Factors Associated With Cancer Disparities Among Low-, Medium-, and High-Income US Counties

Association of poverty-income ratio with cardiovascular disease and mortality in cancer survivors in the United States

BACKGROUND

Lower income is associated with high incident cardiovascular disease (CVD) and mortality. CVD is an important cause of morbidity and mortality in cancer survivors. However, there is limited research on the association between income, CVD, and mortality in this population.

METHODS

This study utilized nationally representative data from the National Health and Nutrition Examination Survey (NHANES), a cross-sectional survey evaluating the health and nutritional status of the US population. Our study included NHANES participants aged ≥20 years from 2003-2014, who self-reported a history of cancer. We evaluated the association between income level, prevalence of CVD, and all-cause mortality. All-cause mortality data was obtained through public use mortality files. Income level was assessed by poverty-income ratio (PIR) that was calculated by dividing family (or individual) income by poverty guideline. We used multivariable-adjusted Cox proportional hazard models through a backward elimination method to evaluate associations between PIR, CVD, and all-cause mortality in cancer survivors.

RESULTS

This cohort included 2,464 cancer survivors with a mean age of 62 (42% male) years. Compared with individuals with a higher PIR tertiles, those in the lowest PIR tertile had a higher rate of pre-existing CVD and post-acquired CVD. In participants with post-acquired CVD, the lowest PIR tertile had over two-fold increased risk mortality (Hazard Ratio (HR) = 2.17; 95% CI: 1.27-3.71) when compared to the highest PIR tertile. Additionally, we found that PIR was as strong a predictor of mortality in cancer survivors as CVD. In patients with no CVD, the lowest PIR tertile continued to have almost a two-fold increased risk of mortality (HR = 1.72; 95% CI: 1.69-4.35) when compared to a reference of the highest PIR tertile.

CONCLUSIONS

In this large national study of cancer survivors, low PIR is associated with a higher prevalence of CVD. Low PIR is also associated with an increased risk of mortality in cancer survivors, showing a comparable impact to that of pre-existing and post-acquired CVD. Urgent public health resources are needed to further study and improve screening and access to care in this high-risk population.

The associations of food environment with gastrointestinal cancer outcomes in the United States

BACKGROUND

Social conditions and dietary behaviors have been implicated in the rising burden of gastrointestinal cancers (GIC). The "food environment" reflects influences on a community level relative to food availability, nutritional assistance, and social determinants of health. Using the US Department of Agriculture-Food Environment Atlas (FEA), we sought to characterize the association of food environment on GIC presenting stage and long-term survival.

METHODS

Patients diagnosed with GIC between 2013 and 2017 were identified using the SEER database. FEA-scores were based on 282 county-level food security variables, store-restaurant availability, SNAP/WIC enrollment, pricing/taxes, and producer vicinity adjusted-for factors of socioeconomic status, race-ethnicity, transportation access, and comorbidities. Relative FEA rankings across US counties were averaged into a composite score and assigned to patients by county-of-residence. The association of FEA, cancer stage, and survival were analyzed using multiple logistic regression and cox-proportional hazard models relative to White/non-White race/ethnicity.

RESULTS

Among 287,148 patients, the most common GIC-sites were colon (n = 97,942, 34%), pancreas (n = 49,785, 17.3%), liver (n = 31,098, 11.0%) and esophagus (n = 16,271, 5.7%). A worse food environment was independently associated with increased odds of late-stage diagnosis (esophageal odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01-1.05; hepatic OR: 1.06, 95% CI: 1.03-1.08; pancreatic OR: 1.04, 95% CI: 1.01-1.06) among all patients; in contrast, food environment was associated with colorectal cancer stage among non-White patients only (OR: 1.04, 95% CI: 1.03-1.06). Worse food environment was associated with worse 3-year survival (colon OR: 1.03, 95% CI: 1.01-1.04; hepatic OR: 1.12, 95% CI: 1.08-1.17; gastric OR: 1.07, 95% CI: 1.01-1.13). Similar associations were noted relative to overall survival among the entire cohort (biliary tract hazard ratio [HR]: 1.03, 95% CI: 1.01-1.05; esophageal HR: 1.02, 95% CI: 1.01-1.04; hepatic HR: 1.07, 95% CI: 1.06-1.09; pancreatic HR: 1.04, 95% CI: 1.02-1.05; rectum HR: 1.03, 95% CI: 1.01-1.04; gastric HR: 1.05, 95% CI: 1.03-1.07), as well as among non-White patients (biliary HR: 1.04, 95% CI: 1.01-1.07; colon HR: 1.03, 95% CI: 1.01-1.05; esophageal HR: 1.05, 95% CI: 1.02-1.08; hepatic HR: 1.08, 95% CI: 1.06-1.10) (all p < 0.003).

CONCLUSIONS

Food environment was independently associated with late-stage tumor presentation and worse 3-year and overall survival among GIC patients. Interventions to address inequities across communities relative to food environments are needed to alleviate disparities in cancer care.

Clinical and socioeconomic determinants of survival in biliary tract adenocarcinomas

BACKGROUND

Despite advances in detection and treatments, biliary tract cancers continue to have poor survival outcomes. Currently, there is limited data investigating the significance of socioeconomic status, race/ethnicity, and environmental factors in biliary tract cancer survival.

AIM

To investigate how socioeconomic status and race/ethnicity are associated with survival.

METHODS

Data from the Surveillance, Epidemiology, and End Results database for biliary and gallbladder adenocarcinomas were extracted from 1975 to 2016. Socioeconomic data included smoking, poverty level, education, adjusted household income, and percentage of foreign-born persons and urban population. Survival was calculated with Cox proportional hazards models for death in the 5-year period following diagnosis.

RESULTS

Our study included 15883 gallbladder, 11466 intrahepatic biliary, 12869 extrahepatic biliary and 7268 ampulla of Vater adenocarcinoma cases. When analyzing county-specific demographics, patients from counties with higher incomes were associated with higher survival rates [hazard ratio (HR) = 0.97, P <0.05]. Similarly, counties with a higher percentage of patients with a college level education and counties with a higher urban population had higher 5-year survival rates (HR = 0.96, P = 0.002 and HR = 0.97, P = 0.004, respectively).

CONCLUSION

Worse survival outcomes were observed in lower income counties while higher income and education level were associated with higher 5-year overall survival among gallbladder and biliary malignancies.

Patterns of Cancer-Related Healthcare Access across Pennsylvania: Analysis of Novel Census Tract-Level Indicators of Persistent Poverty

BACKGROUND

Persistent poverty census tracts have had ≥20% of the population living below the federal poverty line for 30+ years. We assessed the relationship between persistent poverty and cancer-related healthcare access across census tracts in Pennsylvania.

METHODS

We gathered publicly available census tract-level data on persistent poverty, rurality, and sociodemographic variables, as well as potential access to healthcare (i.e., prevalence of health insurance, last-year check-up), realized access to healthcare (i.e., prevalence of screening for cervical, breast, and colorectal cancers), and self-reported cancer diagnosis. We used multivariable spatial regression models to assess the relationships between persistent poverty and each healthcare access indicator.

RESULTS

Among Pennsylvania's census tracts, 2,789 (89.8%) were classified as non-persistent poverty, and 316 (10.2%) were classified as persistent poverty (113 did not have valid data on persistent poverty). Persistent poverty tracts had lower prevalence of health insurance [estimate = -1.70, standard error (SE) = 0.10], screening for cervical cancer (estimate = -4.00, SE = 0.17) and colorectal cancer (estimate = -3.13, SE = 0.20), and cancer diagnosis (estimate = -0.34, SE = 0.05), compared with non-persistent poverty tracts (all P < 0.001). However, persistent poverty tracts had higher prevalence of last-year check-up (estimate = 0.22, SE = 0.08) and screening for breast cancer (estimate = 0.56, SE = 0.15; both P < 0.01).

CONCLUSIONS

Relationships between persistent poverty and cancer-related healthcare access outcomes differed in direction and magnitude. Health promotion interventions should leverage data at fine-grained geographic units (e.g., census tracts) to motivate focus on communities or outcomes.

IMPACT

Future studies should extend these analyses to other states and outcomes to inform public health research and interventions to reduce geographic disparities.

A cross-sectional analysis of the association between sleep disorders and cancer using data from the National Health and Nutrition Examination Survey (NHANES) 2005-2014

STUDY OBJECTIVES

Cancer is one of the main causes of death in the world, and sleep disorders are a serious public health problem, especially in large cities; of these, insomnia and obstructive sleep apnea (OSA) are the most common. In the last decade, studies have pointed to a possible association between sleep disorders and cancer. The aim of this study is to evaluate whether there is any association between sleep disorders and cancer.

METHODS

Five National Health and Nutrition Examination Surveys (NHANES) (2005-2014) from the United States were combined in order to obtain the sample. Two main sleep variables were assessed: having trouble sleeping and/or ever telling a doctor one had a sleep problem. The odds ratio of ever having a cancer diagnosis was the main outcome. Data were analyzed by binary logistic regression models in Jamovi.

RESULTS

The final sample comprised 26,821 participants. Individuals who reported having trouble sleeping had an odds ratio of 1.48 (95% confidence interval = [1.336-1.646]; P < .001) of having been diagnosed with cancer, and those who had already been diagnosed with a sleep disorder had an odds ratio of 1.21 (95% confidence interval = [1.046-1.415]; P = .011), showing an increased chance of having been diagnosed with cancer. In men, these values were even greater, with an odds ratio of 1.56 (95% confidence interval = [1.321-1.843]; P < .001) and an odds ratio of 1.26 (95% confidence interval = [1.013-1.582]; P = .037), respectively, for having trouble sleeping and for having been diagnosed with a sleep disorder, in relation to having been diagnosed with cancer.

