79.1 years, compared with 76.9 years in small urban towns and 76.7 years in rural areas. When stratified by gender, race, and income, life expectancy ranged from 67.7 years among poor black men in nonmetropolitan areas to 89.6 among poor Asian/Pacific Islander women in metropolitan areas. Rural-urban disparities widened over time. In 1969-1971, life expectancy was 0.4 years longer in metropolitan than in nonmetropolitan areas (70.9 vs 70.5 years). By 2005-2009, the life expectancy difference had increased to 2.0 years (78.8 vs 76.8 years). The rural poor and rural blacks currently experience survival probabilities that urban rich and urban whites enjoyed 4 decades earlier. Causes of death contributing most to the increasing rural-urban disparity and lower life expectancy in rural areas include heart disease, unintentional injuries, COPD, lung cancer, stroke, suicide, and diabetes.

CONCLUSIONS

Between 1969 and 2009, residents in metropolitan areas experienced larger gains in life expectancy than those in nonmetropolitan areas, contributing to the widening gap.

Treatment and survival disparities in lung cancer: the effect of social environment and place of residence

OBJECTIVE

The purpose of this study was to measure the extent to which geographic residency status and the social environment are associated with disease stage at diagnosis, receipt of treatment, and five-year survival for patients diagnosed with non-small cell lung cancer (NSCLC).

METHODS AND MATERIALS

This study was a retrospective cohort study of the Georgia Comprehensive Cancer Registry (GCCR) for incident cases of NSCLC diagnosed in the state. Multilevel logistic models were employed for five outcome variables: unstaged and late stage disease at diagnosis; receipt of treatment (surgery, chemotherapy, and radiation); and survival following diagnosis. The social and geographical variables of interest were census tract (CT) poverty level, CT-level educational attainment, and CT-level geographic residency status.

RESULTS

Compared to urban residents, rural and suburban residents had increased odds of unstaged disease (suburban OR=1.23, 95% CI: 1.11-1.37; rural OR=1.63, 95% CI: 1.45-1.83). In this study, rural participants had lower odds of receiving radiotherapy (OR=0.89, 95% CI: 0.82-0.96) and chemotherapy (OR=0.92, 95% CI: 0.85-0.99). Living in CTs with lower educational levels was associated with decreasing odds of receiving both surgery (lowest educational level OR=0.67, 95% CI: 0.59-0.75) and chemotherapy (lowest educational level OR=0.74, 95% CI: 0.68-0.81). Living in areas with higher concentration of deprivation (high level of deprivation HR=1.04, 95% CI: 1.01-1.09) and lower levels of education (lowest educational level HR=1.12, 95% CI: 1.07-1.17) was associated with poorer survival. Rural residents did not show poorer survival when treatment was controlled and they even presented a lower risk of death for early stage disease (HR=0.90, 95% CI: 0.82-0.99).

CONCLUSION

This study concludes that where NSCLC patients live can, to some extent, explain treatment and prognostic disparities. Public health practitioners and policy makers should be cognizant of the importance of where people live and shift their efforts to improve lung cancer outcomes in rural areas and neighborhoods with concentrated poverty.

Geographic residency status and census tract socioeconomic status as determinants of colorectal cancer outcomes

OBJECTIVES

We examined the impact of geographic residency status and census tract (CT)-level socioeconomic status (SES) on colorectal cancer (CRC) outcomes.

METHODS

This was a retrospective cohort study of patients diagnosed with CRC in Georgia for the years 2000 through 2007. Study outcomes were late-stage disease at diagnosis, receipt of treatment, and survival.

RESULTS

For colon cancer, residents of lower-middle-SES and low-SES census tracts had decreased odds of receiving surgery. Rural, lower-middle-SES, and low-SES residents had decreased odds of receiving chemotherapy. For patients with rectal cancer, suburban residents had increased odds of receiving radiotherapy, but low SES resulted in decreased odds of surgery. For survival, rural residents experienced a partially adjusted 14% (hazard ratio [HR] = 1.14; 95% confidence interval [CI] = 1.07, 1.22) increased risk of death following diagnosis of CRC that was somewhat explained by treatment differences and completely explained by CT-level SES. Lower-middle- and low-SES participants had an adjusted increased risk of death following diagnosis for CRC (lower-middle: HR = 1.16; 95% CI = 1.10, 1.22; low: HR = 1.24; 95% CI = 1.16, 1.32).

