Systematic review of neighborhood socioeconomic indices studied across the cancer control continuum

Global Burden, Trends, and Inequalities of Gallbladder and Biliary Tract Cancer, 1990-2021: A Decomposition and Age-Period-Cohort Analysis

BACKGROUND

Gallbladder and biliary tract cancer (GBTC) increasingly aggravates the global malignancy burden. This study aimed to evaluate the updated condition of GBTC temporal burden trends and inequalities from 1990 to 2021.

METHODS

Data on GBTC were extracted from the Global Burden of Disease (GBD) 2021 study. Incidence, deaths, and disability-adjusted life years (DALYs) and their age-standardised rates (ASR) were quantified from 1990 to 2021, stratified by sex, age and sociodemographic index (SDI). The age-period-cohort (APC) model was used to elucidate the effects of age, period, and cohort. Decomposition analysis and cross-country inequality evaluation were performed to assess the contributing factors and disease imbalance, respectively. Bayesian APC analysis was used to estimate the future burden.

RESULTS

In 2021, the global incident cases of GBTC were 216 768, with 171 961 deaths and 3 732 121 DALYs lost. From 1990 to 2021, the ASR of incidence, mortality, and DALYs decreased slightly. Males showed a slight increase in ASR of incidence, while females experienced a significant decrease. High-income regions, particularly in Asia Pacific and Latin America, exhibited a higher burden, while Western Sub-Saharan Africa had the lowest. Low and low-middle SDI regions showed a gradual rise in all metrics despite lower absolute numbers. The APC analysis indicated that the global incidence of GBTC tended to rise with age, but gender differences existed. Besides, a deteriorating cohort effect was detected amongst individuals born between 1907 and 1917. Decomposition analysis revealed that population growth was the primary driver of the increased GBTC burden globally. Significant disparities in GBTC burden by SDI were observed, with a notable decline in inequality over time. Projections indicated a slow decline in the global ASR through 2040, with a more pronounced decrease in females.

CONCLUSIONS

There are significant regional and gender differences in the global burden of GBTC. Population growth remains a major contributor to the burden. Despite the overall decline, the increasing incidence in low and lower-middle SDI regions and the persistent male burden highlight the need for targeted interventions. Future efforts should focus on addressing socio-economic inequalities and reducing risk factors, particularly in vulnerable populations.

Emotional ecosystems: Understanding the relationship between family interactions and anxiety among cancer caregivers

OBJECTIVES

Recent studies have challenged the assumption that families are invariable sources of support for cancer caregivers, noting that relationships with family members can have both positive and negative effects on caregiver well-being. This study expands upon prior literature to examine the relationship between cancer caregivers' perceptions of the quality of their family interactions and their symptoms of anxiety.

METHODS

We employed secondary analysis of baseline data from a multisite randomized clinical trial of an intervention for cancer caregivers conducted at 3 large academic palliative care clinics. We performed linear regression analyses to analyze the relationship between caregivers' perceptions of the quality of their family interactions and their symptoms of anxiety; additional models were estimated to further characterize this relationship with the addition of relevant covariates: race, ethnicity, sex, marital/relationship status, relationship to patient, employment status, household income, and perceived social support received from friends and significant others. We also conducted a sub-analysis of data provided by caregivers who were married or partnered to examine the relationship between their perceptions of the quality of their family interactions and their symptoms of anxiety with relationship satisfaction as a covariate.

RESULTS

Among our analytic sample (n = 244), we identified a significant negative relationship between cancer caregivers' perceptions of the quality of their family interactions and their symptoms of anxiety; this relationship remained statistically significant with the addition of covariates. Relationship satisfaction was not found to be a statistically significant covariate in our sub-analysis of married or partnered caregivers.

SIGNIFICANCE OF RESULTS

Study results provide strong support for the development, testing, and implementation of interventions to improve family interactions as a strategy to reduce caregiver anxiety.

Neighborhood Factors Related to Cancer Screening in Texas: A Spatioecological Study

INTRODUCTION

The purpose of this study is to examine the associations of neighborhood socioeconomic status, ethnic enclaves, and residential Black segregation with screening for breast, cervical, and colorectal cancers across the state of Texas.

METHODS

Using an ecologic study design, spatial clustering of low breast, cervical and colorectal cancer screening rates were identified across Texas census tracts using local Moran's I statistics. Binomial spatial probit regression was used to estimate the associations between nSES, Hispanic/Latino and Asian American ethnic enclave neighborhoods and residential Black segregation with geospatial clusters of low screening, adjusting for behavioral characteristics. Analysis was conducted in 2024.

