Association of Insurance Status and Racial Disparities With the Detection of Early-Stage Breast Cancer

Factors associated with locoregional recurrence after neoadjuvant chemotherapy for breast cancer in a safety-net medical center

BACKGROUND

The management of locally advanced breast cancer poses significant challenges, with contemporary strategies involving an approach that combines systemic and local treatment. The current study was performed to validate the clinical impression that locoregional recurrences have become increasingly uncommon after standardized multimodal treatment protocol.Please check and confirm that the authors and their respective affiliations have been correctly identified and amend if necessary.All authors and affiliations are correct.

METHODS

A retrospective analysis was performed using a single-institution database that included clinical, radiographic, and pathologic parameters for all non-metastatic and non-inflammatory breast cancer patients treated with neoadjuvant chemotherapy (NAC) from 2015 to 2023. Uni- and multivariable analyses were performed to define associations between clinical factors, recurrence, and RFS.

RESULTS

The median age was 51 years for 274 predominantly Hispanic (78%) patients, with a median follow-up of 38.1 months. The recurrence rates were 4% local, 2% regional, and 18% distant. Median time from surgery to local recurrence was 8.2 months and to regional recurrence was 9.7 months. There were no locoregional clinical recurrences in 92 (34%) patients who had pCR or in 85 (31%) patients who had radiological complete response after NAC. Locoregional recurrences were uncommon > 12 months after surgery. Five of 11 local recurrences occurred in patients who had a poor response to NAC (ypT4b). All 6 patients having regional recurrences had adjuvant radiation therapy, and only 2 occurred in patients who were pathologically node-negative (ypN0) post-NAC.

CONCLUSIONS

Favorable responses to NAC were associated with excellent locoregional control rates. Results achieved for predominantly Hispanic patients at a safety net medical center were similar to those reported in prospective, randomized clinical trials.

"Thanks, but no thanks": Factors associated with patients who decline surgical intervention for thyroid cancer

BACKGROUND

Surgery is the mainstay of therapy for thyroid cancer. A rising number of patients decline recommended surgical intervention. This study aimed to identify factors associated with the decision to decline surgery for well-differentiated thyroid cancer.

METHODS

Patients with papillary or follicular thyroid cancer diagnosed between 2004 and 2017 were identified from the National Cancer Database. Patients were grouped based on patient-documented refusal of recommended surgery and patients who successfully completed surgery. Baseline characteristic comparison, univariable and multivariable logistic regression, and survival analyses were performed.

RESULTS

A total of 221,664 patients met inclusion criteria: 565 (0.3%) patients declined and 221,099 (99.7%) underwent recommended surgery. Patients who declined surgery were older, male, Black or Asian, and not privately insured. They more frequently had Charlson-Deyo scores ≥3, were diagnosed at academic centers, and presented with larger tumors and advanced clinical stage. Multivariable modeling demonstrated that older age, Black or Asian race, diagnosis at an academic center, no insurance or lack of private insurance, clinical N stage ≥1a, and clinical M stage >0 were associated with higher odds of declining surgery (P < .001). A mean survival of 10 years was found among patients who declined surgery versus 16 years among patients who underwent surgery (P < .0001).

CONCLUSION

Most patients diagnosed with well-differentiated thyroid cancer undergo physician-recommended surgical intervention. Declining surgery is associated with worse overall survival and is more likely in older, male, Black, or Asian patients with socioeconomic disadvantage. This study underscores the importance of understanding barriers to thyroid cancer surgery and opportunities to optimize outcomes and reduce disparities for these populations.

Cancer statistics for African American and Black people, 2025

African American and other Black individuals (referred to as Black people in this article) have a disproportionate cancer burden, including the lowest survival of any racial or ethnic group for most cancers. Every 3 years, the American Cancer Society estimates the number of new cancer cases and deaths for Black people in the United States and compiles the most recent data on cancer incidence (herein through 2021), mortality (through 2022), survival, screening, and risk factors using population-based data from the National Cancer Institute and the Centers for Disease Control and Prevention. In 2025, there will be approximately 248,470 new cancer cases and 73,240 cancer deaths among Black people in the United States. Black men have experienced the largest relative decline in cancer mortality from 1991 to 2022 overall (49%) and in almost every 10-year age group, by as much as 65%-67% in the group aged 40-59 years. This progress largely reflects historical reductions in smoking initiation among Black teens, advances in treatment, and earlier detections for some cancers. Nevertheless, during the most recent 5 years, Black men had 16% higher mortality than White men despite just 4% higher incidence, and Black women had 10% higher mortality than White women despite 9% lower incidence. Larger inequalities for mortality than for incidence reflect two-fold higher death rates for prostate, uterine corpus, and stomach cancers and for myeloma, and 40%-50% higher rates for colorectal, breast, cervical, and liver cancers. The causes of ongoing disparities are multifactorial, but largely stem from inequalities in the social determinants of health that trace back to structural racism. Increasing diversity in clinical trials, enhancing provider education, and implementing financial incentives to ensure equitable care across the cancer care continuum would help close these gaps.

Racial disparities in presenting stage and surgical management among octogenarians with breast cancer: a national cancer database analysis

BACKGROUND

As the US faces a diverse aging population, racial disparities in breast cancer outcomes among elderly patients remain poorly understood. We evaluate the association of race with presenting stage, treatment, and survival of invasive breast cancer among octogenarians.

METHODS

Women (≥ 80 years) with invasive breast cancer were identified in 2004-2020 NCDB. To facilitate comparison, only non-Hispanic Black and non-Hispanic White patients were included; patients of Hispanic ethnicity were excluded. Demographics, tumor characteristics, and treatments were assessed by race. Overall survival was compared using the logrank test. Multivariable logistic and Cox proportional hazard regression models were developed to evaluate the independent association of race with outcomes of interest.

RESULTS

Of 222,897 patients, 19,059 (8.6%) were Black. Most patients had stage I ER + HER2- invasive ductal carcinoma. Black patients more frequently had greater comorbidities, low income and education, and advanced stage (p < 0.001 each; ref: White). Following adjustment, Black women had increased likelihood of Stage III/IV over time, as well as increased odds of chemotherapy (AOR 1.22, 95% CI 1.15 - 1.29) and non-operative management (AOR 1.82, 95% CI 1.72 - 1.92; ref: White). Although Black patients had lower survival rates compared to White, race was not associated with 5-year mortality following adjustment for stage, receipt of surgery, and adjuvant treatments (p = 0.34).

CONCLUSIONS

Inferior survival among elderly Black patients appears be driven by advanced stage at presentation. While such disparities are narrowing in the present era, future work must consider upstream interventions to ensure equitable outcomes for all races.

Association between health insurance coverage and stage of diagnosis for cervical cancer among females in Indiana from 2011 - 2019

Introduction

Health insurance status is an important determinant of health outcomes for patients with cancer. This study aimed to assess the extent to which health insurance coverage in Indiana is a contributing factor to the stage of cervical cancer diagnosis.

Methods

We examined reported cervical cancer cases among females (N = 2518) using cancer registry data from the Indiana Department of Health from 2011 to 2019. Analyses were carried out in SPSS. Using multinomial logistic regression, we examined associations of both insurance status and race/ethnicity with stage of diagnosis after adjusting for age at diagnosis.

Results

The multinomial analysis showed that uninsured females (OR = 2.42, 95 % CI = 1.35-4.35) and those who have Medicaid (OR = 2.36, 95 % CI = 1.62-3.42) were significantly more likely to be diagnosed at the regional stage than the in-situ stage compared to females with private insurance. Additionally, Black (OR = 1.98, 95 % CI = 1.21-3.24) and Hispanic females (OR = 2.19, 95 %CI = 1.04-4.61) were significantly more likely to be diagnosed at the regional stage than the in-situ stage when compared to Non-Hispanic White females. Females who are uninsured (OR = 4.43, 95 % CI = 2.23-8.44) and those who have Medicaid (OR = 3.03, 95 % CI = 1.91-4.80) were significantly more likely to be diagnosed at the distant stage than in-situ, compared to females with private insurance.

Conclusion

Insurance status and race/ethnicity are associated with later stages of cervical cancer diagnosis. Increased coverage for routine cervical cancer screening and preventive care services is recommended, especially for racial/ethnic minority populations, the uninsured and those with public insurance.

Contribution of health insurance to racial and ethnic disparities in advanced-stage diagnosis of 10 cancers

For many anatomic cancer sites, it is unclear to what extent differences in health insurance coverage contribute to racial and ethnic disparities in the diagnosis of stage III and IV disease. Using the National Cancer Database (1 893 026 patients aged 18-64 years, diagnosed between 2013 and 2019), we investigated a potential mediating role of health insurance (privately insured vs uninsured) in explaining racial and ethnic disparities in stage at diagnosis of 10 cancers-breast (female), prostate, colorectum, lung, cervix, uterus, stomach, urinary bladder, head and neck, and skin melanoma- detectable early through screening, physical examination, or clinical symptoms. The analyses provided evidence of mediation of disparities among non-Hispanic Black vs White individuals in 8 cancers (range of proportions mediated: 4.5%-29.1%), in Hispanic vs non-Hispanic White individuals in 6 cancers (13.2%-68.8%), and in non-Hispanic Asian or Pacific Islander vs White individuals in 3 cancers (5.8%-11.3%). To summarize, health insurance accounts for a statistically significant proportion of the racial and ethnic disparities in diagnosis of stage III and IV disease across a range of cancer types.