CONCLUSIONS

Individuals who had trouble sleeping or who had been diagnosed with a sleep disorder at any time in their life were more likely to have been diagnosed with cancer.

CITATION

Porcacchia AS, Pires GN, Andersen ML, Tufik S. A cross-sectional analysis of the association between sleep disorders and cancer using data from the National Health and Nutrition Examination Survey (NHANES) 2005-2014. J Clin Sleep Med. 2024;20(4):515-520.

Association of household net worth with healthcare costs after radical cystectomy using real-world data

BACKGROUND

Financial toxicity of bladder cancer care may influence how patients utilize healthcare resources, from emergency department (ED) encounters to office visits. We aim to examine whether greater household net worth (HHNW) confers differential access to healthcare resources after radical cystectomy (RC).

METHODS

This population-based cohort study examined the association between HHNW and healthcare utilization costs in the 90 days post-RC in commercially insured patients with bladder cancer. Costs accrued from the index hospitalization to 90 days after including health plan costs (HPC) and out-of-pocket costs (OPC). Multivariable logistic regression models were generated by encounter (acute inpatient, ED, outpatient, and office visit).

RESULTS

A total of 141,903 patients were identified with HHNW categories near evenly distributed. Acute inpatient encounters incurred the greatest HPC and OPC. Office visits conferred the lowest HPC while ED visits had the lowest OPC. Black patients harbored increased odds of an acute inpatient encounter (OR 1.22, 95% CI 1.16-1.29) and ED encounter (OR 1.20, 95% CI 1.14-1.27) while Asian (OR 0.76, 95% CI 0.69-0.85) and Hispanic (OR 0.74, 95% CI 0.69-0.78, p < 0.001) patients had lower odds of an outpatient encounter, compared to White counterpart. Increasing HHNW was associated with decreasing odds of acute inpatient or ED encounters and greater odds of office visits.

CONCLUSIONS

Lower HHNW conferred greater risk of costly inpatient encounters while greater HHNW had greater odds of less costly office visits, illustrating how financial flexibility fosters differences in healthcare utilization and lower costs. HHNW may serve as a proxy for financial flexibility and risk of financial hardship than income alone.

Disparity in treatment patterns among Medicare beneficiaries diagnosed with chronic lymphocytic leukemia: an analysis of patient and contextual factors

This study characterizes the patterns and timing of CLL treatment and, to our knowledge, is the first to identify social vulnerability factors associated with CLL treatment receipt in the Medicare population. A total of 3508 Medicare beneficiaries diagnosed with CLL from 2017 to 2019 were identified. We reported the proportion of individuals who received CLL treatment and the time until the first CLL treatment receipt after the first observed claim with a CLL diagnosis. Logistic regression and time-to-event models provided adjusted odds ratios and hazard ratios associated with baseline individual-level and county-level factors. Sixteen percent of individuals received CLL treatment, and the median follow-up time was 540 d. The median time to receipt of CLL treatment was 61 d. Older age and residence in a county ranked high in social vulnerability (as defined by minority status and language) were negatively associated with treatment receipt and time to treatment receipt.

Competing-risks analysis for evaluating the prognosis of patients with microinvasive cutaneous squamous cell carcinoma based on the SEER database

BACKGROUND

Utilizing the traditional Cox regression model to identify the factors affecting the risk of mortality due to microinvasive cutaneous squamous cell carcinoma (micSCC) may produce skewed results. Since cause-specific mortality can guide clinical decision-making, this study employed the Fine-Gray model based on the Surveillance, Epidemiology, and End Results (SEER) database to identify significant predictive variables for the risk of micSCC-related mortality.

METHODS

This study used the information of patients with micSCC who were listed in the SEER database during 2000-2015. Cox regression and Fine-Gray models were utilized for the multivariable analysis, and Gray's test and the cumulative incidence function were used for the univariable analyses.

RESULTS

There were 100 patients who died from other reasons and 38 who died from micSCC among the 1259 qualified patients with micSCC. Most were female, white, married, had localized metastasis, etc. According to the univariable Gray's test (P < 0.05), the cumulative incidence rate for events of interest was strongly associated with age, sex, marital status, American Joint Committee on Cancer staging, radiation status, summary stage, chemotherapy status, surgery status, and tumor size. Multivariable Cox regression analysis and multivariable competing-risks analysis indicated that age, tumor size, and income were independent risk variables for the prognosis of patients with micSCC. In both age and tumor size variables, the competing-risks model showed a slight decrease in the hazard ratio and a slight narrowing of the 95% confidence interval compared with the Cox regression model. However, this pattern is not evident in the income variable.

CONCLUSIONS

This study established a Fine-Gray model for identifying the independent risk factors that influence the risk of mortality among patients with micSCC. This study uncovers that, in the context of competing risks, age, tumor size, and income serve as independent risk factors influencing the risk of mortality due to micSCC among patients. Our findings have the potential to provide more accurate risk assessments for patient outcomes and contribute to the development of individualized treatment plans.

Socioeconomic disparities in patients with small bowel neuroendocrine tumors

BACKGROUND AND OBJECTIVES

Demographic and socioeconomic disparities affect cancer specific outcomes in numerous malignancies, but the impact of these for patients with small bowel neuroendocrine tumors (SBNETs) is not well understood. The primary objective was to investigate the impact of demographic and socioeconomic factors on overall survival (OS) for patients with SBNETs.

METHODS

We performed a retrospective cohort study utilizing the National Cancer Database to assess patients diagnosed with SBNET between 2004 and 2015. Patients were stratified by demographics, socioeconomic factors, insurance status, and place of living.

RESULTS

The 5-year OS for the entire cohort was 78.5%. The 5-year survival was worse in patients with lower income (p < 0.0001), lower education (p < 0.0001), not in proximity to a metro area (p = 0.0004), and treatment at a community cancer center (p < 0.0001). Adjusting for age and sex, factors associated with worse OS were lower income (<$38 000) (hazard ratio [HR]: 1.16, 95% confidence interval [CI]: 1.04-1.28), lower education (>20% no HSD) (HR: 1.14, 95% CI: 1.02-1.26), no insurance (HR: 1.66, 95% CI: 1.33-2.06), and not living in proximity to a metro area (HR: 1.27, 95% CI: 1.10-1.47).

CONCLUSIONS

Patient demographics and socioeconomic factors play an important role in survival of patients with SBNETs, specifically proximity to a metro area, median income, education level, and type of treatment center. Strategies to improve access to care must be considered in this at-risk population.

Integrating social care into gynecologic oncology: Identifying and addressing patient's social needs

OBJECTIVE

We aimed to identify social needs of gynecologic oncology patients using a self-administered social needs assessment tool (SNAT), compare the SNAT to a formal social work assessment performed by cancer care navigators (CCN), and provide SNAT-informed community resources.

METHODS

We analyzed prospectively collected data from a performance improvement initiative in a safety-net gynecologic oncology clinic between October 2021 and July 2022. We screened for eight social needs domains, health literacy, desire for social work, and presence of urgent needs. Clinicodemographic data were abstracted from the electronic medical record. Univariate descriptive statistics were used. Inter-rater reliability for social needs domains was assessed using percent agreement.

RESULTS

1010 unique patients were seen over this study period. 488 (48%) patients completed the SNAT, of which 265 (54%) screened positive for ≥1 social need. 83 (31%) patients were actively receiving cancer treatment, 140 (53%) were in post-treatment surveillance, and 42 (16%) had benign gynecologic diagnoses. Transportation (19% vs 25%), housing insecurity (18% vs 19%), and desire to speak with a social worker (16% vs 27%) were the 3 most common needs in both the entire cohort and among patients actively receiving cancer treatment. 78% patients in active treatment were seen by a CCN and received SNAT informed community resources. The percent agreement between the SNAT and formal CCN assessment ranged from 72%-94%.

CONCLUSIONS

The self-administered SNAT identified many unmet social needs among gynecologic oncology patients, corresponded well with the formal social work CCN assessment, and informed the provision of community resources.

Socioeconomic status on survival outcomes in patients with colorectal cancer: a cross-sectional study

BACKGROUND

Colorectal cancer (CRC) is widely acknowledged as a prevalent malignancy and the second most common cause of cancer-related mortality worldwide. The aim of this study was to examine the independent impact of Median Household Income (MHI) on prognosis and survival outcomes in patients with CRC.

METHODS

Data from 17 cancer registries of the United States Surveillance, Epidemiology, and End Results program, with follow-up extended until November 2022 was analyzed. A Cox proportional hazards regression analysis was conducted to evaluate the influence of different levels of MHI on survival outcomes among patients with CRC. A total of 761,697 CRC patient records were retrieved from the SEER database.

RESULTS

The Cox regression analysis results indicated that patients with higher MHI exhibited improved overall survival outcomes when compared to those with lower MHI (MMHI: P < 0.001; HMHI: P < 0.001). Regardless of the specific tumor location, gender, stage of CRC, or treatment method, higher MHI is consistently linked to improved survival outcomes. However, this association was not found to be statistically significant among American Indian/Alaska Native (MMHI: P = 0.017; HMHI: P = 0.081), Asian or Pacific Islander (MMHI: P = 0.223; HMHI: P = 0.002) and unmarried or domestic partner patients (MMHI: P = 0.311; HMHI: P = 0.011).

CONCLUSION

These results emphasize the importance of considering socioeconomic factors, such as income level, in understanding and addressing disparities in survival outcomes of CRC patients.

Individual-level home values and cancer mortality in a statewide registry

BACKGROUND

Prior work assessing disparities in cancer outcomes has relied on regional socioeconomic metrics. These metrics average data across many individuals, resulting in a loss of granularity and confounding with other regional factors.