CONCLUSIONS

Future efforts should focus on developing interventions and policies that target rural residents and lower SES areas to eliminate disparities in CRC-related outcomes.

Distribution of HPV Genotypes and Involvement of Risk Factors in Cervical Lesions and Invasive Cervical Cancer: A Study in an Indian Population

Human papilloma virus (HPV) is considered as the main sexually transmitted etiological agent for the cause and progression of preneoplastic cervical lesions to cervical cancer. This study is discussing the prevalence of HPV and its genotypes in cervical lesions and invasive cervical cancer tissues and their association with various risk factors in women from Varanasi and its adjoining areas in India. A total of 122 cervical biopsy samples were collected from SS Hospital and Indian Railways Cancer Institute and Research Centre, Varanasi and were screened for HPV infection by PCR using primers from L1 consensus region of the viral genome. HPV positive samples were genotyped by type-specific PCR and sequencing. The association of different risk factors with HPV infection in various grades of cervical lesion was evaluated by chi-square test. A total of 10 different HPV genotypes were observed in women with cervicitis, CIN, invasive squamous cell cervical carcinoma and adenocarcinoma. Increased frequency of HPV infection with increasing lesion grade (p=0.002) was observed. HPV16 being the predominant type was found significantly associated with severity of the disease (p=0.03). Various socio- demographic factors other than HPV including high parity (p<0.0001), rural residential area (p<0.0001), elder age (p<0.0001), low socio-economic status (p<0.0001) and women in postmenopausal group (p<0.0001) were also observed to be associated with cervical cancer.These findings show HPV as a direct cause of cervical cancer suggesting urgent need of screening programs and HPV vaccination in women with low socio-economic status and those residing in rural areas.

Disparities in breast cancer stage at diagnosis in urban and rural adult women: a systematic review and meta-analysis

PURPOSE

Survival from breast cancer is dependent on stage at diagnosis and some evidence suggests that rural women are more likely than urban women to be diagnosed with advanced stage disease. This systematic review and meta-analysis compared the stage of breast cancer at diagnosis between women residing in urban and rural areas.

METHODS

PubMed (1951-2012), EMBASE (1966-2012), CINAHL (1982-2012), RURAL (1966-2012), and Sociological abstracts (1952-2012) were systematically searched in November 2012 for relevant peer reviewed studies. Studies on adult women were included if they reported quantitative comparisons of rural and urban differences in staging of breast cancer at diagnosis.

RESULTS

Twenty-four studies were included in the systematic review and 21 studies had sufficient information for inclusion in the meta-analysis (N = 879,660). Evidence indicated that patients residing in rural areas were more likely to be diagnosed with more advanced breast cancer. Using a random effects model, the results of the meta-analysis showed that rural breast cancer patients had 1.19 higher odds (95% confidence interval, 1.12-1.27) of late stage breast cancer compared with urban breast cancer patients.

CONCLUSIONS

Rural women were more likely than urban women to be diagnosed at a later stage. Preventive measures may need to target the rural population.

Prostate cancer in Scotland: does geography matter? An analysis of incidence, disease characteristics and survival between urban and rural areas

Objective:

The objective of this article is to identify whether there is a difference in survival from prostate cancer in urban and rural areas of Scotland and to identify potential inequalities in incidence, disease characteristics and the treatment of prostate cancer between these areas.

Subjects/patients and methods:

A retrospective cohort study was undertaken. Retrospective analysis of data from Information Services Division and regional cancer databases from 2005 to 2010 was performed. A comparison of NHS Highland & Western Isles as the rural group with NHS Lothian as the urban group was made. Data were collected on patient and disease characteristics, first treatment and mortality. Non-parametric continuous data were analysed using the Mann-Whitney U test. Categorical data were assessed using a two-tailed Z test. The p value for statistical significance was set at < 0.05.