RESULTS

Of 5,186 tracts, 5.4%, 4.6%, and 8.7% tracts were in low screening clusters for colorectal, cervical, and breast cancer, respectively. Medium and high neighborhood socioeconomic status tracts had reduced odds of being part of low cervical cancer screening clusters. Medium neighborhood socioeconomic status tracts and Hispanic enclave tracts had increased odds of being within a low breast cancer screening cluster. Asian American enclave tracts displayed an increased odds of being in low colorectal cancer and low cervical cancer screening clusters. Tracts with high residential Black segregation demonstrated reduced odds of being in low colorectal cancer and low breast cancer screening clusters.

CONCLUSIONS

Geospatial clusters of screening uptake are associated with neighborhood socioeconomic status and racial and ethnic neighborhood characteristics. This indicates a need for place-based culturally sensitive interventions to address the specific assets and needs of communities with low screening uptake.

Area-level socioeconomic inequalities in mortality in China: a nationwide cohort study based on the ChinaHEART project

BACKGROUND

Socioeconomic status is a key social determinant of health. Compared with individual-level socioeconomic status, the association between area-level socioeconomic status and mortality has not been well investigated in China. We aimed to assess associations between area-level socioeconomic status and all-cause mortality and cause-specific mortality in China, as well as the interplay of area-level and individual-level socioeconomic status on mortality.

METHODS

In this nationwide cohort study, residents aged 35-75 years from 453 districts and counties were included in the China Health Evaluation and Risk Reduction Through Nationwide Teamwork (ChinaHEART) Study. The composite value of area-level socioeconomic status was generated from national census data and categorised into tertiles. Mortality rates and their 95% CIs were calculated using the Clopper-Pearson method. Cox frailty models were fitted to calculate adjusted hazard ratios and 95% CIs for area-level socioeconomic status with the risk of all-cause mortality and cause-specific mortality and their disparities across different population. We also assessed the roles of multiple individual factors as potential mediators.

FINDINGS

Between December, 2015, and December, 2022, 1 119 027 participants were included, for whom the mean age was 56·1 (SD 9·9) years and 672 385 (60·1%) were female. 24 426 (5·24 [95% CI 5·18-5·31] per 1000 person-years) deaths occurred during the median 4·5-year follow-up. Compared with high area-level socioeconomic status, low area-level socioeconomic status was significantly associated with an increased risk of all-cause (hazard ratio 1·11, 95% CI 1·07-1·16), cardiovascular disease (1·38, 1·29-1·48), and respiratory disease (1·44, 1·22-1·71) mortality. The stronger associations were observed in people older than 60 years, females, and participants with lower individual-level socioeconomic status. The individual-level socioeconomic, behavioural, and metabolic factors mediated 39·5% of the association between area-level socioeconomic status and mortality, of which individual-level socioeconomic status made the largest contribution.

INTERPRETATION

There are substantial area-level socioeconomic status-related inequalities in mortality in China. Individual-level socioeconomic, behavioural, and metabolic factors had mediating effects. Actions to improve area-level circumstances and individual factors are needed to improve health equity.

FUNDING

The Chinese Academy of Medical Sciences Innovation Fund for Medical Science, the National High Level Hospital Clinical Research Funding, the Ministry of Finance of China, and the National Health Commission of China.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

The Context of Poverty and Cancer: Denying Human Potential

Poverty is a carcinogen and a leading cause of cancer disparities and overall mortality in the United States. Poverty is often viewed as an individual failure for "being poor," but in fact, poverty is structurally driven, intergenerational, and place-based that socially deprives and denies human potential. Disparities in timely cancer prevention, diagnosis, treatment, survivorship, and survival disproportionally impact people living in poverty and especially in persistent poverty areas, an extreme form of place-based poverty that affects communities over multiple generations. There has been some progress made to address place-based conditions that exacerbate poverty, such as the NCI's initiative on persistent poverty. However, gross inequality and cancer disparities continue to exist and persist. The time is now to accelerate the development of research-informed strategies and solutions with communities along with multisectoral collaborations with education, housing, occupation/workforce, foster care, criminal justice, transportation, and data collection systems. This commentary discusses the structural, place-based, and generational context of poverty, illustrates how entrenched inequities shape poor cancer outcomes, and describes opportunities for future research.