METHODS

Using patients' addresses at the time of diagnosis from the Ohio Cancer Incidence Surveillance System, we retrieved individual home price estimates from an online real estate marketplace. This individual-level estimate was compared with the Area Deprivation Index (ADI) at the census block group level. Multivariable Cox proportional hazards models were used to determine the relationship between home price estimates and all-cause and cancer-specific mortality.

RESULTS

A total of 667 277 patients in Ohio Cancer Incidence Surveillance System were linked to individual home prices across 16 cancers. Increasing home prices, adjusted for age, stage at diagnosis, and ADI, were associated with a decrease in the hazard of all-cause and cancer-specific mortality (hazard ratio [HR] = 0.92, 95% confidence interval [CI] = 0.92 to 0.93, and HR = 0.95, 95% CI = 0.94 to 0.95, respectively). Following a cancer diagnosis, individuals with home prices 2 standard deviations above the mean had an estimated 10-year survival probability (7.8%, 95% CI = 7.2% to 8.3%) higher than those with home prices 2 standard deviations below the mean. The association between home price and mortality was substantially more prominent for patients living in less deprived census block groups (Pinteraction < .001) than for those living in more deprived census block groups.

CONCLUSION

Higher individual home prices were associated with improved all-cause and cancer-specific mortality, even after accounting for regional measures of deprivation.

Diet quality and lung cancer incidence in a low-income population in the United States

BACKGROUND

Although tobacco smoking is the leading cause of lung cancer, interest in the relationship of diet quality on risk has been growing.

METHODS

We examined the association between Healthy Eating Index-2010 (HEI-10) at enrollment and lung cancer incidence among 70,802 participants in a predominantly African American and low-income prospective cohort in the southern United States. Outcomes were ascertained through linkages with state cancer registries and the National Death Index (NDI). Hazard ratios by HEI-10 quartiles were assessed using Cox proportional hazard models adjusted for potential confounders.

RESULTS

During ≤16 years of follow-up, 1454 incident lung cancers were identified. The lowest HEI-10 quartile compared to the highest was adversely associated with lung cancer risk (HR: 1.89, 95% CI 1.16-3.07) among male former smokers and female never smokers (HR: 2.58, 95% CI 1.06-6.28).

CONCLUSIONS

Low-quality diet was associated with increased lung cancer risk among male former smokers and female never smokers but cautious interpretation of the findings should be taken due to the small number of lung cancers among never smokers and the possibility of residual confounding by smoking in ever smokers.

Socioeconomic status and inequities in treatment initiation and survival among patients with cancer, 2011-2022

BACKGROUND

Lower neighborhood socioeconomic status (SES) is associated with suboptimal cancer care and reduced survival. Most studies examining cancer inequities across area-level socioeconomic status tend to use less granular or unidimensional measures and pre-date the COVID-19 pandemic. Here, we examined the association of area-level socioeconomic status on real-world treatment initiation and overall survival among adults with 20 common cancers.

METHODS

This retrospective cohort study used electronic health record-derived deidentified data (Flatiron Health Research Database, 2011-2022) linked to US Census Bureau data from the American Community Survey (2015-2019). Area-level socioeconomic status quintiles (based on a measure incorporating income, home values, rental costs, poverty, blue-collar employment, unemployment, and education information) were computed from the US population and applied to patients based on their mailing address. Associations were examined using Cox proportional hazards models adjusted for diagnosis year, age, sex, performance status, stage, and cancer type.

RESULTS

This cohort included 291 419 patients (47.7% female; median age = 68 years). Patients from low-SES areas were younger and more likely to be Black (21.9% vs 3.3%) or Latinx (8.4% vs 3.0%) than those in high-SES areas. Living in low-SES areas (vs high) was associated with lower treatment rates (hazard ratio = 0.94 [95% confidence interval = 0.93 to 0.95]) and reduced survival (median real-world overall survival = 21.4 vs 29.5 months, hazard ratio = 1.20 [95% confidence interval = 1.18 to 1.22]). Treatment and survival inequities were observed in 9 and 19 cancer types, respectively. Area-level socioeconomic inequities in treatment and survival remained statistically significant in the COVID-19 era (after March 2020).

CONCLUSION

To reduce inequities in cancer outcomes, efforts that target marginalized, low-socioeconomic status neighborhoods are necessary.

Assessing the Needs of Those Who Serve the Underserved: A Qualitative Study among US Oncology Clinicians

BACKGROUND

The American Society of Clinical Oncology established the 'Supporting Providers Serving the Underserved' (SUS) Task Force with a goal to develop recommendations to support cancer clinicians who deliver care for populations at risk for cancer disparities. As a first step, the Task Force explored barriers and facilitators to equitable cancer care delivery.

METHODS

Clinicians across the United States who deliver care predominantly for low-income and racially and ethnically minoritized populations were identified based on lists generated by the Task Force and the Health Equity Committee. Through purposive sampling based on geographical location, clinicians were invited to participate in 30-60 min semi-structured interviews to explore experiences, barriers, and facilitators in their delivery of cancer care. Interviews were recorded, transcribed, imported into qualitative data management software, and analyzed using thematic analysis.

RESULTS

Thematic analysis revealed three major themes regarding barriers (lack of executive leadership recognition of resources; patient-related socio-economic needs; clinician burnout) and two major themes regarding facilitators (provider commitment, experiential training).

CONCLUSIONS

Findings reveal modifiable barriers and potential solutions to facilitate equitable cancer care delivery for populations at risk for cancer disparities.

Inequity in care delivery in cardio-oncology: dissecting disparities in underrepresented populations

It is well known that patients with cancer have a significantly higher cardiovascular mortality risk than the general population. Cardio-oncology has emerged to focus on these issues including risk reduction, detection, monitoring, and treatment of cardiovascular disease or complications in patients with cancer. The rapid advances in early detection and drug development in oncology, along with socioeconomic differences, racial inequities, lack of support, and barriers to accessing quality medical care, have created disparities in various marginalized populations. In this review, we will discuss the factors contributing to disparities in cardio-oncologic care in distinct populations, including Hispanic/Latinx, Black, Asian and Pacific Islander, indigenous populations, sex and gender minorities, and immigrants. Some factors that contribute to differences in outcomes in cardio-oncology include the prevalence of cancer screening rates, genetic cardiac/oncologic risk factors, cultural stressors, tobacco exposure rates, and physical inactivity. We will also discuss the barriers to cardio-oncologic care in these communities from the racial and socioeconomic context. Appropriate and timely cardiovascular and cancer care in minority groups is a critical component in addressing these disparities, and there need to be urgent efforts to address this widening gap.

Neighborhood and racial influences on triple negative breast cancer: evidence from Northeast Ohio

PURPOSE

Triple negative breast cancer (TNBC) is an aggressive subtype of breast cancer (BC) with higher recurrence rates and poorer prognoses and most prevalent among non-Hispanic Black women. Studies of multiple health conditions and care processes suggest that neighborhood socioeconomic position is a key driver of health disparities. We examined roles of patients' neighborhood-level characteristics and race on prevalence, stage at diagnosis, and mortality among patients diagnosed with BC at a large safety-net healthcare system in Northeast Ohio.

METHODS

We used tumor registry to identify BC cases from 2007 to 2020 and electronic health records and American Community Survey for individual- and area-level factors. We performed multivariable regression analyses to estimate associations between neighborhood-level characteristics, measured by the Area Deprivation Index (ADI), race and comparative TNBC prevalence, stage at diagnosis, and total mortality.

RESULTS

TNBC was more common among non-Hispanic Black (53.7%) vs. non-Hispanic white patients (46.4%). Race and ADI were individually significant predictors of TNBC prevalence, stage at diagnosis, and total mortality. Race remained significantly associated with TNBC subtype, adjusting for covariates. Accounting for TNBC status, a more disadvantaged neighborhood was significantly associated with a worse stage at diagnosis and higher death rates.

CONCLUSION

Our findings suggest that both neighborhood socioeconomic position and race are strongly associated with TNBC vs. other BC subtypes. The burden of TNBC appears to be highest among Black women in the most socioeconomically disadvantaged neighborhoods. Our study suggests a complex interplay of social conditions and biological disease characteristics contributing to racial disparities in BC outcomes.

Area-level Socioeconomic Disadvantage and Cancer Survival in Metropolitan Detroit

BACKGROUND

Racial segregation is linked to poorer neighborhood quality and adverse health conditions among minorities, including worse cancer outcomes. We evaluated relationships between race, neighborhood social disadvantage, and cancer survival.

METHODS

We calculated overall and cancer-specific survival for 11,367 non-Hispanic Black (NHB) and 29,481 non-Hispanic White (NHW) individuals with breast, colorectal, lung, or prostate cancer using data from the Metropolitan Detroit Cancer Surveillance System. The area deprivation index (ADI) was used to measure social disadvantage at the census block group level, where higher ADI is associated with poorer neighborhood factors. Associations between ADI and survival were estimated using Cox proportional hazards mixed-effects models accounting for geographic grouping and adjusting for demographic and clinical factors.

RESULTS

Increasing ADI quintile was associated with increased overall mortality for all four cancer sites in multivariable-adjusted models. Stratified by race, these associations remained among breast (NHW: HR = 1.16, P < 0.0001; NHB: HR = 1.20, P < 0.0001), colorectal (NHW: HR = 1.11, P < 0.0001; NHB: HR = 1.09, P = 0.00378), prostate (NHW: HR = 1.18, P < 0.0001; NHB: HR = 1.18, P < 0.0001), and lung cancers (NHW: HR = 1.06, P < 0.0001; NHB: HR = 1.07, P = 0.00177). Cancer-specific mortality estimates were similar to overall mortality. Adjustment for ADI substantially attenuated the effects of race on mortality for breast [overall proportion attenuated (OPA) = 47%, P < 0.0001; cancer-specific proportion attenuated (CSPA) = 37%, P < 0.0001] prostate cancer (OPA = 51%, P < 0.0001; CSPA = 56%, P < 0.0001), and colorectal cancer (OPA = 69%, P = 0.032; CSPA = 36%, P = 0.018).

