Cancer Care in the Incarcerated Population: Barriers to Quality Care and Opportunities for Improvement

Does the cost of cancer care for people in prison differ from those in the general population? Analysis of matched English cancer registry and hospital records

Background

People in prison experience poorer mental and physical health compared to their peers in the general population. The causes are multi-dimensional ranging from lifestyle factors to poorer access to healthcare. Little is known about cancer in people in prison or how the cost of their care compares to the general population.

Methods

Data on people diagnosed with cancer while in English prisons were identified in National Cancer Registration dataset and linked to Hospital Episode Statistics (HES) for the years 2012-2017. General population matched patients were identified using a 1-5 ratio, based on age, gender, year of diagnosis, cancer type and disease stage. Outpatient and inpatient HES data up to six-months from diagnosis were costed using NHS Reference costs and inflated to 2017/2018 costs.

Findings

879 prison and 4326 general population cancer diagnoses were identified in HES. The adjusted six-month cost of cancer care was significantly lower for people in prison (-£1216.95% confidence interval (CI) -1638 to -795), driven by fewer outpatient attendances. However, people diagnosed in prison had higher emergency care costs (£497.95% CI 375-619). Security escorts further increased the total cost of care.

Interpretation

Following a cancer diagnosis, people in English prisons have significantly lower planned care costs, but higher emergency care costs and an overall higher cost due to security escorts. Further work is required to identify ways of improving cancer care for people in prisons to ensure it is equivalent to that received by the general population.

Funding

National Institute for Health and Social Care Research 16/52/53.

Systematic Review of Surgical Care in the Incarcerated Population: Identifying Knowledge Gaps for Future Research

Objective

This study, examining literature up to December 2023, aims to comprehensively assess surgical care for incarcerated individuals, identifying crucial knowledge gaps for informing future health services research and interventions.

Background

The US prison system detains around 2 million individuals, mainly young, indigent males from ethnic and racial minorities. The constitutional right to healthcare does not protect this population from unique health challenges and disparities. The scarcity of literature on surgical care necessitates a systematic review to stimulate research, improve care quality, and address health issues within this marginalized community.

Methods

A systematic review, pre-registered with the International Prospective Register of Systematic Reviews (CRD42023454782), involved searches in PubMed, Embase, and Web of Science. Original research on surgical care for incarcerated individuals was included, excluding case reports/series (<10 patients), abstracts, and studies involving prisoners of war, plastic surgeries for recidivism reduction, transplants using organs from incarcerated individuals, and nonconsensual surgical sterilization.

Results

Out of 8209 studies screened, 118 met inclusion criteria, with 17 studies from 16 distinct cohorts reporting on surgical care. Predominantly focusing on orthopedic surgeries, supplemented by studies in emergency general, burns, ophthalmology, and kidney transplantation, the review identified delayed hospital presentations, a high incidence of complex cases, and low postoperative follow-up rates. Notable complications, such as nonfusion and postarthroplasty infections, were more prevalent in incarcerated individuals compared with nonincarcerated individuals. Trauma-related mortality rates were similar, despite lower intraabdominal injuries following penetrating abdominal injuries in incarcerated patients.

Conclusion

While some evidence suggests inferior surgical care in incarcerated patients, the limited quality of available studies underscores the urgency of addressing knowledge gaps through future research. This is crucial for patients, clinicians, and policymakers aiming to enhance care quality for a population at risk of surgical complications during incarceration and postrelease.

Locked in and left out: the "prison penalty" for implementation of evidence-based interventions

BACKGROUND

While the broader medical community grapples with the widely accepted notion that it takes an average of 17 years for research evidence to be incorporated into clinical practice, the implementation of evidence-based interventions in carceral settings (i.e., jails and prisons) faces longer delays, exacerbating health disparities.

MAIN BODY

The "prison implementation penalty" describes the significant delay in and limited adoption of evidence-based healthcare practices in carceral settings. We explore the complex challenges of implementing evidence-based interventions in jails and prisons, environments where healthcare often plays a secondary role under security and discipline. We use specific frameworks to highlight the unique barriers within these settings and propose potential implementation strategies. These challenges have broad implications for health equity due to the disproportionate impact on the marginalized groups affected by mass incarceration. Implementation science has potential to mitigate these disparities.