Association Between COVID-19 and Planned and Postponed Cancer Screenings Among American Indian Adults Residing in California and Oklahoma, March-December 2020

OBJECTIVE

Little is known about how the COVID-19 pandemic affected cancer screenings among American Indian people residing in California and Oklahoma, 2 states with the largest American Indian populations. We assessed rates and factors associated with cancer screenings among American Indian adults during the pandemic.

METHODS

From October 2020 through January 2021, we surveyed 767 American Indian adults residing in California and Oklahoma. We asked participants whether they had planned to obtain screenings for breast cancer, cervical cancer, and colorectal cancer (CRC) from March through December 2020 and whether screening was postponed because of COVID-19. We calculated adjusted odds ratios (AORs) for factors associated with reasons for planned and postponed cancer screening.

RESULTS

Among 395 participants eligible for breast cancer screening, 234 (59.2%) planned to obtain the screening, 127 (54.3%) of whom postponed it. Among 517 participants eligible for cervical cancer screening, 357 (69.1%) planned to obtain the screening, 115 (32.2%) of whom postponed it. Among 454 participants eligible for CRC screening, 282 (62.1%) planned to obtain CRC screening, 80 of whom (28.4%) postponed it. In multivariate analyses, women who lived with a child (vs did not) had lower odds of planning to obtain a breast cancer screening (AOR = 0.6; 95% CI, 0.3-1.0). Adherence to social distancing recommendations was associated with planning to have and postponement of cervical cancer screening (AOR = 7.3; 95% CI, 0.9-58.9). Participants who received (vs did not receive) social or financial support had higher odds of planning to have CRC screening (AOR = 2.0; 95% CI, 1.1-3.9).

CONCLUSION

The COVID-19 pandemic impeded completion of cancer screenings among American Indian adults. Interventions are needed to increase the intent to receive evidence-based cancer screenings among eligible American Indian adults.

Impact of Structural Racism and Social Determinants of Health on Disparities in Breast Cancer Mortality

The striking ethnic and racial disparities in breast cancer mortality are not explained fully by pathologic or clinical features. Structural racism contributes to adverse conditions that promote cancer inequities, but the pathways by which this occurs are not fully understood. Social determinants of health, such as economic status and access to care, account for a portion of this variability, yet interventions designed to mitigate these barriers have not consistently led to improved outcomes. Based on the current evidence from multiple disciplines, we describe a conceptual model in which structural racism and racial discrimination contribute to increased mortality risk in diverse groups of patients by promoting adverse social determinants of health that elevate exposure to environmental hazards and stress; these exposures in turn contribute to epigenetic and immune dysregulation, thereby altering breast cancer outcomes. Based on this model, opportunities and challenges arise for interventions to reduce racial and ethnic disparities in breast cancer mortality.

Addressing Breast Cancer Disparities: A Comprehensive Approach to Health Equity

This article addresses the persistent disparities in breast cancer outcomes across different racial, ethnic, and socioeconomic groups despite advancements in diagnosis and treatment. The disparities are rooted in various factors, including access to care, socioeconomic status, and cultural barriers. The article emphasizes the need for targeted interventions, such as expanding insurance coverage, mobile mammography units, and culturally tailored outreach programs to promote health equity. Achieving this requires comprehensive strategies addressing systemic and social determinants of health.

Centering intersectional breast cancer screening experiences among black, Latina, and white women: a qualitative analysis

Objective

Mammography screening guidelines in the United States highlight the importance of informing and involving women when making their breast cancer screening decisions. However, the complexity of interpreting and applying these population-level guidelines can contribute to patient burden. Patient-centered communication strategies can alleviate patient burden, but few consider perspectives from racially and ethnically marginalized populations. We examine diverse women's perspectives on screening to characterize patient-centered experiences.

Methods

We conducted 28 focus groups with 134 non-Latina Black (n = 51), non-Latina White (n = 39), and Latina (n = 44) participants. We coded participants' discussion of their screening influences. We used deductive and inductive qualitative methods to identify common themes.

Results

We identified three themes: (1) personal relationships with primary care providers, (2) potential impacts of cancer on families, and (3) interactions with medical systems. Most White participants described trusting physician relationships in contrast to perfunctory, surface-level relationships experienced by many Black participants; high costs of care prevented many Latina participants from accessing care (Theme 1). Diagnosis was a concern for most Black participants as it could burden family and most Latina participants as it could prevent them from maintaining family well-being (Theme 2). While many White participants had general ease in accessing and navigating healthcare, Latina participants were often held back by embarrassment-and Black participants frequently described disrespectful providers, false negatives, and unnecessary pain (Theme 3).

Conclusion

Cultural and structural factors appeared to influence participants' approaches to breast cancer screening. Structural barriers may counteract culturally salient beliefs, especially among Black and Latina participants. We suggest patient-centered communication interventions be culturally adjusted and paired with structural changes (e.g., policy, insurance coverage, material resources) to reflect women's nuanced values and intersectional social contexts.

Demographic Characteristics and Survival in Young-Onset Colorectal Neuroendocrine Neoplasms

BACKGROUND/OBJECTIVES

Recent epidemiological studies have revealed an upward trend in young-onset colorectal cancer (YOCRC) overall, whereas specific data on young-onset colorectal neuroendocrine neoplasms (YONEN) remain limited. This study investigated the demographic characteristics and survival trends in YONEN and compared these with those of young-onset colorectal adenocarcinoma (YOADC), the most common histologic subtype of YOCRC.

METHODS

A retrospective analysis was conducted from 2000 to 2019 using the Surveillance, Epidemiology, and End Results (SEER) database. Survival outcomes were assessed using univariate and multivariable Cox proportional models, with demographic differences evaluated via Wilcoxon rank sum and Chi-square tests.

RESULTS

Out of 61,705 patients aged 20-49 with colorectal cancer, 8% had NEN, and 92% had adenocarcinoma. The YONEN cohort had a higher proportion of Black patients and a lower proportion of White patients than the YOADC cohort (21% vs. 13% and 44% vs. 57%, respectively). NEN was more commonly found in the rectum (79%), and adenocarcinoma was mostly colonic (57%) in origin. YONEN patients had better survival than YOADC patients. Multivariate analysis in YONEN patients revealed that Hispanic patients had better overall survival compared to White patients (HR 0.67, 95% CI 0.47-0.95, p = 0.024).

CONCLUSIONS

Racial disparities should be investigated further to aid in policymaking and targeted interventions.

Healthy Lifestyle, Metabolic Signature, and Risk of Cardiovascular Diseases: A Population-Based Study

BACKGROUND

Although healthy lifestyle has been linked with a reduced risk of cardiovascular diseases (CVDs), the potential metabolic mechanism underlying this association remains unknown.

METHODS

We included 161,018 CVD-free participants from the UK Biobank. Elastic net regression was utilized to generate a healthy lifestyle-related metabolic signature. The Cox proportional hazards model was applied to investigate associations of lifestyle-related metabolic signature with incident CVDs, and mediation analysis was conducted to evaluate the potential mediating role of metabolic profile on the healthy lifestyle-CVD association. Mendelian randomization (MR) analysis was conducted to detect the causality.

RESULTS

During 13 years of follow-up, 17,030 participants developed incident CVDs. A healthy lifestyle-related metabolic signature comprising 123 metabolites was established, and it was inversely associated with CVDs. The hazard ratio (HR) was 0.83 (95% confidence interval [CI]: 0.81, 0.84) for CVD, 0.83 (95% CI: 0.81, 0.84) for ischemic heart disease (IHD), 0.86 (95% CI: 0.83, 0.90) for stroke, 0.86 (95% CI: 0.82, 0.89) for myocardial infarction (MI), and 0.75 (95% CI: 0.72, 0.77) for heart failure (HF) per standard deviation increase in the metabolic signature. The metabolic signature accounted for 20% of the association between healthy lifestyle score and CVD. Moreover, MR showed a potential causal association between the metabolic signature and stroke.

CONCLUSIONS

Our study revealed a potential link between a healthy lifestyle, metabolic signatures, and CVD. This connection suggests that identifying an individual's metabolic status and implementing lifestyle modifications may provide novel insights into the prevention of CVD.

Experiences of Racism in Health Care and Medical Mistrust Shape Cancer Prevention and Control Behaviors Among Black Residents of Black Hawk County, Iowa: A Qualitative Study

BACKGROUND

Non-Hispanic Black Iowans have substantially higher incidence of and mortality from cancer than their non-Hispanic White (NHW) counterparts in all but the oldest age groups; rates are particularly high in Black Hawk County, which contains the city of Waterloo, a highly segregated city with a documented history of redlining and distinct racial differences in the social drivers of health.

OBJECTIVE

To gather perspectives on race, racism, healthcare, and engagement with cancer prevention and control behaviors, among Black individuals living in Black Hawk County, Iowa.

METHODS

We conducted semi-structured interviews with 20 individuals (10 male, 10 female), questions included experiences in healthcare and feelings towards the healthcare system, trust of the healthcare system, experiences of racism or other perceived biases within healthcare, and how experiences of racism/bias and/or feelings towards the healthcare system impact desire or ability to participate in cancer prevention and control activities.

RESULTS

Almost all interviewees reported both positive and negative experiences in healthcare. Nine themes emerged from analysis of the interviews: everyday racism and racism in healthcare, medical mistrust, need for more Black healthcare professionals, communication with healthcare professionals, need to break down cultural stigma around cancer, need and desire for community education around health and cancer, ability to choose, self-advocacy, and social support.

CONCLUSIONS

There are substantial barriers for Black individuals engaging with cancer prevention and control behaviors in Iowa. Multi-level interventions are needed to address structural, healthcare facility, and individual-level barriers to care; interventions may build on existing resiliencies within the community.