The role of multiple mediation with contextual neighborhood measures in ovarian cancer survival

BACKGROUND

Mediation by multiple agents can affect the relation between neighborhood deprivation and segregation indices and ovarian cancer survival. In this paper, we examine a variety of potential clinical mediators in the association between deprivation indices (DIs) and segregation indices (SIs) with all-cause survival among women with ovarian cancer in the African American Cancer Epidemiology Study (AACES).

METHODS

We use novel Bayesian multiple mediation structural models to assess the joint role of mediators (stage at diagnosis, histology, diagnostic delay) combined with the DIs and SIs (Yost, ADI, Kolak's URB, ICE-income) and a set of confounders with survival. The confounder set is selected in a preliminary step, and each DI or SI is included in separate model fits.

RESULTS

When multiple mediators are included, the total impact of DIs and SIs on survival is much reduced. Unlike the single mediator examples previously reported, the Yost, ADI and ICE-income indices do not display significant direct effects. This suggests that when important clinical mediators are included, the impact of neighborhood SES indices is significantly attenuated. It is also clear that certain behavioral and demographic measures such as physical activity, smoking, or adjusted family income do not have a significant role in survival when mediated by clinical factors.

CONCLUSION

Multiple mediation via clinical and diagnostic-related measures reduces the contextual effects of neighborhood measures on ovarian cancer survival. The robust association of the Kolak URB index on survival may be due to its relevance to access to care, unlike SES-based indices whose impact was significantly reduced when important clinical mediators were included.

Socioeconomic inequality in prostate cancer diagnostics, primary treatment, rehabilitation, and mortality in Sweden

We designed a nationwide study to investigate the association between socioeconomic factors (household income and education) and different aspects of prostate cancer care, considering both individual- and neighbourhood-level variables. Data were obtained from Prostate Cancer data Base Sweden (PCBaSe), a research database with data from several national health care registers including clinical characteristics and treatments for nearly all men diagnosed with prostate cancer in Sweden. Four outcomes were analysed: use of pre-biopsy magnetic resonance imaging (MRI) in 2018-2020 (n = 11,843), primary treatment of high-risk non-metastatic disease in 2016-2020 (n = 6633), rehabilitation (≥2 dispensed prescriptions for erectile dysfunction within 1 year from surgery in 2016-2020, n = 6505), and prostate cancer death in 7770 men with high-risk non-metastatic disease diagnosed in 2010-2016. Unadjusted and adjusted odds and hazard ratios (OR/HRs) with 95% confidence intervals (CIs) were calculated. Adjusted odds ratio (ORs) comparing low versus high individual education were 0.74 (95% CI 0.66-0.83) for pre-biopsy MRI, 0.66 (0.54-0.81) for primary treatment, and 0.82 (0.69-0.97) for rehabilitation. HR gradients for prostate cancer death were significant on unadjusted analysis only (low vs. high individual education HR 1.41, 95% CI 1.17-1.70); co-variate adjustments markedly attenuated the gradients (low vs. high individual education HR 1.10, 95% CI 0.90-1.35). Generally, neighbourhood-level analyses showed weaker gradients over the socioeconomic strata, except for pre-biopsy MRI. Socioeconomic factors influenced how men were diagnosed with prostate cancer in Sweden but had less influence on subsequent specialist care. Neighbourhood-level socioeconomic data are more useful for evaluating inequality in diagnostics than in later specialist care.

Area Socioeconomic Status is Associated with Refusal of Recommended Surgery in Patients with Metastatic Bone and Joint Disease

BACKGROUND

This study sought to identify associations between the Yost Index, a geocoded area neighborhood socioeconomic status (nSES) score, and race/ethnicity with patient refusal of recommended surgery for metastatic bone disease.

METHODS

Patients with metastatic bone disease were extracted from the Surveillance, Epidemiology, and End Results database. The Yost Index was geocoded using factor analysis and categorized into quintiles using census tract-level American Community Service (ACS) 5-year estimates and seven nSES measures. Multivariable logistic regression models calculated odds ratios (ORs) of refusal of recommended surgery and 95% confidence intervals (CIs), adjusting for clinical covariates.

RESULTS

A total of 138,257 patients were included, of which 14,943 (10.8%) were recommended for surgical resection. Patients in the lowest nSES quintile had 57% higher odds of refusing surgical treatment than those in the highest quintile (aOR = 1.57, 95% CI 1.30-1.91, p < 0.001). Patients in the lowest nSES quintile also had a 31.2% higher age-adjusted incidence rate of not being recommended for surgery compared with those in the highest quintile (186.4 vs. 142.1 per 1 million, p < 0.001). Black patients had 34% higher odds of refusing treatment compared with White patients (aOR = 1.34, 95% CI 1.14-1.58, p = 0.003). Advanced age, unmarried status, and patients with aggressive cancer subtypes were associated with higher odds of refusing surgery (p < 0.001).