CONCLUSION

Bridging the gap between healthcare evidence and practice in carceral settings offers a public health opportunity. Implementation science offers a unique role in improving healthcare standards and reducing health inequities in this environment.

National Survey of Oncologists' Knowledge, Attitudes, and Practice Behaviors: Caring for Cancer Patients Experiencing Incarceration

Cancer is the leading cause of illness-related death in state prisons in the United States. The experiences of physicians providing oncological care to individuals experiencing incarceration are underexplored. The study aims were to evaluate knowledge, attitudes, and practices of oncologists caring for cancer patients who are incarcerated. An online survey was distributed to a random sample of 150 oncologists from the American Society of Clinical Oncology and the American Society for Radiation Oncology from July 2020 to December 2021. Statistical analyses included two proportion Z-test, Fisher's exact test, Kruskal-Wallis test, and Cramer's V to estimate factors associated with attitudes and barriers to care. Of the 55 respondents (36.7% response rate), 21 were medical oncologists and 34 were radiation oncologists. Academic center oncologists were more likely to report caring for incarcerated patients than community or private practice oncologists (p = .04). Most (53%) incorrectly reported "heart disease" as the leading cause of death, as opposed to "cancer" (15% identified correctly). Oncologists practicing at both academic and community centers were more likely to report care coordination barriers than oncologists at academic or community centers (p < .01). We identified potential barriers in caring for incarcerated cancer patients. Future studies should explore ways to improve care coordination between oncology teams and prisons.

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.

Cancer equity for those impacted by mass incarceration

The cancer disparities between people with incarceration histories compared with those who do not have those histories are vast. Opportunities for bolstering cancer equity among those impacted by mass incarceration exist in criminal legal system policy; carceral, community, and public health linkages; better cancer prevention, screening, and treatment services in carceral settings; expansion of health insurance; education of professionals; and use of carceral sites for health promotion and transition to community care. Clinicians, researchers, persons with a history of incarceration, carceral administrators, policy makers, and community advocates could play a cancer equity role in each of these areas. Raising awareness and setting a cancer equity plan of action are critical to reducing cancer disparities among those affected by mass incarceration.

Caring for people in prison with palliative and end-of-life care needs

PURPOSE OF REVIEW

The prison population is growing and ageing, and many people will die from natural causes while incarcerated. This article provides a contemporary review of key issues related to palliative and end-of-life care in prisons.

RECENT FINDINGS

Few countries have integrated prison hospices. Palliative care needs may go unrecognised in prison. Older offenders may not trust the prison to care for them and may benefit from segregation. Cancer remains a major cause of death. Training staff remains a priority, and technology can help facilitate this. The coronavirus disease 2019 (COVID-19) had a significant impact on prisons, less is known about its impact on palliative care. Compassionate release is underutilised, and the issue of medically assisted dying adds complexity to decisions around end-of-life care. Peer carers can provide reliable symptom assessment. Family members are often absent when someone dies in prison.

SUMMARY

Palliative and end-of-life care in prisons requires a joined-up approach, and staff must understand the challenges of both this and custodial care in general. The relational network both inside and outside of the prison should be involved, and when possible and appropriate, we should consider alternatives to dying whilst incarcerated, such as compassionate release.

Fractured and delayed: A qualitative analysis of disruptions in care for gynecologic malignancies during incarceration

OBJECTIVE

Women are experiencing growing rates of incarceration at twice the pace of that for men. Additionally, one-third will be older than 55 years of age by the end of the decade. Women who are incarcerated experience a higher prevalence of gynecologic malignancies and present with higher stage disease, which may be contributing to the greater mortality from cancer than the age-adjusted US population. Limited access to guideline-recommended screening and prevention and resource limitations across correctional facilities may result in gynecologic cancer disparities. Reasons for delayed gynecologic cancer care in prisons remain underexplored. Therefore, we sought to identify contributors to delayed gynecologic cancer care among women experiencing incarceration.

METHODS

Women at a single tertiary center in the Southeastern U.S. who were incarcerated and were diagnosed with a gynecologic cancer during 2014-2021 were identified in the electronic medical record. Note text was extracted and contributors to delay were identified and categorized using the RADaR method. Descriptive statistics were used to assess quantitative data.