Effects of Medicaid managed care on early detection of cancer: Evidence from mandatory Medicaid managed care program in Pennsylvania

OBJECTIVE

To examine changes in late- versus early-stage diagnosis of cancer associated with the introduction of mandatory Medicaid managed care (MMC) in Pennsylvania.

DATA SOURCES AND STUDY SETTING

We analyzed data from the Pennsylvania cancer registry (2010-2018) for adult Medicaid beneficiaries aged 21-64 newly diagnosed with a solid tumor. To ascertain Medicaid and managed care status around diagnosis, we linked the cancer registry to statewide hospital-based facility records collected by an independent state agency (Pennsylvania Health Care Cost Containment Council).

STUDY DESIGN

We leveraged a natural experiment arising from county-level variation in mandatory MMC in Pennsylvania. Using a stacked difference-in-differences design, we compared changes in the probability of late-stage cancer diagnosis among those residing in counties that newly transitioned to mandatory managed care to contemporaneous changes among those in counties with mature MMC programs.

DATA COLLECTION/EXTRACTION METHODS

N/A.

PRINCIPAL FINDINGS

Mandatory MMC was associated with a reduced probability of late-stage cancer diagnosis (-3.9 percentage points; 95% CI: -7.2, -0.5; p = 0.02), particularly for screening-amenable cancers (-5.5 percentage points; 95% CI: -10.4, -0.6; p = 0.03). We found no significant changes in late-stage diagnosis among non-screening amenable cancers.

CONCLUSIONS

In Pennsylvania, the implementation of mandatory MMC for adult Medicaid beneficiaries was associated with earlier stage of diagnosis among newly diagnosed cancer patients with Medicaid, especially those diagnosed with screening-amenable cancers. Considering that over half of the sample was diagnosed with late-stage cancer even after the transition to mandatory MMC, Medicaid programs and managed care organizations should continue to carefully monitor receipt of cancer screening and design strategies to reduce barriers to guideline-concordant screening or diagnostic procedures.

An assessment of the association between patient characteristics and timely lung cancer treatment

PURPOSE

Prior data have demonstrated relationships between patient characteristics, the use of surgery to treat lung cancer, and the timeliness of treatment. Our study examines whether these relationships were observable in 2019 in patients with Medicare Advantage health plans being treated for lung cancer.

METHODS

Claims data pertaining to patients with Medicare Advantage health plans who had received radiation therapy (RT) or surgery to treat lung cancer within 90 days of diagnostic imaging were extracted. Other databases were used to determine patients' demographics, comorbidities, the urbanicity of their ZIP code, the median income of their ZIP code, and whether their treatment was ordered by a physician at a hospital. Multivariable logistic and Cox Proportional Hazards models were used to assess the association between patient characteristics, receipt of surgery, and time to non-systemic treatment (surgery or RT), respectively.

RESULTS

A total of 2,682 patients were included in the analysis. In an adjusted analysis, patients were significantly less likely to receive surgery if their first ordering physician was based in a hospital, if they were older, if they had a history of congestive heart failure (CHF), if they had a history of chronic obstructive pulmonary disease, or if they had stage III lung cancer. Likewise, having stage III cancer was associated with significantly shorter time to treatment.

CONCLUSIONS

Within a Medicare Advantage population, patient demographics were found to be significantly associated with the decision to pursue surgery, but factors other than stage were not significantly associated with time to non-systemic treatment.

Associations between subjective social status and predictors of interest in genetic testing among women diagnosed with breast cancer at a young age

PURPOSE

Genetic testing for gene mutations which elevate risk for breast cancer is particularly important for women diagnosed at a young age. Differences remain in access and utilization to testing across social groups, and research on the predictors of interest in genetic testing for women diagnosed at a young age is limited.

METHODS

We examined the relationships between subjective social status (SSS) and variables previously identified as possible predictors of genetic testing, including genome sequencing knowledge, genetic worry, cancer worry, health consciousness, decision-making preferences, genetic self-efficacy, genetic-related beliefs, and subjective numeracy, among a cohort of women who were diagnosed with breast cancer at a young age.

RESULTS

In this sample (n = 1,076), those who had higher SSS had significantly higher knowledge about the limitations of genome sequencing (Odds Ratio (OR) = 1.11; 95% CI = 1.01-1.21) and significantly higher informational norms (OR = 1.93; 95% CI = 1.19-3.14) than those with lower SSS. Similarly, education (OR = 2.75; 95% CI = 1.79-4.22), health status (OR = 2.18; 95% CI = 1.44-3.31) were significant predictors among higher SSS women compared to lower SSS women in our multivariate analysis. Lower SSS women with low self-reported income (OR = 0.13; 95% CI = 0.08-0.20) had lower odds of genetic testing interest. Our results are consistent with some prior research utilizing proxy indicators for socioeconomic status, but our research adds the importance of using a multidimensional indicator such as SSS to examine cancer and genetic testing predictor outcomes.

CONCLUSION

To develop interventions to improve genetic knowledge, researchers should consider the social status and contexts of women diagnosed with breast cancer at a young age (or before 40 years old) to ensure equity in the distribution of genetic testing benefits.

Implementation of social needs screening for minoritized patients newly diagnosed with breast cancer: a mixed methods evaluation in a pragmatic patient navigation trial

BACKGROUND

Social needs inhibit receipt of timely medical care. Social needs screening is a vital part of comprehensive cancer care, and patient navigators are well-positioned to screen for and address social needs. This mixed methods project describes social needs screening implementation in a prospective pragmatic patient navigation intervention trial for minoritized women newly diagnosed with breast cancer.

METHODS

Translating Research Into Practice (TRIP) was conducted at five cancer care sites in Boston, MA from 2018 to 2022. The patient navigation intervention protocol included completion of a social needs screening survey covering 9 domains (e.g., food, transportation) within 90 days of intake. We estimated the proportion of patients who received a social needs screening within 90 days of navigation intake. A multivariable log binomial regression model estimated the adjusted rate ratios (aRR) and 95% confidence intervals (CI) of patient socio-demographic characteristics and screening delivery. Key informant interviews with navigators (n = 8) and patients (n = 21) assessed screening acceptability and factors that facilitate and impede implementation. Using a convergent, parallel mixed methods approach, findings from each data source were integrated to interpret study results.

RESULTS

Patients' (n = 588) mean age was 59 (SD = 13); 45% were non-Hispanic Black and 27% were Hispanic. Sixty-nine percent of patients in the navigators' caseloads received social needs screening. Patients of non-Hispanic Black race/ethnicity (aRR = 1.25; 95% CI = 1.06-1.48) and those with Medicare insurance (aRR = 1.13; 95% CI = 1.04-1.23) were more likely to be screened. Screening was universally acceptable to navigators and generally acceptable to patients. Systems-based supports for improving implementation were identified.

CONCLUSIONS

Social needs screening was acceptable, yet with modest implementation. Continued systems-based efforts to integrate social needs screening in medical care are needed.

Identifying and Addressing Barriers to Screening Mammography in a Medically Underserved Community

RATIONALE AND OBJECTIVES

Breast cancer mortality is 40% higher for Black women compared to White women. This study seeks to assess knowledge of breast cancer screening recommendations and identify barriers to risk assessment and mammographic screening among a medically underserved, low-income, predominantly Black community in West Philadelphia.

MATERIALS AND METHODS

During a free mobile mammography screening event, women were offered surveys to assess perceptions of and barriers to breast cancer risk assessment and screening. Among those who subsequently underwent mobile screening, health insurance and time to additional diagnostic imaging and biopsy, when relevant, were retrospectively collected.

RESULTS

233 women completed surveys (mean age 54 ± 13 years). Ninety-three percent of respondents identified as Black. The most frequently cited barrier to screening mammography was cost and/or lack of insurance coverage (30%). Women under 50 reported more barriers to screening compared to older women. Among those recalled from screening and recommended to undergo biopsy, there was a trend toward longer delays between screening and biopsy among those without a PCP (median 45 days, IQR 25-53) compared to those with a PCP (median 24 days, IQR 16-29) (p = 0.072).

CONCLUSION

In a study of a medically underserved community of primarily Black patients, barriers to breast cancer risk assessment, screening, and diagnosis were identified by self-report and by documented care delays. While free mobile mammography initiatives that bring medical professionals into communities can help mitigate barriers to screening, strategies for navigation and coordination of follow-up are critical to promote timely diagnostic resolution for all patients.

Simulating the population impact of interventions to reduce racial gaps in breast cancer treatment

BACKGROUND

Inequities in guideline-concordant treatment receipt contribute to worse survival in Black patients with breast cancer. Inequity-reduction interventions (eg, navigation, bias training, tracking dashboards) can close such treatment gaps. We simulated the population-level impact of statewide implementation of inequity-reduction interventions on racial breast cancer inequities in North Carolina.

METHODS

Using registry-linked multipayer claims data, we calculated inequities between Black and White patients receiving endocrine therapy (n = 12 033) and chemotherapy (n = 1819). We then built cohort-stratified (endocrine therapy and chemotherapy) and race-stratified Markov models to simulate the potential increase in the proportion of patients receiving endocrine therapy or chemotherapy and subsequent improvements in breast cancer outcomes if inequity-reducing intervention were implemented statewide. We report uncertainty bounds representing 95% of simulation results.