CONCLUSIONS

nSES and race/ethnicity are independent predictors of a patient refusing surgery for metastatic cancer to bone, even after adjusting for various clinical covariates. Effective strategies for addressing these inequalities and improving the access and quality of care of patients with a lower nSES and minority backgrounds are needed.

Multilevel contributors to racial and ethnic inequities in the resolution of abnormal mammography results

PURPOSE

Multiple ecological levels influence racial inequities in the completion of diagnostic testing after receiving abnormal mammography results (diagnostic resolution). Yet, few studies examine more than two ecological levels. We investigated the contributions of county, imaging facility, and patient characteristics on our primary and secondary outcomes, the achievement of diagnostic resolution by (1)Black women and Latinas, and (2) the entire sample. We hypothesized that women of color would be less likely to achieve resolution than their White counterparts, and this relationship would be mediated by imaging facility features and moderated by county characteristics.

METHODS

Records for 25,144 women with abnormal mammograms between 2011 and 2019 from the Carolina Mammography Registry were merged with publicly available county data. Diagnostic resolution was operationalized as the percentage of women achieving resolution within 60 days of receiving abnormal results and overall time to resolution and examined using mixed effects logistic regression and Cox proportional hazard models, respectively.

RESULTS

Women of color with abnormal screening mammograms were less likely to achieve resolution within 60 days compared with White women (OR 0.83, CI 0.78-0.89; OR 0.74, CI.60-0.91, respectively) and displayed longer resolution times (HR 0.87, CI 0.84-0.91; HR 0.78, CI 0.68-0.89). Residential segregation had a moderating effect, with Black women in more segregated counties being less likely to achieve resolution by 60 days but lost statistical significance after adjustment. No mediators were discovered.

CONCLUSION

More work is needed to understand how imaging center and community characteristics impact racial inequities in resolution and resolution in general.

The association between neighborhood-level income and cancer stage at diagnosis and survival in Alberta

BACKGROUND

Socioeconomic status (SES) is associated with a range of health outcomes, including cancer diagnosis and survival. However, the evidence for this association is inconsistent between countries with and without single-payer health care systems. In this study, the relationships between neighborhood-level income, cancer stage at diagnosis, and cancer-specific mortality in Alberta, Canada, were evaluated.

METHODS

The Alberta Cancer Registry was used to identify all primary cancer diagnoses between 2010 and 2020. Average neighborhood income was determined by linking the Canadian census to postal codes and was categorized into quintiles on the basis of income distribution in Alberta. Multivariable multinomial logistic regression was used to model the association between income quintile and stage at diagnosis, and the Fine-Gray proportional subdistribution hazards model was used to estimate the association between SES and cancer-specific mortality.

RESULTS

Out of the 143,818 patients with cancer included in the study, those in lower income quintiles were significantly more likely to be diagnosed at stage III (odds ratio [OR], 1.07; 95% CI [confidence interval], 1.06-1.09) or IV (OR, 1.12; 95% CI, 1.11-1.14) after adjusting for age and sex. Lower income quintiles also had significantly worse cancer-specific survival for breast, colorectal, liver, lung, non-Hodgkin lymphoma, oral cavity, pancreas, and prostate cancers.

CONCLUSIONS

Disparities were observed in cancer outcomes across neighborhood-level income groups in Alberta, which demonstrates that health inequities by SES exist in countries with single-payer health care systems. Further research is needed to better understand the underlying causes and to develop strategies to mitigate these disparities.

Most deprived Louisiana census tracts have higher hepatocellular carcinoma incidence and worse survival

Background

Liver cancer incidence increased in the US from 1975 through 2015 with heterogeneous rates across subpopulations. Upstream or distal area-level factors impact liver cancer risks.

Objective

The aim of this study was to examine the association between area-level deprivation and hepatocellular carcinoma (HCC) incidence and survival. We also explored the association between area deprivation and treatment modalities.