RESULTS

14 patients were identified with a total of 14,879 text excerpts. Data reduction was performed to identify excerpts that were relevant to the central research question resulting in 175 relevant note excerpts. Delays prior to the tertiary care visit included patient and institutional contributors. Delays during transition from the tertiary center to prison included discharge planning and loss to follow-up during/after incarceration. Transportation, authorization, and restraints were concrete contributors. Abstract contributors included communication, and the patient's emotional experience.

CONCLUSIONS

We identify myriad contributors to delayed or fractured gynecologic cancer care in women experiencing incarceration. The impact of these issues warrants further study and intervention to improve care.

Cancer incidence among incarcerated and formerly incarcerated individuals: A statewide retrospective cohort study

BACKGROUND

Cancer incidence among individuals with incarceration exposure has been rarely studied due to the absence of linked datasets. This study examined cancer incidence during incarceration and postincarceration compared to the general population using a statewide linked cohort.

METHODS

We constructed a retrospective cohort from a linkage of state tumor registry and correctional system data for Connecticut residents from 2005 to 2016, and identified cancers diagnosed during and within 12 months postincarceration. We estimated incidence rates (including for screen-detectable cancers) and calculated the standardized incidence ratios (SIR) for the incarcerated and recently released populations, relative to the general population. We also examined cancer incidence by race and ethnicity within each group.

RESULTS

Cancer incidence was lower in incarcerated individuals (SIR = 0.64, 95% CI 0.56-0.72), but higher in recently released individuals (SIR = 1.34, 95% CI 1.23-1.47) compared with the general population, and across all race and ethnic strata. Similarly, nonscreen-detectable cancer incidence was lower in incarcerated and higher in recently released populations compared to the general population. However, non-Hispanic Black individuals had elevated incidence of screen-detectable cancers compared with non-Hispanic White individuals across all three populations (incarcerated, SIR = 1.66, 95% CI 1.03-2.53; recently released, SIR = 1.83, 95% CI 1.32-2.47; and general population, SIR = 1.18, 95% CI 1.16-1.21).

CONCLUSION

Compared with the general population, incarcerated persons have a lower cancer incidence, whereas recently released persons have a higher cancer incidence. Irrespective of incarceration status, non-Hispanic Black individuals have a higher incidence of screen-detectable cancers compared with non-Hispanic White individuals. Supplemental studies examining cancer screening and diagnoses during incarceration are needed to discern the reasons for observed disparities in incidence.

A correlation study affecting survival in patients after radical colon cancer surgery: A retrospective study

The objective of this study was to explore the relevant factors affecting the 5-year survival rate of patients after radical colon cancer surgery, and to provide some basis for improving the quality of life and prognosis of colon cancer patients. The clinical data of 116 colon cancer patients who underwent treatment in our hospital from January 2017 to December 2017 were retrospectively selected. Using the date of performing surgical treatment as the starting point and the completion of 5 years after surgery or patient death as the end point, all patients were followed up by telephone to count the 5-year survival rate and analyze the influence of each factor with the prognosis of colon cancer patients. Of the 116 patients, 14 patients were lost to follow-up. Of the 102 patients with complete follow-up, 33 patients were died, with an overall 5-year survival rate of 67.6%. After univariate analysis, it was found that distant metastasis (χ2 = 10.493, P = .001), lymph node metastasis (χ2 = 25.145, P < .001), depth of muscle infiltration (χ2 = 14.929, P < .001), alcohol consumption (χ2 = 15.263, P < .001), and preoperative obstruction (χ2 = 9.555, P = .002) were significantly associated with the prognosis of colon cancer patients. Multivariate logistic analysis showed that distant metastasis (odds ratio [OR]: 1.932, 95% confidence intervals [CI]: 1.272-2.934, P = .002), lymph node metastasis (OR: 1.219, 95% CI: 1.091-1.362, P < .001), and obstruction (OR: 1.970, 95% CI: 1.300-2.990, P < .001) were significant independent risk factors affecting the prognosis in patients after radical colon cancer surgery. In summary, preoperative obstruction, lymph node metastasis, and distant metastasis are independent factors influencing 5-year survival rate after radical colon cancer surgery. Patients with risk factors should be followed up more closely and reasonable postoperative adjuvant chemotherapy regimens should be used to improve long-term survival.