RESULTS

In total, 75.6% and 72.1% of Black patients received endocrine therapy and chemotherapy, respectively, over the 2006-2015 and 2004-2015 periods (vs 79.3% and 78.9% of White patients, respectively). Inequity-reduction interventions could increase endocrine therapy and chemotherapy receipt among Black patients to 89.9% (85.3%, 94.6%) and 85.7% (80.7%, 90.9%). Such interventions could also decrease 5-year and 10-year breast cancer mortality gaps from 3.4 to 3.2 (3.0, 3.3) and from 6.7 to 6.1 (5.9, 6.4) percentage points in the endocrine therapy cohorts and from 8.6 to 8.1 (7.7, 8.4) and from 8.2 to 7.8 (7.3, 8.1) percentage points in the chemotherapy cohorts.

CONCLUSIONS

Inequity-focused interventions could improve cancer outcomes for Black patients, but they would not fully close the racial breast cancer mortality gap. Addressing other inequities along the cancer continuum (eg, screening, pre- and postdiagnosis risk factors) is required to achieve full equity in breast cancer outcomes.

Quality of Life After Axillary Lymph Node Dissection Among Racial and Ethnic Minority Women

Importance

Higher lymphedema rates after axillary lymph node dissection (ALND) have been found in Black and Hispanic women; however, there is poor correlation between subjective symptoms, quality of life (QOL), and measured lymphedema. Additionally, racial and ethnic differences in QOL have been understudied.

Objective

To evaluate the association of race and ethnicity with long-term QOL in patients with breast cancer treated with ALND.

Design, Setting, and Participants

This cohort study enrolled women aged 18 years and older with breast cancer who underwent unilateral ALND at a tertiary cancer center between November 2016 and March 2020. Preoperatively and at 6-month intervals, arm volume was measured by perometer and QOL was assessed using the Upper Limb Lymphedema-27 (ULL-27) questionnaire, a validated tool for assessing lymphedema that evaluates how arm symptoms affect physical, psychological, and social functioning. Data were analyzed from November 2016 to October 2023.

Exposures

Breast surgery and unilateral ALND in the primary setting or after sentinel lymph node biopsy.

Main Outcomes and Measures

Scores in each domain of the ULL-27 were compared by race and ethnicity. Factors impacting QOL were identified using multivariable regression analyses.

Results

The study included 281 women (median [IQR] age, 48 [41-58] years) with breast cancer who underwent unilateral ALND and had at least 6 months of follow-up. Of these, 30 patients (11%) self-identified as Asian individuals, 57 (20%) as Black individuals, 23 (8%) as Hispanic individuals, and 162 (58%) as White individuals; 9 individuals (3%) who did not identify as part of a particular group or who were missing race and ethnicity data were categorized as having unknown race and ethnicity. Median (IQR) follow-up was 2.97 (1.96-3.67) years. The overall 2-year lymphedema rate was 20% and was higher among Black (31%) and Hispanic (27%) women compared with Asian (15%) and White (17%) women (P = .04). Subjective arm swelling was more common among Asian (57%), Black (70%), and Hispanic (87%) women than White (44%) women (P < .001), and lower physical QOL scores were reported by racial and ethnic minority women at nearly every follow-up. For example, at 24 months, median QOL scores were 87, 79, and 80 for Asian, Black, and Hispanic women compared with 92 for White women (P = .003). On multivariable analysis, Asian race (β = -5.7; 95% CI, -9.5 to -1.8), Hispanic ethnicity (β = -10.0; 95% CI, -15.0 to -5.2), and having Medicaid (β = -5.4; 95% CI, -9.2 to -1.7) or Medicare insurance (β = -6.9; 95% CI, -10.0 to -3.4) were independently associated with worse physical QOL (all P < .001).

Conclusions and Relevance

Findings of this cohort study suggest that Asian, Black, and Hispanic women experience more subjective arm swelling after unilateral ALND for breast cancer compared with White women. Black and Hispanic women had higher rates of objective lymphedema than their White counterparts. Both minority status and public medical insurance were associated with worse physical QOL. Understanding disparities in QOL after ALND is an unmet need and may enable targeted interventions to improve QOL for these patients.

Discharge within 1 day following elective single-level transforaminal lumbar interbody fusion: a propensityscore-matched analysis of predictors, complications, and readmission

STUDY DESIGN

This was a retrospective case-control study using 8 years of data from a nationwide database of surgical outcomes in the United States.

PURPOSE

This study aimed to improve our understanding of the risk factors associated with a length of stay (LOS) >1 day and aid in reducing postoperative hospitalization and complications.

OVERVIEW OF LITERATURE

Despite the proven safety of transforaminal lumbar interbody fusion (TLIF), some patients face prolonged postoperative hospitalization.

METHODS

Data were collected from the American College of Surgeons National Surgical Quality Improvement Program dataset from 2011 to 2018. The cohort was divided into patients with LOS up to 1 day (LOS ≤1 day), defined as same day or next-morning discharge, and patients with LOS >1 day (LOS >1 day). Univariable and multivariable regression analyses were performed to evaluate predictors of LOS >1 day. Propensity-score matching was performed to compare pre- and postdischarge complication rates.

RESULTS

A total of 12,664 eligible patients with TLIF were identified, of which 14.8% had LOS ≤1 day and 85.2% had LOS >1 day. LOS >1 day was positively associated with female sex, Hispanic ethnicity, diagnosis of spondylolisthesis, American Society of Anesthesiologists classification 3, and operation length of >150 minutes. Patients with LOS >1 day were more likely to undergo intraoperative/postoperative blood transfusion (0.3% vs. 4.5%, p<0.001) and reoperation (0.1% vs. 0.6%, p=0.004). No significant differences in the rates of postdischarge complications were found between the matched groups.

CONCLUSIONS

Patients with worsened preoperative status, preoperative diagnosis of spondylolisthesis, and prolonged operative time are more likely to require prolonged hospitalization and blood transfusions and undergo unplanned reoperation. To reduce the risk of prolonged hospitalization and associated complications, patients indicated for TLIF should be carefully selected.

Association of geographical disparities and segregation in regional treatment facilities for Black patients with aneurysmal subarachnoid hemorrhage in the United States

Background and objectives

This study investigates geographic disparities in aneurysmal subarachnoid hemorrhage (aSAH) care for Black patients and aims to explore the association with segregation in treatment facilities. Understanding these dynamics can guide efforts to improve healthcare outcomes for marginalized populations.

Methods

This cohort study evaluated regional differences in segregation for Black patients with aSAH and the association with geographic variations in disparities from 2016 to 2020. The National Inpatient Sample (NIS) database was queried for admission data on aSAH. Black patients were compared to White patients. Segregation in treatment facilities was calculated using the dissimilarity (D) index. Using multivariable logistic regression models, the regional disparities in aSAH treatment, functional outcomes, mortality, and end-of-life care between Black and White patients and the association of geographical segregation in treatment facilities was assessed.

Results

142,285 Black and White patients were diagnosed with aSAH from 2016 to 2020. The Pacific division (D index = 0.55) had the greatest degree of segregation in treatment facilities, while the South Atlantic (D index = 0.39) had the lowest. Compared to lower segregation, regions with higher levels of segregation (global F test p < 0.001) were associated a lower likelihood of mortality (OR 0.91, 95% CI 0.82-1.00, p = 0.044 vs. OR 0.75, 95% CI 0.68-0.83, p < 0. 001) (p = 0.049), greater likelihood of tracheostomy tube placement (OR 1.45, 95% CI 1.22-1.73, p < 0.001 vs. OR 1.87, 95% CI 1.59-2.21, p < 0.001) (p < 0. 001), and lower likelihood of receiving palliative care (OR 0.88, 95% CI 0.76-0.93, p < 0.001 vs. OR 0.67, 95% CI 0.59-0.77, p < 0.001) (p = 0.029).

Conclusion

This study demonstrates regional differences in disparities for Black patients with aSAH, particularly in end-of-life care, with varying levels of segregation in regional treatment facilities playing an associated role. The findings underscore the need for targeted interventions and policy changes to address systemic healthcare inequities, reduce segregation, and ensure equitable access to high-quality care for all patients.

Predictors of Breast Cancer Outcome in a Cohort of Women Seeking Care at a Safety Net Hospital

RATIONALE AND OBJECTIVES

This study aimed to identify predictors associated with lower mortality in a population of women diagnosed and treated for breast cancer at a safety net hospital.

METHODS

From 2008 to 2014, 1115 patients were treated for breast cancer at our academic safety net hospital. 208 were excluded due to diagnosis at an outside facility, and the remaining 907 (81%) formed the study cohort. Retrospective charts and imaging reviews looked at race, ethnicity, insurance status, social determinants of health, screening utilization, treatment regimen, and 7-13-year follow-up care, including the cause of death. Multivariable logistic regression modeling assessed mortality, and adjusted odds ratios (aOR) with 95% confidence intervals (CI) were computed.

RESULTS

Of the 907 women, the mean age was 59 years (inter-quartile range 50-68 years), with 40% White, 46% Black, 4% Asian, and 10% Other. Increasing age (aOR=1.03, p = 0.001) and more advanced stage at diagnosis (aOR=6.37, p < 0.0001) were associated with increased mortality. There was no significant difference in mortality based on race or ethnicity (p > 0.05). Of 494 with screening prior to diagnosis, longer screening time was observed for patients with advanced stage (median 521 days) vs. early stage (median 404 days), p = 0.0004. Patients with Medicaid, insurance not specified, and no insurance were less likely to undergo screening before diagnosis than privately insured (all p < 0.05). Shorter screening time was associated with lower all-cause mortality (aOR=0.57, 95% CI=0.36-0.89, p = 0.013).

DISCUSSION

In a safety net population, a more advanced stage at diagnosis was associated with higher mortality and lower odds of undergoing screening mammography in the two years prior to a breast cancer diagnosis. Early screening was associated with lower mortality. Finally, given no racial or ethnic differences in mortality, the safety net infrastructure at our institution effectively provides equitable cancer care once a cancer is confirmed.