Results:

The incidence of prostate cancer was higher in rural areas. Rural patients were older at diagnosis ( p < 0.0001), presented with higher risk disease ( p < 0.0001) and underwent less curative treatment ( p < 0.0001). There was potentially poorer survival in rural areas.

Conclusions:

Men living in rural areas of Scotland present with more aggressive prostate cancer and may have poorer survival. This could be due to high levels of PSA testing in urban areas, therefore further studies are needed to identify patterns of PSA testing in Scotland. These inequalities will be highlighted to the Scottish Government to inform the ‘Detect Cancer Early’ campaign for its second phase in 2015.

Factors associated with perceptions of the cancer care system: a multilevel modeling approach

Perceptions about the health care system are a key driver of disparities and utilization. This study examined individual and contextual factors related to care and noncare dimensions and their relationship to perceptions of the cancer care system. A national sample of 877 cases was modeled using a multilevel modeling approach. Insurance complaints, number of treatments, and advocacy impact were negatively associated with satisfaction with the cancer care system at the individual level. Also, respondents in states where more Christians resided and lower hospital capacity were more likely to indicate satisfaction. Findings suggest implications for practitioners and health policy makers.

Stage-adjusted lung cancer survival does not differ between low-income Blacks and Whites

INTRODUCTION

Few lung cancer studies have focused on lung cancer survival in underserved populations. We conducted a prospective cohort study among 81,697 racially diverse and medically underserved adults enrolled in the Southern Community Cohort Study throughout an 11-state area of the Southeast from March 2002 to September 2009.

METHODS

Using linkages with state cancer registries, we identified 501 incident non-small-cell lung cancer cases. We applied Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for subsequent mortality among black and white participants.

RESULTS

The mean observed follow-up time (the time from diagnosis to death or end of follow-up) was 1.25 years (range, 0-8.3 years) and 75% (n = 376) of cases died during follow-up. More blacks were diagnosed at distant stage than whites (57 versus 45%; p = 0.03). In multivariable analyses adjusted for pack-years of smoking, age, body mass index, health insurance, socioeconomic status and disease stage, the lung cancer mortality HR was higher for men versus women (HR = 1.41; 95% CI, 1.09-1.81) but similar for blacks versus whites (HR = 0.99; 95% CI, 0.74-1.32).

CONCLUSION

These findings suggest that although proportionally more blacks present with distant-stage disease there is no difference in stage-adjusted lung cancer mortality between blacks and whites of similar low socioeconomic status.

Examining potential colorectal cancer care disparities in the Veterans Affairs health care system

PURPOSE

Racial disparities in cancer treatment and outcomes are a national problem. The nationwide Veterans Affairs (VA) health system seeks to provide equal access to quality care. However, the relationship between race and care quality for veterans with colorectal cancer (CRC) treated within the VA is poorly understood. We examined the association between race and receipt of National Comprehensive Cancer Network guideline-concordant CRC care.

PATIENTS AND METHODS

This was an observational, retrospective medical record abstraction of patients with CRC treated in the VA. Two thousand twenty-two patients (white, n = 1,712; African American, n = 310) diagnosed with incident CRC between October 1, 2003, and March 31, 2006, from 128 VA medical centers, were included. We used multivariable logistic regression to examine associations between race and receipt of guideline-concordant care (computed tomography scan, preoperative carcinoembryonic antigen, clear surgical margins, medical oncology referral for stages II and III, fluorouracil-based adjuvant chemotherapy for stage III, and surveillance colonoscopy for stages I to III). Explanatory variables included demographic and disease characteristics.

RESULTS

There were no significant racial differences for receipt of guideline-concordant CRC care. Older age at diagnosis was associated with reduced odds of medical oncology referral and surveillance colonoscopy. Presence of cardiovascular comorbid conditions was associated with reduced odds of medical oncology referral (odds ratio, 0.65; 95% CI, 0.50 to 0.89).