Methods

Louisiana Tumor Registry identified 4,151 adult patients diagnosed with malignant HCC from 2011 to 2020 and linked residential address to census tract (CT)-level Area Deprivation Index (ADI) categorized into quartiles (Q1 = least deprived). ANOVA examined the association between ADI quartile and CT age-adjusted incidence rate (AAIR) per 100,000. Chi-square tested the distribution of demographic and clinical characteristics across ADI quartiles. Kaplan-Meier and proportional hazard models evaluated survival by deprivation quartile.

Results

Among the 1,084 CTs with incident HCC, the average (SD) AAIR was 8.02 (7.05) HCC cases per 100,000 population. ADI was observed to be associated with incidence, and the mean (SD) AAIR increased from 5.80 (4.75) in Q1 to 9.26 (7.88) in Q4. ADI was also associated with receipt of surgery (p < 0.01) and radiation (p < 0.01) but not chemotherapy (p = 0.15). However, among those who received chemotherapy, people living in the least deprived areas began treatment approximately 10 days sooner than those living in other quartiles. Q4 patients experienced the worst survival with a median of 247 (95% CI 211-290) days vs. Q1 patients with a median of 474 (95% CI 407-547) days (p < 0.0001). Q4 had marginally poorer survival (HR 1.20, 1.05-1.37) than Q1 but the association became non-significant (HR 1.12, 0.96-1.30) when adjusted for rurality, liquor store density, sex, race/ethnicity, age, insurance, BMI, stage, hepatitis diagnosis, and comorbidities.

Conclusion

Increasing neighborhood (CT) deprivation (ADI) was observed to be associated with increased HCC incidence and poorer HCC survival. However, the association with poorer survival becomes attenuated after adjusting for putative confounders.

Incidence of Stomach, Liver, and Colorectal Cancers by Geography and Social Vulnerability Among American Indian and Alaska Native Populations, 2010-2019

Social determinants of health and associated systems, policies, and practices are important drivers of health disparities. American Indian and Alaska Native (AI/AN) populations in the United States have elevated incidence rates of stomach, liver, and colorectal cancers compared with other racial/ethnic groups. In this study, we examined incidence rates of 3 types of gastrointestinal cancer among non-Hispanic AI/AN (NH-AI/AN) and non-Hispanic White (NHW) populations by geographic region and Social Vulnerability Index (SVI) score. Incident cases diagnosed during 2010-2019 were identified from population-based cancer registries linked with the Indian Health Service patient registration databases. Age-adjusted incidence rates (per 100,000 population) for stomach, liver, and colorectal cancers were compared within NH-AI/AN populations and between the NH-AI/AN and NHW populations by SVI score. Rates were higher among NH-AI/AN populations in moderate- and high-SVI-score counties in Alaska, the Southern Plains, and the East than in low-SVI counties. Incidence rates among NH-AI/AN populations were elevated when compared with NHW populations by SVI category. Results indicated that higher social vulnerability may drive elevated cancer incidence among NH-AI/AN populations. Additionally, disparities between NH-AI/AN and NHW populations persist even when accounting for SVI. Exploring social vulnerability can aid in designing more effective interventions to address root causes of cancer disparities among AI/AN populations.

Association of neighborhood gentrification with prostate cancer and immune markers in African American and European American men

BACKGROUND

Prior studies showed that neighborhood deprivation increases the risk of lethal prostate cancer. However, the role of neighborhood gentrification in prostate cancer development and outcome remains poorly understood. We examined the relationships of gentrification with prostate cancer and serum proteome-defined inflammation and immune function in a diverse cohort.

METHODS

The case-control study included 769 cases [405 African American (AA), 364 European American (EA) men] and 1023 controls (479 AA and 544 EA), with 219 all-cause and 59 prostate cancer-specific deaths among cases. Geocodes were linked to a neighborhood gentrification index (NGI) derived from US Census data. Cox and logistic regression, and MANOVA, were used to determine associations between NGI, as continuous or quintiles (Q), and outcomes.

RESULTS

Adjusting for individual socioeconomic status (SES), continuous NGI was positively associated with prostate cancer among all men (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.01-1.14). AA and low-income men experienced the highest odds of prostate cancer when residing in tracts with moderate gentrification, whereas EA men experienced reduced odds of regional/metastatic cancer with increased gentrification in SES-adjusted analyses. Continuous NGI also associated with mortality among men presenting with localized disease and low-income men in SES-adjusted Cox regression analyses. NGI was not associated with serum proteome-defined chemotaxis, inflammation, and tumor immunity suppression.

CONCLUSIONS

Findings show that neighborhood gentrification associates with prostate cancer and mortality in this diverse population albeit associations were heterogenous within subgroups. The observations suggest that changing neighborhood socioeconomic environments may affect prostate cancer risk and outcome, likely through multifactorial mechanisms.