Disparities in Cancer Stage Outcomes by Catchment Areas for a Comprehensive Cancer Center

Importance

The National Cancer Institute comprehensive cancer centers (CCCs) lack spatial and temporal evaluation of their self-designated catchment areas.

Objective

To identify disparities in cancer stage at diagnosis within and outside a CCC's catchment area across a 10-year period using spatial and statistical analyses.

Design, Setting, and Participants

This cross-sectional, population-based study conducted between 2010 and 2019 utilized cancer registry data for the Johns Hopkins Sidney Kimmel CCC (SKCCC). Eligible participants included patients with cancer in the contiguous US who received treatment for cancer, a diagnosis of cancer, or both at SKCCC. Patients were geocoded to zip code tabulation areas (ZCTAs). Individual-level variables included sociodemographic characteristics, smoking and alcohol use, treatment type, cancer site, and insurance type. Data analysis was performed between March and July 2023.

Exposures

Distance between SKCCC and ZCTAs were computed to generate a catchment area of the closest 75% of patients and outer zones in 5% increments for comparison.

Main Outcomes and Measures

The primary outcome was cancer stage at diagnosis, defined as early-stage, late-stage, or unknown stage. Multinomial logistic regression was used to determine associations of catchment area with stage at diagnosis.

Results

This study had a total of 94 007 participants (46 009 male [48.94%] and 47 998 female [51.06%]; 30 195 aged 22-45 years [32.12%]; 4209 Asian [4.48%]; 2408 Hispanic [2.56%]; 16 004 non-Hispanic Black [17.02%]; 69 052 non-Hispanic White [73.45%]; and 2334 with other or unknown race or ethnicity [2.48%]), including 47 245 patients (50.26%) who received a diagnosis of early-stage cancer, 19 491 (20.73%) who received a diagnosis of late-stage cancer , and 27 271 (29.01%) with unknown stage. Living outside the main catchment area was associated with higher odds of late-stage cancers for those who received only a diagnosis (odds ratio [OR], 1.50; 95% CI, 1.10-2.05) or only treatment (OR, 1.44; 95% CI, 1.28-1.61) at SKCCC. Non-Hispanic Black patients (OR, 1.16; 95% CI, 1.10-1.23) and those with Medicaid (OR, 1.65; 95% CI, 1.46-1.86) and no insurance at time of treatment (OR, 2.12; 95% CI, 1.79-2.51) also had higher odds of receiving a late-stage cancer diagnosis.

Conclusions and Relevance

In this cross-sectional study of CCC data from 2010 to 2019, patients residing outside the main catchment area, non-Hispanic Black patients, and patients with Medicaid or no insurance had higher odds of late-stage diagnoses. These findings suggest that disadvantaged populations and those living outside of the main catchment area of a CCC may face barriers to screening and treatment. Care-sharing agreements among CCCs could address these issues.

Socioecologic Factors and Racial Differences in Breast Cancer Multigene Prognostic Scores in US Women

Importance

Disproportionately aggressive tumor biology among non-Hispanic Black women with early-stage, estrogen receptor (ER)-positive breast cancer contributes to racial disparities in breast cancer mortality. It is unclear whether socioecologic factors underlie racial differences in breast tumor biology.

Objective

To examine individual-level (insurance status) and contextual (area-level socioeconomic position and rural or urban residence) factors as possible mediators of racial and ethnic differences in the prevalence of ER-positive breast tumors with aggressive biology, as indicated by a high-risk gene expression profile.

Design, Setting, and Participants

This retrospective cohort study included women 18 years or older diagnosed with stage I to II, ER-positive breast cancer between January 1, 2007, and December 31, 2015. All data analyses were conducted between December 2022 and April 2023.

Main Outcomes and Measures

The primary outcome was the likelihood of a high-risk recurrence score (RS) (≥26) on the Oncotype DX 21-gene breast tumor prognostic genomic biomarker.

Results

Among 69 139 women (mean [SD] age, 57.7 [10.5] years; 6310 Hispanic [9.1%], 274 non-Hispanic American Indian and Alaskan Native [0.4%], 6017 non-Hispanic Asian and Pacific Islander [8.7%], 5380 non-Hispanic Black [7.8%], and 51 158 non-Hispanic White [74.0%]) included in our analysis, non-Hispanic Black (odds ratio [OR], 1.33; 95% CI, 1.23-1.43) and non-Hispanic American Indian and Alaska Native women (OR, 1.38; 95% CI, 1.01-1.86) had greater likelihood of a high-risk RS compared with non-Hispanic White women. There were no significant differences among other racial and ethnic groups. Compared with non-Hispanic White patients, there were greater odds of a high-risk RS for non-Hispanic Black women residing in urban areas (OR, 1.35; 95% CI, 1.24-1.46), but not among rural residents (OR, 1.05; 95% CI, 0.77-1.41). Mediation analysis demonstrated that lack of insurance, county-level disadvantage, and urban vs rural residence partially explained the greater odds of a high-risk RS among non-Hispanic Black women (proportion mediated, 17%; P < .001).

Conclusions and Relevance

The findings of this cohort study suggest that the consequences of structural racism extend beyond inequities in health care to drive disparities in breast cancer outcome. Additional research is needed with more comprehensive social and environmental measures to better understand the influence of social determinants on aggressive ER-positive tumor biology among racial and ethnic minoritized women from disadvantaged and historically marginalized communities.

Breast Cancer Incidence Among Asian American Women in New York City: Disparities in Screening and Presentation

BACKGROUND

Asian American (AsAm) women have some of the lowest rates of up-to-date breast cancer screening, and lack of disaggregated racial/ethnic data can mask disparities. We evaluated presentation patterns among AsAms at two hospitals with distinct communities: New York Presbyterian-Queens (NYPQ), in Flushing, Queens and Weill Cornell Medical Center (WCM), on the Upper East Side (UES) neighborhood of Manhattan.

PATIENTS AND METHODS

Patients with newly diagnosed breast cancer between January 2019 and December 2022 were identified using a prospective database and clinical data collected. Patients were categorized as self-reported Asian versus Non-Asian. The Asian group was disaggregated as Chinese-Asian versus Other-Asian. Physician workforce data were obtained from public records.

RESULTS

A total of 3546 patients (1162 NYPQ, 2384 WCM) were included. More NYPQ patients identified as Asian compared with WCM (49 vs. 14%, p < 0.001). Asian patients were mostly East Asian Chinese (NYPQ 61%, WCM 53%). More Chinese patients at NYPQ reported Chinese as their preferred language (81 vs. 33%, p < 0.001). Greatest differences of screen-detected disease frequency were seen between NYPQ and WCM Chinese patients (75 vs. 59%, p < 0.001). Eighty percent of NYPQ Chinese patients presented with stage 0/I disease versus 69% at WCM (p = 0.007), a difference not observed between Other-Asian patients (75% NYPQ, 68% WCM, p = 0.095). 3% of UES physicians versus 16% in Flushing reported speaking Chinese.

CONCLUSIONS

Chinese patients residing in a neighborhood with more Chinese-speaking physicians more frequently presented with screen-detected, early-stage breast cancer. Stage distribution differences were not apparent among the aggregated pool of Other-Asian patients, suggesting cancer disparities may be masked when ethnic groups are studied in aggregate.

Diagnostic delays in breast cancer among young women: An emphasis on healthcare providers

Despite advances in breast cancer care, breast cancer in young women (BCYW) faces unique challenges, diagnostic delays, and limited awareness in many countries. Here, we discuss the challenges and consequences associated with the delayed diagnosis of BCYW. The consequences of delayed diagnosis in young women - which generally varies among developed, developing, or underdeveloped countries - are severe due to a faster breast tumor growth rate than tumors in older women, also contributing to advanced cancer stages and poorer outcomes. Though there are many underlying reasons for diagnostic delays due to age, the article delves explicitly deep into the diagnostic delay of BCYW, focusing on healthcare providers, potential contributing factors, its consequences, and the urgent need to start minimizing such incidences. The article suggests several strategies to address these issues, including increasing awareness, developing educational programs for healthcare providers to identify signs and symptoms in young women, developing clear diagnostic guidelines, and improving screening strategies.

Climate change and cancer: the Environmental Justice perspective

Despite advances in cancer control-prevention, screening, diagnosis, treatment, and survivorship-racial disparities in cancer incidence and survival persist and, in some cases, are widening in the United States. Since 2020, there's been growing recognition of the role of structural racism, including structurally racist policies and practices, as the main factor contributing to historical and contemporary disparities. Structurally racist policies and practices have been present since the genesis of the United States and are also at the root of environmental injustices, which result in disproportionately high exposure to environmental hazards among communities targeted for marginalization, increased cancer risk, disruptions in access to care, and worsening health outcomes. In addition to widening cancer disparities, environmental injustices enable the development of polluting infrastructure, which contribute to detrimental health outcomes in the entire population, and to climate change, the most pressing public health challenge of our time. In this commentary, we describe the connections between climate change and cancer through an Environmental Justice perspective (defined as the fair treatment and meaningful involvement of people of all racialized groups, nationalities, or income, in all aspects, including development, implementation, and enforcement, of policies and practices that affect the environment and public health), highlighting how the expertise developed in communities targeted for marginalization is crucial for addressing health disparities, tackling climate change, and advancing cancer control efforts for the entire population.