CONCLUSIONS

Area-level socioeconomic disadvantage is related to cancer mortality in a racially diverse population, impacting racial differences in cancer mortality.

IMPACT

Understanding the role of neighborhood quality in cancer survivorship could improve community-based intervention practices.

The Association of Socioeconomic Factors and Well-Differentiated Thyroid Cancer

INTRODUCTION

Well-differentiated thyroid cancer (WDTC) is the most common thyroid malignancy, and the worldwide incidence is increasing. Early stage disease is curable with surgery. We hypothesized that patients who live at greater distances from health care institutions or have complicating socioeconomic barriers may present with more advanced diseases and have worse outcomes.

METHODS

The National Cancer Database (NCDB) was used to identify patients who were diagnosed with WDTC between 2004 and 2018. Race, ethnicity, insurance status, income status, and distance from residence to health care clinic of diagnosis (great circle distance [GCD]) were analyzed with respect to the severity of disease at presentation (stage) and outcomes. Binary logistic regression and Cox regression were used to determine associations between socioeconomic variables and tumor stage or survival.

RESULTS

The Hispanic (OR: 1.49, CI: 1.45-1.54, P < 0.001) and Asian (OR: 1.49, CI: 1.43-1.55, P < 0.001) populations had higher odds of developing an advanced disease when compared to the White population separately. Patients without insurance displayed higher odds of developing an advanced disease at diagnosis compared to those with insurance (OR: 1.39, CI: 1.31-1.47, P < 0.001). Adjusted-Cox regression analysis of survival revealed that Black patients had detrimental survival outcomes when compared to White patients (HR: 1.24, P < 0.001), and patients with private insurance had improved survival outcomes when compared to those without insurance (HR: 0.58, P < 0.001).

CONCLUSIONS

Hispanic and Asian patients were found to be more likely to present with an advanced disease but also displayed greater overall survival when compared to the White population. The Black population, patients without insurance, and patients with lower income status exhibited worse survival outcomes.

An Analysis of Cancer Center-Provided Rideshare Utilization for Radiation Therapy

OBJECTIVES

The potential of rideshare services to facilitate timely radiation therapy (RT), especially for resource-limited patients, is understudied.

METHODS

Patients (n = 63) who received 73 courses of RT (1,513 fractions) and utilized free hospital-provided rideshare service (537 rides) were included in this retrospective study. A multidimensional analysis was conducted including a comparison of demographic, disease characteristics, and treatment completion data; a revenue analysis to evaluate the financial impact of rideshare services; and a geospatial analysis to evaluate community-level characteristics of patients.

RESULTS

Median age was 59; most were female (56%) and self-identified as Black or African American (56%), not working (91%), not partnered (83%), high school educated or less (78%), and insured with Medicaid (51%). Geospatial analysis revealed that patients lived in communities with significantly higher rates of resource deprivation. Median rideshare distance was 6.4 miles (interquartile range 3.4-11.2) with a median cost of $13.04 per rideshare (interquartile range 9-19). Of the rideshare-facilitated treatments, 100% were completed, with an overall course completion rate of 97.3% compared with 85.4% for those who did not use rideshare (P = .001); two patients discontinued RT for reasons unrelated to transportation. High rideshare utilization (n = 32), defined as utilization ≥ 45% of the treatment course, was associated with significantly shorter treatment courses and lower radiation doses compared with low rideshare utilization (P = .04). Total rideshare cost for high utilizers and whole cohort was $11,589 and $16,895, facilitating an estimated revenue of $401,952 and $1,175,119, respectively.

CONCLUSIONS

Free hospital-provided rideshare service is economically feasible and associated with high RT completion rates. It may help enhance quality radiation care for those who come from resource-limited communities.

The Association Between Tobacco Retailer Outlet Density and Prevalence of Cigarette Smoking in Virginia

OBJECTIVE

We examine the association between tobacco retail outlet density and adult smoking prevalence at the county level in Virginia, controlling for spatial autocorrelations.

AIMS AND METHODS

Pooling data from 2020 County Health Rankings (compiled data from various sources including, but not limited to, the National Center for Health Statistics-Mortality Files, the Behavioral Risk Factor Surveillance System (BRFSS), and the American Community Survey) and Counter Tools, we conducted regression analyses that accounted for spatial autocorrelation (spatial lag models, LMlag) and adjusted for county-level access to healthcare, demographics, SES, environmental factors, risk conditions or behaviors, and population health measures.

RESULTS

Our estimates provide evidence that every increase of one tobacco retail outlet per 1000 persons was associated with 1.16 percentage points (95% CI: 0.80-1.52) higher smoking prevalence at the county level in Virginia after controlling for spatial autocorrelation. The effect of outlet density was largely explained by social determinants of health such as SES, risky conditions or behaviors, and environmental factors. We further noticed that the impact of social determinants of health were closely related and can be explained by indicators of population health (rates of mental distress (β = 1.49, 95% CI: 1.31-1.67) and physical inactivity (β = 0.07, 95% CI: 0.04-0.10).

CONCLUSIONS

Although higher tobacco outlet density was associated with an increase in county-level smoking prevalence, the impact of outlet density was largely explained by social determinants of health and mental illness. Improving well-being at the community level could be a promising strategy in future tobacco control policies.

IMPLICATION

The influence of tobacco outlet density seems to be explained by other social determinants of health and population level of mental or physical health. Thus, efforts to reduce tobacco use and consequent negative health effects should explore the impact of improving regional living standards. However, a sole focus on economic growth may not be sufficient, whereas a focus on such things as promoting work-life balance and improving overall well-being at the community level may be more.

Socioeconomic Inequalities in Cancer Incidence: A Comparative Investigation Based on Population of Iranian Provinces

Cancer is the second important cause of death worldwide. Cancer is one of the top health priorities in Iran. We aimed to study the socio-economic inequality of cancer incidence in Iran provinces. We conducted this cross-sectional study using provincial data. We obtained the required data from the statistical yearbook report, the Statistics Center Report and the National Cancer Registration Program Report of Iran's Ministry of Health and Medical Education (MoHME) for 2018. Socio-economic inequality of cancer incidence was analyzed by estimating the concentration index and extracting the concentration curve. Statistical analyzes were performed using STATA 14. Our findings revealed that cancer incidence was unequally distributed in terms of the socio-economic status in Iranian provinces. Cancer incidence is slightly concentrated in the provinces with higher than average literacy, per capita income and insurance coverage and household size below average. The concentration of cancer incidence has been to the detriment of the provinces that have a slightly better ranking in terms of the socio-economic index. The employment rate did not significantly affect cancer's distribution burden. We recommend policymakers facilitate early cancer detection by providing insurance coverage for screening services, payment exemptions, and public awareness.

Disparities in Access to Radiation Therapy by Race and Ethnicity in the United States With Focus on American Indian/Alaska Native People

OBJECTIVES

Striking disparities in access to radiation therapy (RT) exist, especially among racial and ethnic-minority patients. We analyzed census block group data to evaluate differences in travel distance to RT as a function of race and ethnicity, socioeconomic status, and rurality.

METHODS

The Directory of Radiotherapy Centers provided the addresses of facilities containing linear accelerators for RT. We classified block groups as majority (≥ 50%) American Indian/Alaska Native (AI/AN), black, white, Asian, no single racial majority, or Hispanic regardless of race. We used the Area Deprivation Index to classify deprivation and Rural-Urban Commuting Area codes to classify rurality. Generalized linear mixed models tested associations between these factors and distance to nearest RT facility.

RESULTS

Median distance to nearest RT facility was 72 miles in AI/AN-majority block groups, but 4 to 7 miles in block groups with non-AI/AN majorities. Multivariable models estimated that travel distances in AI/AN-majority block groups were 39 to 41 miles longer than in areas with non-AI/AN majorities. Travel distance was 1.3 miles longer in the more deprived areas versus less deprived areas and 16 to 32 miles longer in micropolitan, small town, and rural areas versus metropolitan areas.

CONCLUSIONS

Cancer patients in block groups with AI/AN-majority populations, nonmetropolitan location, and low socioeconomic status experience substantial travel disparities in access to RT. Future research with more granular community- and individual-level data should explore the many other known barriers to access to cancer care and their relationship to the barriers posed by distance to RT care.

Utilization of National Cancer Institute-Designated Cancer Centers by Medicare Beneficiaries with Cancer

BACKGROUND

Little is known about which patients use National Cancer Institute-designated cancer centers (NCICCs) nationally. This study aimed to identify sociodemographic characteristics associated with decreased NCICC use among Medicare beneficiaries.

METHODS

This study examined a national cohort of 534,008 Medicare beneficiaries with cancer in 2017 using multivariable logistic regressions for NCICC use. The covariates in the study were sex, age, cancer type, race/ethnicity, dual-eligibility status for Medicaid and Medicare, and NCICC presence in the home state.

RESULTS

In 2017, 19.5 % of Medicare beneficiaries with cancer used an NCICC at least once. Dual-eligible beneficiaries had 29 % lower adjusted odds of NCICC use than non-dual-eligible beneficiaries (adjusted odds ratio [aOR], 0.71; 95 % confidence interval [CI], 0.70-0.73; p < 0.001). American Indian/Alaska Native beneficiaries had 40 % lower odds of NCICC use than non-Hispanic white (NHW) beneficiaries (aOR, 0.60; 95 % CI, 0.53-0.68; p < 0.001). Compared with NHW beneficiaries, the odds of NCICC use were higher for black beneficiaries by 15 % (aOR, 1.15; 95 % CI, 1.12-1.18; p < 0.001), for Hispanic beneficiaries by 31 % (aOR, 1.31; 95 % CI, 1.26-1.35; p < 0.001), and for Asian/Pacific Islander beneficiaries by 126 % (aOR, 2.26; 95 % CI, 2.16-2.36; p < 0.001). Utilization declined steadily in older groups, with beneficiaries older than 95 years showing 73 % lower odds of NCICC use than beneficiaries younger than 65 years (aOR, 0.27; 95 % CI, 0.24-0.29; p < 0.001).