CONCLUSION

In these data, we observed no evidence of racial disparities in CRC care quality. Future studies could examine causal pathways for the VA's equal, quality care and ways to translate the VA's success into other hospital systems.

Differences between referred and nonreferred patients in cancer research

BACKGROUND

In Canada, provincial cancer registries have been established to provide rigorous population-based data for patients with colorectal cancer. Databases maintained by regional cancer agencies contain a broader scope of information and have been used as a surrogate source of information for colorectal cancer research. It is unclear whether these data can be reliably extrapolated to all patients affected by colorectal cancer. We sought to determine whether patients included in a referral-based database are systematically different from patients who are not included.

METHODS

We conducted a retrospective cohort study to compare patients referred to the British Columbia Cancer Agency with those who were not referred. Comparison was based on age, sex and geographic location. We used univariate and logistic regression analysis to identify significant differences between the cohorts.

RESULTS

Univariate analysis demonstrated that the referral and nonreferral cohorts differed in sex, age and geographic location. For patients with rectal cancer, the referral and nonreferral cohorts varied in age and geographic location. Multivariate analysis demonstrated significant differences in age and geographic location but not sex for patients with colon and rectal cancer.

CONCLUSION

Patients included in the referral database differed in age and geographic location from those included only in the provincial database. Studies using large data sets from referral centres must be interpreted with caution and may not be representative of the entire patient population.

Distribution of Industrial Farms in the United States and Socioeconomic, Health, and Environmental Characteristics of Counties

The method of producing food animals has changed in the United States over the past century, moving from traditional burns to enclosed structures resembling industrial buildings, where animals are raised in high stocking density (commonly known as “Concentrated Animal Feeding Operations,” CAFOs). The objective to maximize profit has resulted in poor farm management; raised issues of environmental pollution, public health, animal rights, and environmental justice, and had socio-economic impacts. Studies concerning the issues are limited to specific regions and types of CAFOs. In addition, studies on the spatial distribution and temporal changes of CAFO at a country scale are lacking. This study bridges some of the gaps by analyzing the spatial distribution of industrial farms in the United States in 2002 and 2007 and their relationship with vulnerable population and exploring the relationships among the concentrations of farms, socio-economic, health, and environmental characteristics of the counties. A range of spatial statistics tools were applied in this study. The study revealed variations in spatial distribution depending on the type of the CAFOs. The issue of environmental justice was found prevalent depending on the types of industrial farms. Each type of industrial farm was found to interact uniquely with the selected demographic, health, and environmental parameters.

Patient scenario identifies gaps in breast cancer services in a rural region

Studies have demonstrated that community-based cancer coalitions can effectively address cancer disparities in rural areas. Scenario plots have been used to assess community needs in health care and public health. The social and medical context of a woman with undetected breast cancer was developed as a patient scenario implemented at a rural cancer coalition meeting to rapidly identify gaps in services. Transportation, fragmentation of cancer care, access to insurance coverage, patient navigation, and survivorship services were identified as gaps in ensuring patient compliance across the continuum of breast cancer care throughout the region. Results will be used to shape coalition priorities.

The role of family history of cancer on cervical cancer screening behavior in a population-based survey of women in the Southeastern United States

BACKGROUND

Our objective was to determine the association of self-reported family history of cancer (FHC) on cervical cancer screening to inform a potential link with cancer preventive behaviors in a region with persistent cancer disparities.

METHODS

Self-reported FHC, Pap test behavior, and access to care were measured in a statewide population-based survey of human papillomavirus and cervical cancer (n = 918). Random-digit dial, computer-assisted telephone interviews were used to contact eligible respondents (adult [ages 18-70] women in South Carolina with landline telephones]. Logistic regression models were estimated using STATA 12.