Breast Cancer Disparity and Outcomes in Underserved Women

Women in the United States who continue to face obstacles accessing health care are frequently termed an underserved population. Safety-net health care systems play a crucial role in mitigating health disparities and reducing burdens of disease, such as breast cancer, for underserved women. Disparities in health care are driven by various factors, including race and ethnicity, as well as socioeconomic factors that affect education, employment, housing, insurance status, and access to health care. Underserved women are more likely to be uninsured or underinsured throughout their lifetimes. Hence they have greater difficulty gaining access to breast cancer screening and are less likely to undergo supplemental imaging when needed. Therefore, underserved women often experience significant delays in the diagnosis and treatment of breast cancer, leading to higher mortality rates. Addressing disparities requires a multifaceted approach, with formal care coordination to help at-risk women navigate through screening, diagnosis, and treatment. Mobile mammography units and community outreach programs can be leveraged to increase community access and engagement, as well as improve health literacy with educational initiatives. Radiology-community partnerships, comprised of imaging practices partnered with local businesses, faith-based organizations, homeless shelters, and public service departments, are essential to establish culturally competent breast imaging care, with the goal of equitable access to early diagnosis and contemporary treatment. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the Online Learning Center. See the invited commentary by Leung in this issue.

A Scoping Review of Personalized, Interactive, Web-Based Clinical Decision Tools Available for Breast Cancer Prevention and Screening in the United States

Introduction. Personalized web-based clinical decision tools for breast cancer prevention and screening could address knowledge gaps, enhance patient autonomy in shared decision-making, and promote equitable care. The purpose of this review was to present evidence on the availability, usability, feasibility, acceptability, quality, and uptake of breast cancer prevention and screening tools to support their integration into clinical care. Methods. We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist to conduct this review. We searched 6 databases to identify literature on the development, validation, usability, feasibility, acceptability testing, and uptake of the tools into practice settings. Quality assessment for each tool was conducted using the International Patient Decision Aid Standard instrument, with quality scores ranging from 0 to 63 (lowest-highest). Results. We identified 10 tools for breast cancer prevention and 9 tools for screening. The tools included individual (e.g., age), clinical (e.g., genomic risk factors), and health behavior (e.g., alcohol use) characteristics. Fourteen tools included race/ethnicity, but no tool incorporated contextual factors (e.g., insurance, access) associated with breast cancer. All tools were internally or externally validated. Six tools had undergone usability testing in samples including White (median, 71%; range, 9%-96%), insured (99%; 97%-100%) women, with college education or higher (60%; 27%-100%). All of the tools were developed and tested in academic settings. Seven (37%) tools showed potential evidence of uptake in clinical practice. The tools had an average quality assessment score of 21 (range, 9-39). Conclusions. There is limited evidence on testing and uptake of breast cancer prevention and screening tools in diverse clinical settings. The development, testing, and integration of tools in academic and nonacademic settings could potentially improve uptake and equitable access to these tools.

Highlights

There were 19 personalized, interactive, Web-based decision tools for breast cancer prevention and screening.Breast cancer outcomes were personalized based on individual clinical characteristics (e.g., age, medical history), genomic risk factors (e.g., BRCA1/2), race and ethnicity, and health behaviors (e.g., smoking). The tools did not include contextual factors (e.g., insurance status, access to screening facilities) that could potentially contribute to breast cancer outcomes.Validation, usability, acceptability, and feasibility testing were conducted mostly among White and/or insured patients with some college education (or higher) in academic settings. There was limited evidence on testing and uptake of the tools in nonacademic clinical settings.

Racial and Ethnic Disparities in Preventive Service Use Among Adults Before and During the COVID-19 Pandemic

Our objective was to assess changes in preventive services use before and during the COVID-19 pandemic. We obtained secondary survey data from the National Health Interview Survey for 2019 and 2021. We examined, six preventive services among all adults. Descriptive and multivariate analyses assessed changes in preventive service use among adults and by race/ethnicity for 2019 and 2021 (drawing from an unweighted sample of 60 843 weighted to be 386.2 million across both years). We used Ordinary least squares estimation to conduct a difference-in-differences analysis that assessed changes in service use for non-white racial/ethnic groups relative to changes for white non-Hispanic adults between 2019 and 2021. We found preventive services use declined overall for each screening service assessed. Asian adults experienced the largest declines relative to white adults for "well visit within the last year" (-7.45 percentage points (pp) relative to white adults), "blood pressure screening within the last year" (-7.85 pp), and "mammograms within the last year" (-12.3 pp). While adults in other racial/ethnic groups did not experience significant declines in preventive services use relative to white adults between 2019 and 2021, pre-existing disparities remained for Hispanic and American Indian/Alaska Native (AIAN) adults compared to white adults. In conclusion, preventive service use declined in the first years of the COVID-19 public health emergency, and existing disparities in access for Hispanic and AIAN adults continued. Future research should investigate barriers Asian adults may face in obtaining access to preventive services after the conclusion of the public health emergency and federal pandemic-related protections.

Social Determinants of Cancer Disparities

Cancer is a major public health issue that is associated with significant morbidity and mortality across the globe. At its root, cancer represents a genetic aberration, but socioeconomic, environmental, and geographic factors contribute to different cancer outcomes for selected population subsets. The disparities in the delivery of healthcare affect all aspects of cancer management from early prevention to end-of-life care. In an effort to address the inequality in the delivery of healthcare among socioeconomically disadvantaged populations, the World Health Organization defined social determinants of health (SDOH) as conditions in which people are born, live, work, and age. These factors play a significant role in the disproportionate cancer burden among different population groups. SDOH are associated with disparities in risk factor burden, screening modalities, diagnostic testing, treatment options, and quality of life of patients with cancer. The purpose of this article is to describe a more holistic and integrated approach to patients with cancer and address the disparities that are derived from their socioeconomic background.

Association of County-Level Food Deserts and Food Swamps with Hepatopancreatobiliary Cancer Outcomes

BACKGROUND

Malnutrition has been linked to the development of hepatopancreatobiliary (HPB) cancer. We sought to examine the association between food swamps and food deserts on surgical outcomes of patients with HPB cancer.

METHODS

Patients who underwent surgery for HPB cancer between 2014 and 2020 were identified from the Medicare Standard Analytic Files. Patient-level data were linked to the United States Department of Agriculture data on food swamps and deserts. Multivariable regression was performed to examine the association between the food environment and outcomes.

RESULTS

Among 53,426 patients, patients from the worse food environment were more likely to be Black, have a higher Charlson Comorbidity Index, and reside in areas with high social vulnerability. Following surgery, the overall incidence of textbook outcome (TO) was 41.6% (n = 22,220). Patients residing in the worse food environments less often achieved a TO versus individuals residing in the healthiest food environments (food swamp: 39.4% vs. 43.9%; food desert: 38.5% vs 42.2%; p < 0.05). On multivariable analysis, individuals residing in the poorest food environments were associated with lower odds of achieving TO compared with individuals living in healthiest food environments (food swamp: OR 0.83, 95%CI 0.75-0.92, food desert: OR 0.86, 95%CI 0.76-0.97; both p < 0.05).

CONCLUSION

The surrounding food environment of patients may serve as a modifiable socio-demographic risk factor that contributes to disparities in surgical outcomes of HPB cancer.

The Military Health System: Minimizing Disparities in Breast Cancer Treatment

BACKGROUND

The Military Health System (MHS) is a universal health care system, in which health care disparities are theoretically minimized. This study aimed to identify disparities and assess their impact on the initiation of timely treatment for breast cancer within a universally insured population.

METHODS

A retrospective cohort study was performed to evaluate the treatment of female breast cancer patients ≥18 years of age within the MHS from January 1, 2014, to December 31, 2018. Incident breast cancer was defined as ≥2 breast cancer diagnoses without a prior diagnosis of breast cancer during the three continuous years before index diagnosis. Time from index diagnosis to initial treatment was calculated and dichotomized as receiving treatment within a clinically acceptable time course. Poisson regression was used to estimate relative risk (RR) with 95% CIs.

RESULTS

Among the 30,761 female breast cancer patients identified in the MHS, only 6% of patients had a prolonged time to initial treatment. Time to initial treatment decreased during the study period from a mean (SD) of 63.2 (152.0) days in 2014 to 37.1 (28.8) days in 2018 (P < 0.0001). Age, region, and military characteristics remained significantly associated with receiving timely treatment even after the adjustment of confounders. Patients 70-79 years old were twice as likely as 18-39 years olds to receive timely treatment (RR: 2.0100, 95% CI, 1.52-2.6563, P < 0.0001). Senior officers and their dependents were more likely to receive timely initial treatment compared to junior enlisted patients and their dependents (RR: 1.5956, 95% CI, 1.2119-2.1005, P = 0.004).

CONCLUSIONS

There have been significant improvements in the timely initiation of breast cancer treatment within the MHS. However, demographic and socioeconomic disparities can be identified that affect the timely initiation of therapy.

Structural Racism, Lifestyle Behaviors, and Obesity-related Cancers among Black and Hispanic/Latino Adults in the United States: A Narrative Review

One in three adults in the United States has obesity; a chronic disease that is implicated in the etiology of at least 14 cancers. Cancer is the leading cause of death among U.S. Hispanic/Latino adults and the second most common cause of death, after cardiovascular disease, for Black adults. Our country's legacy in overt discrimination (e.g., slavery, segregation) generated inequities across all spheres in which people function as defined by the socioecological model-biological, individual, community, structural-and two of the many areas in which it manifests today are the disproportionate burden of obesity and obesity-related cancers in populations of color. Inequities due to environmental, social, and economic factors may predispose individuals to poor lifestyle behaviors by hindering an individual's opportunity to make healthy lifestyles choices. In this review, we examined the evidence on obesity and the lifestyle guidelines for cancer prevention in relation to cancer risk and outcomes for Black and Hispanic/Latino adults. We also discussed the role of structural and societal inequities on the ability of these two communities to adopt and maintain healthful lifestyle behaviors in accordance with the lifestyle guidelines for cancer prevention and control.