CONCLUSIONS

Medicaid-eligible, American Indian/Alaska Native, and older patients are substantially less likely to use NCICCs. Future research should focus on defining and addressing the barriers to NCICC access for these populations.

Cancer disparities related to poverty and rurality for 22 top cancers in Florida

We aimed to examine poverty and rurality as potential predictors of cancer health disparities. This cross-sectional study used data from the Florida Cancer Data System on all cancer diagnoses in the years 2014–2018 to determine age-adjusted incidence and mortality (per 100,000 population) for the 22 most common cancer sites within rural and urban counties, and high poverty and low poverty communities. Rural/urban and high/low poverty related cancer disparities were tested for statistical significance using the Rate Ratio statistical test. Overall cancer incidence was significantly lower in rural areas than in urban, but significantly higher in high poverty communities. Rurality and poverty were both associated with disparity in cancer incidence risk for tobacco-related cancers. The overall mortality was 22% higher in high poverty areas compared to low poverty areas. Ten cancer sites had mortality disparity from 83% to 17% higher in high poverty areas. Only three cancer sites, all tobacco-related, had higher mortality in rural areas than urban areas, demonstrating the intersectional nature of inhaled and smokeless tobacco use in rural low-income communities. Cancer and mortality rates in rural and urban areas may be largely driven by poverty. The high disparities related to high poverty areas reflects poor access to preventative care and treatment. Low income communities, rural or urban, will require focused efforts to address challenges specific to each population.

Dietary behavior and urinary gallic acid concentration differences among underserved elder racial and ethnic minorities in New York City

Purpose

Diet and nutrition are important for cancer prevention. To investigate associations between dietary behavior, demographics, and risk of cancer, we assessed dietary behavior and urinary concentration of gallic acid, a polyphenol with anticancer properties found in various fruits and vegetables, in racial and ethnic minorities.

Methods

Ninety-one (91) participants were recruited from senior centers in East Harlem, New York City, a racially diverse and underserved community. A National Institute of Health (NIH)—validated dietary survey questionnaire—was used to collect dietary fruits and vegetables consumption data. Demographic and cancer information were also collected. All 91 participants completed the survey and forty-five (45) participants provided urine samples for gallic acid analysis.

Results

Gender differences were significantly associated with dietary behavior and urinary gallic acid concentration (UGAC). Female participants had a higher total daily intake of fruits and a significantly higher UGAC compared to male participants (p < 0.05). Age was negatively associated with the serving quantity of French fries/fried potatoes and white potatoes (p < 0.05), while positively associated with the daily intake frequency and daily intake of fruits (p < 0.05). Furthermore, Asian race was associated with higher daily intake frequencies of fruits and vegetable soup (p < 0.05), compared to other races. In a multivariate analysis, a significant association was observed between the serving quantities of fruits and other vegetables and UGAC (p < 0.05) after controlling for demographic characteristics.

Conclusion

The observed differences in dietary behavior and UGAC in this study provide limited information on the association between demographic differences and cancer prevalence in elder racial and ethnic minorities. Future research should investigate this association further for potential implications in cancer prevention.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10552-022-01581-y.

Disparities in Cardio-oncology: Effects On Outcomes and Opportunities for Improvement

Purpose of Review

The purpose of this article is to provide a comprehensive review of available data on health disparities and the interconnected social determinants of health (SDOH) in cardio-oncology. We identify the gaps in the literature and suggest areas for future research. In addition, we propose strategies to address these disparities at various levels.

Recent Findings

There has been increasing recognition of health disparities and the role of SODH on an individual’s access to health care, quality of care, and outcomes of the illness. There is growing evidence of sex and race-based differences in cancer therapy-related cardiotoxicity. Recent studies have shown how access and quality of health care are affected by financial stability and rurality. Our recent study utilizing the social vulnerability index (SVI) and county-level patient data found graded increase in county-level cardio-oncology mortality with greater social vulnerability. The incremental impact of social vulnerability was higher for cardio-oncology mortality than for mortality related to either cancer or CVD alone. The mortality rates in these patients were higher in rural areas compared to urban areas regardless of social vulnerability. Additionally, for those within the counties within highest social vulnerability, Black individuals had significantly higher cardio-oncology mortality compared with White individuals.

Summary

Disparities in the cardio-oncology population are deep-rooted and widespread, leading to poor quality of life and increased mortality. It is crucial to integrate SDOH, not only in clinical care delivery but also in future research, and registry data to improve our understanding and the outcomes in our unique subset of cardio-oncology patients.

Cancer Groundshot: Building a Robust Cancer Control Platform in Addition To Launching the Cancer Moonshot

Cancer Groundshot is a philosophy that calls for prioritization of strategies in global cancer control. The underlying principle of Cancer Groundshot is that one must ensure access to interventions that are already proven to work before focusing on the development of new interventions. In this article, we discuss the philosophy of Cancer Groundshot as it pertains to priorities in cancer care and research in low- and middle-income countries and the utility of technology in addressing global cancer disparities; we also address disparities seen in high-income countries. The oncology community needs to realign our priorities and focus on improving access to high-value cancer control strategies, rather than allocating resources primarily to the development of technologies that provide only marginal gains at a high cost. There are several "low-hanging fruit" actions that will improve access to quality cancer care in low- and middle-income countries and in high-income countries. Worldwide, cancer morbidity and mortality can be averted by implementing highly effective, low-cost interventions that are already known to work, rather than investing in the development of resource-intensive interventions to which most patients will not have access (i.e., we can use Cancer Groundshot to first save more lives before we focus on the "moonshots").

Strengthening US Food Policies and Programs to Promote Equity in Nutrition Security: A Policy Statement From the American Heart Association

Nutritionally inadequate dietary intake is a leading contributor to chronic cardiometabolic diseases. Differences in dietary quality contribute to socioeconomic and racial and ethnic health disparities. Food insecurity, a household-level social or economic condition of limited access to sufficient food, is a common cause of inadequate dietary intake. Although US food assistance policies and programs are designed to improve food security, there is growing consensus that they should have a broader focus on nutrition security. In this policy statement, we define nutrition security as an individual or household condition of having equitable and stable availability, access, affordability, and utilization of foods and beverages that promote well-being and prevent and treat disease. Despite existing policies and programs, significant gaps remain for achieving equity in nutrition security across the life span. We provide recommendations for expanding and improving current food assistance policies and programs to achieve nutrition security. These recommendations are guided by several overarching principles: emphasizing nutritional quality, improving reach, ensuring optimal utilization, improving coordination across programs, ensuring stability of access to programs across the life course, and ensuring equity and dignity for access and utilization. We suggest a critical next step will be to develop and implement national measures of nutrition security that can be added to the current US food security measures. Achieving equity in nutrition security will require coordinated and sustained efforts at the federal, state, and local levels. Future advocacy, innovation, and research will be needed to expand existing food assistance policies and programs and to develop and implement new policies and programs that will improve cardiovascular health and reduce disparities in chronic disease.

Analysis and Prediction of the Survival Trends of Patients with Clear-Cell Renal Cell Carcinoma: A Model-Based Period Analysis, 2001-2015

Background

Clear-cell renal cell carcinoma (ccRCC) is one of the most common malignant tumors worldwide whose poor prognosis results in a serious disease burden on patients. The changing trend of the long-term relative survival rates (RSRs) of patients with ccRCC was analyzed in this study to evaluate their treatment results over a 15-year period.

Methods

This study is a retrospective study, which assessed and predicted the 1-, 3-, and 5-year survival rates of patients with ccRCC during 2001-2005, 2006-2010, 2011-2015, and 2016-2020 using data extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Period analysis was used in this study to analyze the data from the SEER database and to assess survival differences according to age, sex, race, and socioeconomic status (SES) during the 15-year study period by comparing Kaplan-Meier curves.

Results

During 2001-2015, the 5-year RSR of patients with ccRCC increased from 78.4% to 83.0%, and the generalized linear model predicted that the 5-year RSR increased to 85.7% during 2016-2020. The RSR of patients with ccRCC differed significantly with SES, race, sex, and age. Compared with male patients, the survival advantage of female patients decreased as their age increased. The RSR of all patients with ccRCC was also lower in patients with a lower SES and of black race.

Conclusion

This study found an improvement in the RSR of patients with ccRCC during 2001-2020. Understanding the change trend of the survival rate of patients with ccRCC is helpful to improve the design of clinical trials. It also provides basic data and a scientific basis for evaluating the harm of ccRCC on the health of affected patients and the effect of cancer prevention, and developing cancer prevention plans.

Oncology registered dietitian nutritionists' knowledge, attitudes and practices related to food insecurity among cancer patients: a qualitative study

BACKGROUND

Understanding the knowledge, attitudes and practices pertaining to food insecurity among oncology Registered Dietitian Nutritionists (RDNs) is critical to ensuring that cancer survivors have adequate nutrition-a fundamental component of successful treatment and recovery.

OBJECTIVE

To qualitatively assess Oncology RDN's knowledge, attitudes and practices regarding the food access needs of their patients using a qualitative semantic approach to thematic analysis.

DESIGN

The qualitative cross-sectional study was conducted from September 2018 to January 2019.

PARTICIPANTS/SETTING

Forty-one oncology RDNs working with cancer survivors in various clinical settings across the U.S participated.