FINDINGS

Although FHC+ was not predictive (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.55-2.51), private health insurance (OR, 2.35; 95% confidence interval [CI], 1.15-4.81) and younger age (18-30 years: OR, 7.76; 95% CI, 1.91, 3.16) were associated with recent Pap test behavior. FHC and cervical cancer screening associations were not detected in the sample.

CONCLUSIONS

Findings suggest targeting older women with screening recommendations and providing available screening resources for underserved women.

Efficient mapping and geographic disparities in breast cancer mortality at the county-level by race and age in the U.S

This study identified geographic disparities in breast cancer mortality across the U.S. using kriging to overcome unavailability of data because of confidentiality and reliability concerns. A structured additive regression model was used to detect where breast cancer mortality rates were elevated across nine divisions with 3109 U.S. counties during 1982-2004. Our analysis identified at least 25.8% of counties where breast cancer mortality rates were elevated. High-risk counties compared to lower-risk counties had higher relative risks for African American women than for White women. Greater geographic disparities more likely present in African American women and younger women. To sum up, our statistical approach reduced the impact of unavailable data, and identified the number and location of counties with high breast cancer mortality risk by race and age across the U.S.

Widening Socioeconomic, Racial, and Geographic Disparities in HIV/AIDS Mortality in the United States, 1987-2011

This study examined the extent to which socioeconomic and racial and geographic disparities in HIV/AIDS mortality in the United States changed between 1987 and 2011. Census-based deprivation indices were linked to county-level mortality data from 1987 to 2009. Log-linear, least-squares, and Poisson regression were used to model mortality trends and differentials. HIV/AIDS mortality rose between 1987 and 1995 and then declined markedly for all groups between 1996 and 2011. Despite the steep mortality decline, socioeconomic gradients and racial and geographic disparities in HIV/AIDS mortality increased substantially during the study period. Compared to whites, blacks had 3 times higher HIV/AIDS mortality in 1987 and 8 times higher mortality in 2011. In 1987, those in the most-deprived group had 1.9 times higher HIV/AIDS mortality than those in the most-affluent group; the corresponding relative risks increased to 2.9 in 1998 and 3.6 in 2009. Socioeconomic gradients existed across all race-sex groups, with mortality risk being 8–16 times higher among blacks than whites within each deprivation group. Dramatic reductions in HIV/AIDS mortality represent a major public health success. However, slower mortality declines among more deprived groups and blacks contributed to the widening gap. Mortality disparities reflect inequalities in incidence, access to antiretroviral therapy, and patient survival.

Rural-urban disparities in health status among US cancer survivors

BACKGROUND

Although rural residents are more likely to be diagnosed with more advanced cancers and to die of cancer, little is known about rural-urban disparities in self-reported health among survivors.

METHODS

The authors identified adults who had a self-reported history of cancer from the National Health Interview Survey (2006-2010). Rural-urban residence was defined using US Census definitions. Logistic regression with weighting to account for complex sampling was used to assess rural-urban differences in health status after accounting for differences in demographic characteristics.

RESULTS

Of the 7804 identified cancer survivors, 20.8% were rural residents. This translated to a population of 2.8 million rural cancer survivors in the United States. Rural survivors were more likely than urban survivors to be non-Hispanic white (P < .001), to have less education (P < .001), and to lack health insurance (P < .001). Rural survivors reported worse health in all domains. After adjustment for sex, race/ethnicity, age, marital status, education, insurance, time since diagnosis, and number of cancers, rural survivors were more likely to report fair/poor health (odds ratio, 1.39; 95% confidence interval, 1.20-1.62), psychological distress (odds ratio, 1.23; 95% confidence interval, 1.00-1.50), ≥2 noncancer comorbidities (odds ratio, 1.15; 95% confidence interval, 1.01-1.32), and health-related unemployment (odds ratio, 1.66; 95% confidence interval, 1.35-2.03).

CONCLUSIONS

The current results provide the first estimates of the proportion and number of US adult cancer survivors who reside in rural areas. Rural cancer survivors are at greater risk for a variety of poor health outcomes, even many years after their cancer diagnosis, and should be a target for interventions to improve their health and well being.