Overlooked and Damaging Impact of Structural Racism and Implicit Bias on US Health Care: Overarching Policy Implications

ABSTRACT

Marginalized populations, including racial and ethnic minorities, have historically faced significant barriers to accessing quality health care because of structural racism and implicit bias. A brief review and analysis of past and historic and current policies demonstrate that structural racism and implicit bias continue to underscore a health system characterized by unequal access and distribution of health care resources. Although advances in cancer care have led to decreased incidence and mortality, not all populations benefit. New policies must explicitly seek to eliminate disparities and drive equity for historically marginalized populations to improve access and outcomes.

Mammography Screening Outreach Through Non-Primary Care-Based Services

OBJECTIVE

To estimate the proportion of patients visiting urgent care centers or emergency departments or being hospitalized who were not up to date with recommended mammography screening to assess the potential impact of non-primary care-based cancer screening interventions.

METHODS

Adult participants from the 2019 National Health Interview Survey were included. Among participants not up to date with breast cancer screening guidelines based on ACR recommendations, the proportion of patients reporting an urgent care, emergency department visit, or hospitalization within the last year was estimated accounting for complex survey sampling design features. Multiple variable logistic regression analyses were then conducted to evaluate the association between sociodemographic characteristics and mammography screening adherence.

RESULTS

The study included 9,139 women between the ages of 40 and 74 years without history of breast cancer. Of these respondents, 44.9% did not report mammography screening within the last year. Among participants who did not report mammography screening, 29.2% reported visiting an urgent care center, 21.8% reported visiting an emergency room, and 9.6% reported being hospitalized within the last year. The majority of patients receiving non-primary care-based services, who were not up to date with mammography screening, were from historically underserved groups including Black and Hispanic patients.

CONCLUSION

Nearly 10% to 30% of participants who have not obtained recommended breast cancer screening have visited non-primary care-based services including urgent care centers or emergency rooms or have been hospitalized within the last year.

Disparities in osteoarthritis diagnosis and symptoms between English- and Spanish-speaking Latinas over 40 years of age in the United States: a analysis of the Behavioral Risk Factor Surveillance System

OBJECTIVE

Osteoarthritis (OA) is a prominent musculoskeletal disorder that affects approximately 303 million people worldwide. The challenges that language barriers present to the Latina population in regard to the diagnosis and treatment of OA remain largely unknown. The objective of this study was to examine disparities in the diagnosis and treatment of arthritic conditions in English- and Spanish-speaking Latinas over 40 years of age.

DESIGN

We analyzed data from the CDC's Behavioral Risk Screening and Surveillance System (BRFSS), combining the 2017-2020 cycles using sampling weights provided by BRFSS, adjusted for multiple cycles. Determination of English- or Spanish-speaking groups was based on the language of the survey submitted. We calculated population estimates for arthritis diagnosis, physical limitations, and mean joint pain among language groups and by age (40-64 and 65+) and determined associations via odds ratios.

RESULTS

Rates of arthritis diagnosis between groups were similar; however we found that Spanish-speaking Latinas 65+ were statistically more likely to report being limited by pain (AOR: 1.55; 95% CI: 1.14-2.09), and among both age groups Spanish-speaking Latinas reported higher pain scores than the English-speaking group (40-64 age group: Coef: 0.74, SE = 0.14, P < .001; 65 + age group: Coef: 1.05, SE = 0.2, P < .001).

CONCLUSION

Results from this study show that while there were no significant differences in rates of diagnosis, Spanish-speaking Latinas were more likely to be limited by joint pain and report higher pain scores.

Social Risk Factors That Increase Cardiovascular and Breast Cancer Risk

PURPOSE OF REVIEW

Cardiovascular disease (CVD) and breast cancer (BC) are significant causes of mortality globally, imposing a substantial health burden. This review article aims to examine the shared risk factors and social determinants that contribute to the high prevalence of both diseases, with a focus on social risk factors.

RECENT FINDINGS

The common risk factors for CVD and BC, such as hypertension, diabetes, obesity, aging, and physical inactivity, are discussed, emphasizing their modifiability. Adhering to ideal cardiovascular health behaviors has shown a trend toward lower BC incidence. Increased risk of CVD-related mortality is significantly impacted by age and race in BC patients, especially those over 45 years old. Additionally, racial disparities in both diseases highlight the need for targeted interventions. Social determinants of health, including socioeconomic status, education, employment, and neighborhood context, significantly impact outcomes for both CVD and BC. Addressing social factors is vital in reducing the burden of both CVD and BC and improving overall health equity.

Racial disparities in the screening mammography continuum within a heterogeneous health care system

BACKGROUND

Decreased mammography drives breast cancer disparities. Black women have lower rates of mammography completion than White women, and this contributes to disparities in outcomes. Points of disparity along the continuum for screening mammography remain underresearched.

METHODS

The authors compared mammography referrals for Black and White women aged 40-74 years at a heterogeneous academic medical center. Completion of steps of the screening mammography continuum was compared between Black and White women within two age cohorts: 40-49 and 50-74 years. Multivariable logistic regression was used to evaluate the association between race and mammogram completion.

RESULTS

Among 26,476 women, 3090 (12%) were Black, and 23,386 (88%) were White. Among Black women aged 50-74 years who were due for mammography, 40% had referrals, 39% were scheduled, and 21% completed mammography; the corresponding values for White women were 42%, 41%, and 27%, respectively. Similar differences in referral outcomes were noted for women aged 40-49 years, although Black women had lower rates of provider-initiated referrals (9% vs. 13%). Adjusted analyses for those aged 40-49 and 50-74 years demonstrated an association between Black race and lower rates of mammography completion (odds ratio [OR] for 40-49 years, 0.74; 95% CI, 0.57-0.95; p = .02; OR for 50-74 years, 0.85; 95% CI, 0.74-0.98; p = .02). In multivariable analyses, noncommercial insurance and higher comorbidity were associated with lower rates of mammography. Provider-initiated referral was positively correlated to mammogram completion.

CONCLUSIONS

Black race was associated with 15%-26% lower mammography completion (adjusted). Both groups experienced the highest attrition after scheduling mammograms, although attrition was more precipitous for Black women. These findings have implications for future interventions, including increasing provider-initiated referrals and decreasing barriers to attending scheduled mammograms.

Trends in breast cancer screening during the COVID-19 pandemic within a universally insured health system in the United States, 2017-2022

BACKGROUND

In the United States, breast cancer is the most commonly diagnosed cancer and second leading cause of cancer death in women. Early detection through mammogram screening is instrumental in reducing mortality and incidence of disease. The COVID-19 pandemic posed unprecedented challenges to the provision of care, including delays in preventive screenings. We examined trends in breast cancer screening during the COVID-19 pandemic in a universally insured national population and evaluated rates across racial groups and socioeconomic strata.

METHODS

In this retrospective open cohort study, we used the Military Health System Data Repository to identify female TRICARE beneficiaries ages 40-64 at average risk for breast cancer between FY2018 and FY2022, broken down into prepandemic (September 1, 2018-February 28, 2020), early pandemic (March 1, 2020-September 30, 2020), and late pandemic periods (October 1, 2020-September 30, 2022). The primary outcome was receipt of breast cancer screening.

RESULTS

Screening dropped 74% in the early pandemic period and 22% in the late pandemic period, compared with the prepandemic period. Compared with White women, Asian/Pacific Islander women were less likely to receive mammograms during the late pandemic period (0.92RR; 0.90-0.93 95%CI). American Indian/Alaska Native women remained less likely to receive screenings compared with White women during the early (0.87RR; 0.80-0.94 95% CI) and late pandemic (0.94RR, 0.91-0.98 95% CI). Black women had a higher likelihood of screenings during both the early pandemic (1.10RR; 1.08-1.12 95% CI) and late pandemic (1.12RR, 1.11-1.13 95% CI) periods compared with White women. During the early and late pandemic periods, disparities by rank persisted from prepandemic levels, with a decrease in likelihood of screenings across all sponsor ranks.

CONCLUSION

Our results indicate the influence of race and socioeconomics on mammography screening during COVID-19. Targeted outreach and further evaluation of factors underpinning lower utilization in these populations are necessary to improve access to preventative services across the population.

Sociodemographic Characteristics of Patients Undergoing Surgery for Metastatic Disease of the Spine

INTRODUCTION

Some patients, particularly those who are socioeconomically deprived, are diagnosed with primary and/or metastatic cancer only after presenting to the emergency department. Our objective was to determine sociodemographic characteristics of patients undergoing surgery for metastatic spine disease at our institution.

METHODS

This retrospective case series included patients 18 years and older who presented to the emergency department with metastatic spine disease requiring surgery. Demographics and survival data were collected. Sociodemographic characteristics were estimated using the Social Deprivation Index (SDI) and Area Deprivation Index (ADI) for the state of California. Univariate log-rank tests and Kaplan-Meier curves were used to assess differences in survival for predictors of interest.