MAIN OUTCOME MEASURES

Participants completed a semi-structured, in-depth interview via telephone, lasting an average of 49 minutes.

STATISTICAL ANALYSES PERFORMED

Two coders (primary and secondary) trained in qualitative thematic data analysis methods used a semantic approach to thematic analysis to analyze transcripts. A qualitative and mixed methods online coding program, Dedoose, was used to organize and analyze the data.

RESULTS

Participants defined FI as a lack of access to nutritious foods and a lack of resources to purchase nutritious foods. RDNs stated they believe FI is a serious problem in the U.S., has a greater impact on cancer survivors than healthy individuals and they have specific concerns about FI among their own patients. Despite their concerns, most expressed that they do not use a validated tool to identify FI, nor were they aware that any exists. Only a small proportion of the RDNs stated that they regularly ask patients about their food access needs.

CONCLUSIONS

While Oncology RDNs have heard of FI, they do not routinely assess patients' food security status with a validated tool, nor do they consistently ask patients directly about their food access needs. These findings suggest there is a need for developing education and training opportunities for oncology RDNs in order to enhance their ability to screen for and address FI with their patients.

County-level characteristics associated with incidence, late-stage incidence, and mortality from screenable cancers

BACKGROUND

Cancer screening differs by rurality and racial residential segregation, but the relationship between these county-level characteristics is understudied. Understanding this relationship and its implications for cancer outcomes could inform interventions to decrease cancer disparities.

METHODS

We linked county-level information from national data sources: 2008-2012 cancer incidence, late-stage incidence, and mortality rates (for breast, cervical, and colorectal cancer) from U.S. Cancer Statistics and the National Death Index; metropolitan status from U.S. Department of Agriculture; residential segregation derived from American Community Survey; and prevalence of cancer screening from National Cancer Institute's Small Area Estimates. We used multivariable, sparse Poisson generalized linear mixed models to assess cancer incidence, late-stage incidence, and mortality rates by county-level characteristics, controlling for density of physicians and median household income.

RESULTS

Cancer incidence, late-stage incidence, and mortality rates were 6-18% lower in metropolitan counties for breast and colorectal cancer, and 2-4% lower in more segregated counties for breast and colorectal cancer. Generally, reductions in cancer associated with residential segregation were limited to non-metropolitan counties. Cancer incidence, late-stage incidence, and mortality rates were associated with screening, with rates for corresponding cancers that were 2-9% higher in areas with more breast and colorectal screening, but 2-15% lower in areas with more cervical screening.

DISCUSSION

Lower cancer burden was observed in counties that were metropolitan and more segregated. Effect modification was observed by metropolitan status and county-level residential segregation, indicating that residential segregation may impact healthcare access differently in different county types. Additional studies are needed to inform interventions to reduce county-level disparities in cancer incidence, late-stage incidence, and mortality.

Socioeconomic Determinants of the Use of Molecular Testing in Stage IV Colorectal Cancer

OBJECTIVES

Treatment with epidermal growth factor receptor monoclonal antibodies extends life for patients with advanced colorectal cancers (CRCs) whose tumors exhibit wild-type KRAS, but KRAS testing may be underused. We studied the role of socioeconomic factors in the application of KRAS testing.

MATERIALS AND METHODS

We identified subjects with stage IV colorectal adenocarcinoma diagnosed 2010-2015 in the Surveillance, Epidemiology, and End Results (SEER) database. We used multivariable logistic regression models to evaluate associations between clinical/demographic factors and the rate of KRAS testing. We used multivariable-adjusted Cox proportional hazards models to assess survival.

RESULTS

We identified 37,676 patients with stage IV CRC, 31.1% of whom were tested for KRAS mutations, of those who had documented KRAS testing, 44% were KRAS mutant. Patients were more likely to be tested if they were younger (odds ratio [OR]=5.10 for age 20 to 29 vs. 80+, 95% confidence interval [CI]: 3.99-6.54, P<0.01), diagnosed more recently (OR=1.92 for 2015 vs. 2010, 95% CI: 1.77-2.08, P<0.01), or lived in an area of high median household income (OR=1.24 for median household income of >$69,311 vs. <$49,265, 95% CI: 1.14-1.35, P<0.01). Patients were less likely to be tested if they had Medicaid (OR=0.83, 95% CI: 0.77-0.88, P<0.01) or were unmarried (OR=0.78, 95% CI: 0.75-0.82, P<0.0001). The risk of death was decreased in patients who received KRAS testing (hazard ratio=0.77, 95% CI: 0.75-0.80, P<0.01).

CONCLUSIONS

We found a low rate of KRAS testing in CRC patients with those living in low-income areas less likely to be tested, even after controlling for Medicaid insurance. Our study suggests that socioeconomic disparities persist despite Medicaid insurance.

Nonmedical Cannabis Use: Patterns and Correlates of Use, Exposure, and Harm, and Cancer Risk

Cannabis has certain health benefits, but some people may experience harms from use. Co-use of tobacco and cannabis is common. Smoke from cannabis contains many of the same carcinogens and toxicants as the smoke from tobacco, raising concerns that cannabis smoking may be a risk factor for cancer. With growing access to and acceptance of medical and nonmedical cannabis, there is an urgent need to understand the risks and benefits of the current modes of cannabis use and how cannabis may be associated with cancer risk. This monograph summarizes a session from a National Cancer Institute Symposium on nonmedical cannabis use and cancer risk. We had 3 objectives: describe the relation between nonmedical cannabis use and cancer risk, delineate patterns and correlates of cannabis co-use with tobacco, and document potentially harmful inhalational exposure resulting from smoked and vaped cannabis. Methodological limitations in the literature and future research recommendations are provided.

Association of Community Economic Distress and Breast and Colorectal Cancer Screening, Incidence, and Mortality Rates Among US Counties

INTRODUCTION

Not all Americans may benefit equally from current improvements in breast and colorectal cancer screening and mortality rates.

METHODS

We performed a cross-sectional retrospective review of county-level screening, incidence, and mortality rates for breast and colon cancer utilizing three publicly available data sources from the Centers for Disease Control and Prevention (CDC), and their association with the Distressed Communities Index (DCI), a measure of local economic prosperity across communities.

RESULTS

After controlling for other factors, DCI was associated with county-level screening, incidence, and death rates per 100,000 for breast and colorectal cancer. There was an absolute increase of 0.77 (95% confidence interval [CI] 0.67-0.85, p < 0.001) in the proportion of women aged 40 years or older who had a screening mammogram for every 10-point decrease in DCI, which in turn correlated with an increase in the age-adjusted incidence by 1.68 per 100,000 (95% CI 1.37-2.00, p < 0.001). While the age-adjusted death rate for breast cancer was highest in the most distressed communities, the overall incidence of age-adjusted death decreased by 0.28 per 100,000 (95% CI -0.37 to -0.19, p < 0.001) with every 10-point decrease in DCI. For colorectal cancer, every 10-point decrease in DCI was similarly associated with an absolute 0.60 (95% CI 0.52-0.69, p < 0.001) increase in the proportion of individuals who had screening endoscopy. Increased colorectal screening in low-DCI counties was associated with a lower age-adjusted incidence rate (-0.80 per 100,000; 95% CI -0.94 to -0.65) and age-adjusted death rate (-0.55 per 100,000; 95% CI -0.62 to -0.49) of colorectal cancer per every 10-point decrease in DCI (p < 0.001).

CONCLUSION

The association of county-level socioeconomic and healthcare factors with breast and colorectal cancer outcomes was notable, with level of community distress impacting cancer screening, incidence, and mortality rates.

Social determinants of health and cancer mortality in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study

BACKGROUND

Social determinants of health (SDOHs) cluster together and can have deleterious impacts on health outcomes. Individually, SDOHs increase the risk of cancer mortality, but their cumulative burden is not well understood. The authors sought to determine the combined effect of SDOH on cancer mortality.

METHODS

Using the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, the authors studied 29,766 participants aged 45+ years and followed them 10+ years. Eight potential SDOHs were considered, and retained SDOHs that were associated with cancer mortality (P < .10) were retained to create a count (0, 1, 2, 3+). Cox proportional hazard models estimated associations between the SDOH count and cancer mortality through December 31, 2017, adjusting for confounders. Models were age-stratified (45-64 vs 65+ years).

RESULTS

Participants were followed for a median of 10.6 years (interquartile range [IQR], 6.5, 12.7 years). Low education, low income, zip code poverty, poor public health infrastructure, lack of health insurance, and social isolation were significantly associated with cancer mortality. In adjusted models, among those <65 years, compared to no SDOHs, having 1 SDOH (adjusted hazard ratio [aHR], 1.39; 95% CI, 1.11-1.75), 2 SDOHs (aHR, 1.61; 95% CI, 1.26-2.07), and 3+ SDOHs (aHR, 2.09; 95% CI, 1.58-2.75) were associated with cancer mortality (P for trend <.0001). Among individuals 65+ years, compared to no SDOH, having 1 SDOH (aHR, 1.16; 95% CI, 1.00-1.35) and 3+ SDOHs (aHR, 1.26; 95% CI, 1.04-1.52) was associated with cancer mortality (P for trend = .032).

CONCLUSIONS

A greater number of SDOHs were significantly associated with an increased risk of cancer mortality, which persisted after adjustment for confounders.

Evaluating Medicaid expansion benefits for patients with cancer: National Cancer Database analysis and systematic review

BACKGROUND

Insurance status modifies healthcare access and inequities. The Affordable Care Act expanded Medicaid coverage for people with low incomes in the United States. This study assessed the consequences of this policy change for cancer care after expansion in 2014.

METHODS

National Cancer Database (NCDB) public benchmark reports were queried for each malignancy in 2013 and 2016. Furthermore, a systematic search [PubMed, Embase, Scopus and Cochrane] was performed. Data on insurance status, access to cancer screening and treatment, and socioeconomic disparities in these metrics was collected.

RESULTS

Two-tailed analysis of the NCDB revealed that 14 out of 18 eligible states had a statistically significant increase in Medicaid-insured patients with cancer after expansion. The average percentage increase was 51 % (13.2-204 %). From the systematic review, 229 studies were identified, 26 met inclusion. All 21 relevant articles reported lower uninsured rates. The average increase of Medicaid-insured patients was 77 % (9.5-230 %) and the average decrease of uninsured rates was 55 % (13.4-73 %). 15 out of 21 articles reported increased access to care. 16 out of 17 articles reported reductions in inequities.

CONCLUSION

Medicaid expansion in 2014 increased the number of insured patients with cancer. Expansion also improved access to screening and treatment in most oncologic care, and reduced socioeconomic disparities. Further studies evaluating correlative survival outcomes are needed.

POLICY SUMMARY

This study informs debates on expansion of Medicaid in state governments and electorates in the United States, and on health insurance reform broadly, by providing insight into how health insurance can benefit people with cancer while revealing how less insurance coverage could harm patients with cancer before and after their diagnosis. This study also contributes to discussions of health insurance mandates, subsidized coverage for people with low incomes, and covered healthcare services determinations by public and private health insurance providers in other countries.

Equal access to care and nurse navigation leads to equitable outcomes for minorities with aggressive large B-cell lymphoma

BACKGROUND

Aggressive large B-cell lymphomas (LBCLs) are curable, but previous studies have shown inferior outcomes in minorities. Nurse navigation programs can improve patient outcomes by providing patient support. This study presents the outcomes of White and minority patients with aggressive LBCL at an institution with an active nurse navigation program.

METHODS

The authors prospectively collected baseline characteristics, treatment regimens, and outcome data for patients with aggressive LBCL. Navigation encounters were characterized as low or high intensity. Overall survival (OS) and progression-free survival (PFS) were calculated with Kaplan-Meier methods. Baseline characteristics were compared with Fisher exact tests.

RESULTS

Two hundred four consecutive patients (47 minority patients and 157 White patients) were included. Results were presented as minorities versus Whites. There were no differences in prognostic scores (Revised International Prognostic Index score of 3-5, 43% vs 47%; P = .50), frontline chemotherapy (98% vs 96%; P = .68), or the incidence of relapsed/refractory disease (40% vs 38%; P = .74). For relapsed/refractory LBCL, similar proportions of patients underwent hematopoietic stem cell transplantation (32% vs 29%; P > .99) or chimeric antigen receptor T-cell therapy (16% vs 19%; P > .99). Enrollment in clinical trials was comparable (17% vs 14%; P = .64). More than 85% received nurse navigation, but minorities had higher intensity navigation encounters (42% vs 21%; P = .01). The 2-year OS rates were 81% and 76% for minorities and Whites, respectively (P = .27); the 2-year PFS rates were 62% and 65%, respectively (P = .78).

CONCLUSIONS

This study shows similar survival between Whites and minorities with aggressive LBCL, which was likely due to equal access to guideline-concordant therapy. Minorities received higher intensity navigation encounters, which may have helped them to overcome socioeconomic disadvantages.

Universal social needs assessment in gynecologic oncology: An important step toward more informed and targeted care in the public safety net

BACKGROUND

Social needs are actionable mediators of social determinants of health. Along with distress, they affect quality of life and survival in patients with cancer. The objectives of this study were to identify the most common social needs and distress in a largely immigrant gynecologic oncology patient population at a public safety-net hospital and to evaluate for specific needs associated with distress and poor outcomes.

METHODS

This was a prospective, survey-based cohort study of patients who participated in a performance-improvement initiative offering social needs assessment and distress screening. Patients provided sociodemographic information and completed validated surveys adapted from the Health Leads Social Needs Screening Toolkit, the National Comprehensive Cancer Network Distress Thermometer, and the Emotion Thermometers Tool. Associations between social needs, distress, and treatment outcomes were analyzed.

RESULTS

In total, 135 women were included. Of these, 65.2% had at least 1 unmet social need, and 36.3% screened positive for distress. Help reading hospital materials (30.4%) was the most frequently reported need. Social isolation (odds ratio [OR], 3.65; 95% CI, 1.35-9.9; P = .01) and lack of safety at home (OR, 4.90; 95% CI, 2.23-10.62; P = .0001) were associated with distress. Perceived lack of finances for medical care (OR, 5.69; 95% CI, 1.12-28.9; P = .036) and lack of transportation (OR, 20.5; 95% CI, 2.69-156.7; P = .004) were associated with nonadherence-related treatment interruption, whereas positive distress scores were associated with interruption because of comorbidities or treatment-related toxicities (OR, 20.5; 95% CI, 1.5-268.6; P = .02).

CONCLUSIONS

Systematically identifying social needs and developing interventions aimed at mitigating them may lead to more actionable health care disparities research and affect treatment outcomes.

LAY SUMMARY

Social needs are individual-level social conditions that drive health disparities. In this survey-based study, the objective was to identify common social needs and how these relate to distress and poor health outcomes in a largely immigrant and underserved gynecologic oncology patient population. The authors found that greater than one-third of patients screened positive for distress, nearly two-thirds had at least 1 unmet social need, and these factors were associated with emergency room visits, hospital admissions, and treatment interruptions. These findings suggest that screening for universal social needs allows providers to identify unrecognized needs and implement interventions to mitigate distress and improve health outcomes.

Modeling Strategies to Optimize Cancer Screening in USPSTF Guideline-Noncompliant Women

Importance

In 2018, only half of US women obtained all evidence-based cancer screenings. This proportion may have declined during the COVID-19 pandemic because of social distancing, high-risk factors, and fear.

Objective

To evaluate optimal screening strategies in women who obtain some, but not all, US Preventive Services Task Force (USPSTF)-recommended cancer screenings.

Design, Setting, and Participants

This modeling study was conducted from January 31, 2017, to July 20, 2020, and used 4 validated mathematical models from the National Cancer Institute's Cancer Intervention and Surveillance Modeling Network using data from 20 million simulated women born in 1965 in the US.

Interventions

Forty-five screening strategies were modeled that combined breast, cervical, colorectal, and/or lung cancer (LC) screenings; restricted to 1, 2, 3 or 4 screenings per year; or all eligible screenings once every 5 years.

Main Outcomes and Measures

Modeled life-years gained from restricted cancer screenings as a fraction of those attainable from full compliance with USPSTF recommendations (maximum benefits). Results were stratified by LC screening eligibility (LC-eligible/ineligible). We repeated the analysis with 2018 adherence rates, evaluating the increase in adherence required for restricted screenings to have the same population benefit as USPSTF recommendations.

Results

This modeling study of 20 million simulated US women found that it was possible to reduce screening intensity to 1 carefully chosen test per year in women who were ineligible for LC screening and 2 tests per year in eligible women while maintaining 94% or more of the maximum benefits. Highly ranked strategies screened for various cancers, but less often than recommended by the USPSTF. For example, among LC-ineligible women who obtained just 1 screening per year, the optimal strategy frequently delayed breast and cervical cancer screenings by 1 year and skipped 3 mammograms entirely. Among LC-eligible women, LC screening was essential; strategies omitting it provided 25% or less of the maximum benefits. The top-ranked strategy restricted to 2 screenings per year was annual LC screening and alternating fecal immunochemical test with mammography (skipping mammograms when due for cervical cancer screening, 97% of maximum benefits). If adherence in a population of LC-eligible women obtaining 2 screenings per year were to increase by 1% to 2% (depending on the screening test), this model suggests that it would achieve the same benefit as USPSTF recommendations at 2018 adherence rates.

Conclusions and Relevance

This modeling study of 45 cancer screening strategies suggests that women who are noncompliant with cancer screening guidelines may be able to reduce USPSTF-recommended screening intensity with minimal reduction in overall benefits.

Adherence to Follow-up Testing Recommendations in US Veterans Screened for Lung Cancer, 2015-2019

IMPORTANCE

Lung cancer screening (LCS) can reduce lung cancer mortality with close follow-up and adherence to management recommendations. Little is known about factors associated with adherence to LCS in real-world practice, with data limited to case series from selected LCS programs.

OBJECTIVE

To analyze adherence to follow-up based on standardized follow-up recommendations in a national cohort and to identify factors associated with delayed or absent follow-up.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted in Veterans Health Administration (VHA) facilities across the US. Veterans were screened for lung cancer between 2015 to 2019 with sufficient follow-up time to receive recommended evaluation. Patient- and facility-level logistic regression analyses were performed. Data were analyzed from November 26, 2019, to December 16, 2020.

MAIN OUTCOMES AND MEASURES

Receipt of the recommended next step after initial LCS according to Lung CT Screening Reporting & Data System (Lung-RADS) category, as captured in VHA or Medicare claims.

RESULTS

Of 28 294 veterans (26 835 [94.8%] men; 21 969 individuals [77.6%] were White; mean [SD] age, 65.2 [5.5] years) who had an initial LCS examination, 17 863 veterans (63.1%) underwent recommended follow-up within the expected timeframe, whereas 3696 veterans (13.1%) underwent late evaluation, and 4439 veterans (15.7%) had no apparent evaluation. Facility-level differences were associated with 9.2% of the observed variation in rates of late or absent evaluation. In multivariable-adjusted models, Black veterans (odds ratio [OR], 1.19 [95% CI, 1.10-1.29]), veterans with posttraumatic stress disorder (OR, 1.13 [95% CI, 1.03-1.23]), veterans with substance use disorders (OR, 1.11 [95% CI, 1.01-1.22]), veterans with lower income (OR, 0.88 [95% CI, 0.79-0.98]), and those living at a greater distance from a VHA facility (OR, 1.06 [95% CI, 1.02-1.10]) were more likely to experience delayed or no follow-up; veterans with higher risk findings (Lung-RADS category 4 vs Lung-RADS category 1: OR, 0.35 [95% CI, 0.28-0.43]) and those screened in high LCS volume facilities (OR, 0.38 [95% CI, 0.21-0.67]) or academic facilities (OR, 0.86 [95% CI, 0.80-0.92]) were less likely to experience delayed or no follow-up. In sensitivity analyses, varying how stringently adherence was defined, expected evaluation ranged from 14 486 veterans (49.7%) under stringent definitions to 20 578 veterans (78.8%) under liberal definitions.