RESULTS

Between 2015 and 2021, 64 patients underwent surgery for metastatic disease of the spine. The mean age was 61.0 ± 12.5 years, with 60.9% being male (n = 39). In this cohort, 89.1% of patients were non-Hispanic (n = 57), 71.9% were White (n = 46), and 62.5% were insured by Medicare/Medicaid (n = 40). The mean SDI and ADI were 61.5 ± 28.0 and 7.7 ± 2.2, respectively. 28.1% of patients (n = 18) were diagnosed with primary cancer for the first time while 39.1% of patients (n = 25) were diagnosed with metastatic cancer for the first time. During index hospitalization, 37.5% of patients (n = 24) received palliative care consult. The 3-month, 6-month, and all-time mortality rates were 26.7% (n = 17), 39.5% (n = 23), and 50% (n = 32), respectively, with 10.9% of patients (n = 7) dying during their admission. Payor plan was significant at 3 months ( P = 0.02), and palliative consultation was significant at 3 months ( P = 0.007) and 6 months ( P = 0.03). No notable association was observed with SDI and ADI in quantiles or as continuous variables.

DISCUSSION

In this study, 28.1% of patients were diagnosed with cancer for the first time. Three-month and 6-month mortality rates for patients undergoing surgery were 26.7% and 39.5%, respectively. Furthermore, mortality was markedly associated with palliative care consultation and insurance status, but not with SDI and ADI.

LEVEL OF EVIDENCE

Retrospective case series, Level III evidence.

An assessment of the association between patient race and prior authorization program determinations in the context of radiation therapy

BACKGROUND

When a physician determines that a patient needs radiation therapy (RT), they submit an RT order to a prior authorization program which assesses guideline-concordance. A rule-based clinical decision support system (CDSS) evaluates whether the order is appropriate or potentially non-indicated. If potentially non-indicated, a board-certified oncologist discusses the order with the ordering physician. After discussion, the order is authorized, modified, withdrawn, or recommended for denial. Although patient race is not captured during ordering, bias prior to and during ordering, or during the discussion, may influence outcomes. This study evaluated if associations existed between race and order determinations by the CDSS and by the overall prior authorization program.

METHODS

RT orders placed in 2019, pertaining to patients with Medicare Advantage health plans from one national organization, were analyzed. The association between race and prior authorization outcomes was examined for RT orders for all cancers, and then separately for breast, lung, and prostate cancers. Analyses controlled for the patient's age, urbanicity, and the median income in the patient's ZIP code. Adjusted analyses were conducted on unmatched and racially-matched samples.

RESULTS

Of the 10,145 patients included in the sample, 8,061 (79.5%) were White and 2,084 (20.5%) were Black. Race was not found to have a significant association with CDSS or prior authorization outcomes in any of the analyses.

CONCLUSIONS

CDSS and prior authorization outcomes suggested similar rates of clinical appropriateness of orders for patients, regardless of race.

IMPLICATIONS

Prior authorization utilizing rule-based CDSS was capable of enforcing guidelines without introducing racial bias.

Inequities in referrals to a breast cancer risk assessment and prevention clinic: a mixed methods study

BACKGROUND

Inequitable access to personalized breast cancer screening and prevention may compound racial and ethnic disparities in outcomes. The Breast Cancer Personalized Risk Assessment, Education and Prevention (B-PREP) program, located within the Brigham and Women's Hospital (BWH) Comprehensive Breast Health Center (BHC), provides care to patients at high risk for developing breast cancer. We sought to characterize the differences between BWH primary care patients referred specifically to B-PREP for risk evaluation and those referred to the BHC for benign breast conditions. Through interviews with primary care clinicians, we sought to explore contributors to potentially inequitable B-PREP referral patterns.

METHODS

We used electronic health record data and the B-PREP clinical database to identify patients referred by primary care clinicians to the BHC or B-PREP between 2017 and 2020. We examined associations with likelihood of referral to B-PREP for risk assessment. Semi-structured interviews were conducted with nine primary care clinicians from six clinics to explore referral patterns.

RESULTS

Of 1789 patients, 78.0% were referred for benign breast conditions, and 21.5% for risk assessment. In multivariable analyses, Black individuals were less likely to be referred for risk than for benign conditions (OR 0.38, 95% CI:0.23-0.63) as were those with Medicaid/Medicare (OR 0.72, 95% CI:0.53-0.98; OR 0.52, 95% CI:0.27-0.99) and those whose preferred language was not English (OR 0.26, 95% CI:0.12-0.57). Interviewed clinicians described inconsistent approaches to risk assessment and variable B-PREP awareness.

CONCLUSIONS

In this single-site evaluation, among individuals referred by primary care clinicians for specialized breast care, Black, publicly-insured patients, and those whose preferred language was not English were less likely to be referred for risk assessment. Larger studies are needed to confirm these findings. Interventions to standardize breast cancer risk assessment in primary care may improve equity.

Assessing patterns in cancer screening use by race and ethnicity during the coronavirus pandemic using electronic health record data

BACKGROUND

Efforts to prevent the spread of the coronavirus led to dramatic reductions in nonemergency medical care services during the first several months of the COVID-19 pandemic. Delayed or missed screenings can lead to more advanced stage cancer diagnoses with potentially worse health outcomes and exacerbate preexisting racial and ethnic disparities. The objective of this analysis was to examine how the pandemic affected rates of breast and colorectal cancer screenings by race and ethnicity.

METHODS

We analyzed panels of providers that placed orders in 2019-2020 for mammogram and colonoscopy cancer screenings using electronic health record (EHR) data. We used a difference-in-differences design to examine the extent to which changes in provider-level mammogram and colonoscopy orders declined over the first year of the pandemic and whether these changes differed across race and ethnicity groups.

RESULTS

We found considerable declines in both types of screenings from March through May 2020, relative to the same months in 2019, for all racial and ethnic groups. Some rebound in screenings occurred in June through December 2020, particularly among White and Black patients; however, use among other groups was still lower than expected.

CONCLUSIONS

This research suggests that many patients experienced missed or delayed screenings during the first few months of the pandemic, which could lead to detrimental health outcomes. Our findings also underscore the importance of having high-quality data on race and ethnicity to document and understand racial and ethnic disparities in access to care.

Associations between health insurance status, neighborhood deprivation, and treatment delays in women with breast cancer living in Georgia

BACKGROUND

Little is known regarding the association between insurance status and treatment delays in women with breast cancer and whether this association varies by neighborhood socioeconomic deprivation status.

METHODS

In this cohort study, we used medical record data of women diagnosed with breast cancer between 2004 and 2022 at two Georgia-based healthcare systems. Treatment delay was defined as >90 days to surgery or >120 days to systemic treatment. Insurance coverage was categorized as private, Medicaid, Medicare, other public, or uninsured. Area deprivation index (ADI) was used as a proxy for neighborhood-level socioeconomic status. Associations between delayed treatment and insurance status were analyzed using logistic regression, with an interaction term assessing effect modification by ADI.

RESULTS

Of the 14,195 women with breast cancer, 54% were non-Hispanic Black and 52% were privately insured. Compared with privately insured patients, those who were uninsured, Medicaid enrollees, and Medicare enrollees had 79%, 75%, and 27% higher odds of delayed treatment, respectively (odds ratio [OR]: 1.79, 95% confidence interval [CI]: 1.32-2.43; OR: 1.75, 95% CI: 1.43-2.13; OR: 1.27, 95% CI: 1.06-1.51). Among patients living in low-deprivation areas, those who were uninsured, Medicaid enrollees, and Medicare enrollees had 100%, 84%, and 26% higher odds of delayed treatment than privately insured patients (OR: 2.00, 95% CI: 1.44-2.78; OR: 1.84, 95% CI: 1.48-2.30; OR: 1.26, 95% CI: 1.05-1.53). No differences in the odds of delayed treatment by insurance status were observed in patients living in high-deprivation areas.

DISCUSSION/CONCLUSION

Insurance status was associated with treatment delays for women living in low-deprivation neighborhoods. However, for women living in neighborhoods with high deprivation, treatment delays were observed regardless of insurance status.

Authentication of a survival nomogram for non-invasive micropapillary breast cancer

Purpose

We aimed at establishing a nomogram to accurately predict the overall survival (OS) of non-metastatic invasive micropapillary breast carcinoma (IMPC).

Methods

In the training cohort, data from 429 patients with non-metastatic IMPC were obtained through the Surveillance, Epidemiology, and End Results (SEER) database. Other 102 patients were enrolled at the Xijing Hospital as validation cohort. Independent risk factors affecting OS were ascertained using univariate and multivariate Cox regression. A nomogram was established to predict OS at 3, 5 and 8 years. The concordance index (C-index), the area under a receiver operating characteristic (ROC) curve and calibration curves were utilized to assess calibration, discrimination and predictive accuracy. Finally, the nomogram was utilized to stratify the risk. The OS between groups was compared through Kaplan-Meier survival curves.

Results

The multivariate analyses revealed that race (p = 0.047), surgery (p = 0.003), positive lymph nodes (p = 0.027), T stage (p = 0.045) and estrogen receptors (p = 0.019) were independent prognostic risk factors. The C-index was 0.766 (95% CI, 0.682-0.850) in the training cohort and 0.694 (95% CI, 0.527-0.861) in the validation cohort. Furthermore, the predicted OS was consistent with actual observation. The AUCs for OS at 3, 5 and 8 years were 0.786 (95% CI: 0.656-0.916), 0.791 (95% CI: 0.669-0.912), and 0.774 (95% CI: 0.688-0.860) in the training cohort, respectively. The area under the curves (AUCs) for OS at 3, 5 and 8 years were 0.653 (95% CI: 0.498-0.808), 0.683 (95% CI: 0.546-0.820), and 0.716 (95% CI: 0.595-0.836) in the validation cohort, respectively. The Kaplan-Meier survival curves revealed a significant different OS between groups in both cohorts (p<0.001).

Conclusion

Our novel prognostic nomogram for non-metastatic IMPC patients achieved a good level of accuracy in both cohorts and could be used to optimize the treatment based on the individual risk factors.