CONCLUSIONS AND RELEVANCE

In this cohort study that captured follow-up care from the integrated VHA health care system and Medicare, less than two-thirds of patients received timely recommended follow-up after initial LCS, with higher risk of delayed or absent follow-up among marginalized populations, such as Black individuals, individuals with mental health disorders, and individuals with low income, that have long experienced disparities in lung cancer outcomes. Future work should focus on identifying facilities that promote high adherence and disseminating successful strategies to promote equity in LCS among marginalized populations.

Food Insecurity Is an Independent Risk Factor for Depressive Symptoms in Survivors of Digestive Cancers

BACKGROUND

Colorectal and other digestive cancer survivors are at increased risk of depression, which can negatively affect health outcomes. Food insecurity (FI), the lack of consistent access to enough food, can also contribute to these health complications. The objective of this study was to determine the relationship between FI and depressive symptoms within this population.

METHODS

We conducted a cross-sectional analysis of data from the 2007-2016 National Health and Nutrition Examination Survey. We included all adults (≥20 years) with a self-reported history of a digestive cancer (including colorectal, esophageal, stomach, liver, and pancreas cancer). Our primary exposure was household FI, and our outcome of interest was depressive symptoms, as measured by the validated 9-item Patient Health Questionnaire. We used multivariable ordinal logistic regression to test the association between FI and depressive symptoms, controlling for demographic and clinical covariates.

RESULTS

We included 229 adult digestive cancer survivors (weighted N = 1,510,579). The majority of the study sample was female and non-Hispanic White with mean of 11.0 years since cancer diagnosis; 14.3% reported FI. In multivariable models controlling for demographic and clinical covariates, we found that food insecure digestive cancer survivors had significantly higher odds of depressive symptoms than food secure digestive cancer survivors (OR: 3.25; 95% confidence interval: 1.24-8.55; P = 0.02).

CONCLUSIONS

Among a nationally representative sample of colorectal cancer and other digestive cancer survivors, FI was associated with increased odds of depressive symptoms.

IMPACT

This study adds further evidence to the negative impact FI may have on survivors' physical and mental health.

Socioeconomic Inequalities in Premature Cancer Mortality Among U.S. Counties During 1999 to 2018

BACKGROUND

This study investigated socioeconomic inequalities in premature cancer mortality by cancer types, and evaluated the associations between socioeconomic status (SES) and premature cancer mortality by cancer types.

METHODS

Using multiple databases, cancer mortality was linked to SES and other county characteristics. The outcome measure was cancer mortality among adults ages 25-64 years in 3,028 U.S. counties, from 1999 to 2018. Socioeconomic inequalities in mortality were calculated as a concentration index (CI) by income (annual median household income), educational attainment (% with bachelor's degree or higher), and unemployment rate. A hierarchical linear mixed model and dominance analyses were used to investigate SES associated with county-level mortality. The analyses were also conducted by cancer types.

RESULTS

CIs of SES factors varied by cancer types. Low-SES counties showed increasing trends in mortality, while high-SES counties showed decreasing trends. Socioeconomic inequalities in mortality among high-SES counties were larger than those among low-SES counties. SES explained 25.73% of the mortality. County-level cancer mortality was associated with income, educational attainment, and unemployment rate, at -0.24 [95% (CI): -0.36 to -0.12], -0.68 (95% CI: -0.87 to -0.50), and 1.50 (95% CI: 0.92-2.07) deaths per 100,000 population with one-unit SES factors increase, respectively, after controlling for health care environment and population health.

CONCLUSIONS

SES acts as a key driver of premature cancer mortality, and socioeconomic inequalities differ by cancer types.

IMPACT

Focused efforts that target socioeconomic drivers of mortalities and inequalities are warranted for designing cancer-prevention implementation strategies and control programs and policies for socioeconomically underprivileged groups.

Caregiving burden of informal caregivers of older adults with advanced cancer: The effects of rurality and education

OBJECTIVES

Rural-urban disparities in the experiences of caregivers of older adults with advanced cancer may exist. This study examined factors associated with caregiver mastery and burden and explored whether rural-urban disparities in caregiver outcomes differed by education.

MATERIALS AND METHODS

Longitudinal data (baseline, 4-6 weeks, and 3 months) on caregivers of older adults (≥ 70) with advanced cancer were obtained from a multicenter geriatric assessment (GA) trial (ClinicalTrials.gov: NCT02107443). Rurality was determined based on 2010 Rural-Urban Commuting Area codes. Caregivers' education was categorized as ≥ some college vs ≤ high school. Caregiver outcomes included Ryff Environmental Mastery (scored 7-35) and Caregiver Reaction Assessment (including self-esteem, disrupted schedules, financial problems, lack of social support, and health problems; each scored 1-5). Separate linear mixed models with interaction term of education and rurality were performed.

RESULTS

Of 414 caregivers, 64 (15.5%) were from rural areas and 263 (63.5%) completed ≥ some college. Rurality was significantly associated with more disrupted schedules (β = 0.21), financial problems (β = 0.17), and lack of social support (β = 0.11). A significant interaction between education and rurality was found, with rurality associated with lower mastery (β = -1.27) and more disrupted schedule (β = 0.25), financial problems (β = 0.33), and lack of social support (β = 0.32) among caregivers with education ≤ high school.

CONCLUSION

Our study identifies subgroups of caregivers who are vulnerable to caregiving burden, specifically those from rural areas and with lower education. Multifaceted interventions are needed to improve caregivers' competency and reduce caregiving burden.

Quantifying the contribution of modifiable risk factors to socio-economic inequities in cancer morbidity and mortality: a nationally representative population-based cohort study

BACKGROUND

Compared with those with a higher socio-economic position (SEP), individuals with a lower SEP have higher cancer morbidity and mortality. However, the contribution of modifiable risk factors to these inequities is not known. This study aimed to quantify the mediating effects of modifiable risk factors to associations between SEP and cancer morbidity and mortality.

METHODS

This study used a prospective observational cohort design. We combined eight cycles of the Canadian Community Health Survey (2000/2001-2011) as baseline data to identify a cohort of adults (≥35 years) without cancer at the time of survey administration (n = 309 800). The cohort was linked to the Discharge Abstract Database and the Canadian Mortality Database for cancer morbidity and mortality ascertainment. Individuals were followed from the date they completed the Canadian Community Health Survey until 31 March 2013. Dates of individual first hospitalizations for cancer and deaths due to cancer were captured during this time period. SEP was operationalized using a latent variable combining measures of education and household income. Self-reported modifiable risk factors, including smoking, excess alcohol consumption, low fruit-and-vegetable intake, physical inactivity and obesity, were considered as potential mediators. Generalized structural equation modelling was used to estimate the mediating effects of modifiable risk factors in associations between low SEP and cancer morbidity and mortality in the total population and stratified by sex.

RESULTS

Modifiable risk factors together explained 45.6% of associations between low SEP and overall cancer morbidity and mortality. Smoking was the most important mediator in the total population and for males, accounting for 15.5% and 40.2% of the total effect, respectively. For females, obesity was the most important mediator.

CONCLUSIONS

Modifiable risk factors are important mediators of socio-economic inequities in cancer morbidity and mortality. Nevertheless, more than half of the variance in these associations remained unexplained. Midstream interventions that target modifiable risk factors may help to alleviate inequities in cancer risk in the short term. However, ultimately, upstream interventions that target structural determinants of health are needed to reduce overall socio-economic inequities in cancer morbidity and mortality.

Challenges in Diversity, Equity, and Inclusion in Research and Clinical Oncology

Disparities are common and well-known in the field of clinical oncology and cancer research. In patient care, poor access and a number of other factors disadvantage patients and this can lead to inadequate screening, prevention or treatment of cancer and poor patient outcomes. World-wide, socioeconomic status, health care expenditures and a number of other challenges contribute to disparities in cancer care and patient outcomes. Access to cancer clinical trials remains inadequate for underrepresented minorities as well as non-white racial and ethnic groups. There are also disparities and many challenges in the biomedical research enterprise that can limit innovation and that must be addressed as part of active interventions.

Financial constraints on genetic counseling and further risk-management decisions among U.S. women at elevated breast cancer risk

Clinical guidelines recommend that women at high risk of breast cancer should consider various risk-management options, which remain widely underutilized. We conducted semi-structured, qualitative interviews with 50 high-risk women to understand how financial constraints affect use of genetic counseling, genetic testing, and further risk-management decisions. Inductive analyses revealed three categories of health-related financial constraint: (a) lack of insurance, (b) underinsurance, and (c) other financial constraints (e.g., medical debt, raising children, managing comorbidities). Various breast cancer risk-management actions were limited by these financial constraints, including genetic counseling, genetic testing, enhanced screening, and prophylactic surgeries. Women's narratives also identified complex relationships between financial constraint and perceptions of healthcare providers and insurance companies, particularly as related to bias, price transparency, and potential genetic discrimination. Results from this study have implications for further research and expansion of genetic counseling services delivery to more economically and racially diverse women.