The Impact of Neighborhood Deprivation on the Survival Rates of Patients with Cancer in Korea

The objective of this study is to investigate the correlation between the neighborhood deprivation index and survival rates of cancer patients in Korea. In this study, 5-year age-standardized survival rates of patients with cancer were determined using the National Cancer Cohort from 2014 to 2018 in Korea. The primary cancer sites were the stomach, colorectum, liver, lung, breast, cervix, prostate, and thyroid. Disparities were measured, and their impact on the overall survival rates was assessed using the Korean version of the Neighborhood Deprivation Index. Pearson's correlation coefficient was calculated to determine the strength of the correlation. The study cohort comprised 726,665 patients with cancer, of whom 50.7% were male. The predominant primary cancer sites were the stomach (n = 138,462), colorectum (n = 125,156), and thyroid gland (n = 120,886). Urban residents showed better survival outcomes than those situated in rural areas. The most deprived quartile had the lowest survival rate, while the least deprived quartile had the highest (p < 0.001). Most cancer types revealed significant correlations between neighborhood deprivation and 5-year age-standardized overall survival, with lung cancer showing the most substantial negative correlation (r = -0.510), followed by prostate cancer (r = -0.438). However, thyroid cancer showed only a marginal correlation (p = 0.069). The results of this study suggested that neighborhood deprivation is closely linked to disparities in overall survival across various types of cancer. A substantial negative correlation between the neighborhood deprivation index and all-cause mortality for lung and prostate cancer, as compared to breast and cervical cancers covered by the National Cancer Screening Program, may reinforce the need to address healthcare access and improve the early detection of cancer in socioeconomically deprived neighborhoods.

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.

The Association between Mediated Deprivation and Ovarian Cancer Survival among African American Women

BACKGROUND

Deprivation indices are often used to adjust for socio-economic disparities in health studies. Their role has been partially evaluated for certain population-level cancer outcomes, but examination of their role in ovarian cancer is limited. In this study, we evaluated a range of well-recognized deprivation indices in relation to cancer survival in a cohort of self-identified Black women diagnosed with ovarian cancer. This study aimed to determine if clinical or diagnostic characteristics lie on a mediating pathway between socioeconomic status (SES) and deprivation and ovarian cancer survival in a minority population that experiences worse survival from ovarian cancer.

METHODS

We used mediation analysis to look at the direct and indirect causal effects of deprivation indices with main mediators of the SEER stage at diagnosis and residual disease. The analysis employed Bayesian structural equation models with variable selection. We applied a joint Bayesian structural model for the mediator, including a Weibull mixed model for the vital outcome with deprivation as exposure. We selected modifiers via a Monte Carlo model selection procedure.

RESULTS

The results suggest that high SES-related indices, such as Yost, Kolak urbanicity (URB), mobility (MOB) and SES dimensions, and concentrated disadvantage index (CDI), all have a significant impact on improved survival. In contrast, area deprivation index (ADI)/Singh, and area level poverty (POV) did not have a major impact. In some cases, the indirect effects have very wide credible intervals, so the total effect is not well estimated despite the estimation of the direct effect.

CONCLUSIONS

First, it is clear that commonly used indices such as Yost, or CDI both significantly impact the survival experience of Black women diagnosed with epithelial ovarian cancer. In addition, the Kolak dimension indices (URB, MOB, mixed immigrant: MICA and SES) also demonstrate a significant association, depending on the mediator. Mediation effects differ according to the mediator chosen.

Incidence of Vulvar Lichen Sclerosus and of Cancer Among Vulvar Lichen Sclerosus Patients: Does Socioeconomic Status Have a Role?

OBJECTIVE

Socioeconomic status (SES) impacts on the incidence of many inflammatory diseases and cancers, but there is no evidence on its implication in vulvar lichen sclerosus (VLS). The authors aimed to assess possible associations between SES and both occurrence of VLS and cancer occurrence among VLS patients.

MATERIALS AND METHODS

A retrospective cohort of women resident in the province of Ferrara, Italy, affected with VLS diagnosed between 2001 and 2020, was investigated for assessing any association of SES with VLS and cancer incidence. The SES was expressed through an ecological-based deprivation index identifying 5 subgroups.

RESULT

Four-hundred women were diagnosed with VLS during the study period, with double the number of cases in the second decade (2011-2020) compared with the first (2001-2010). More VLS patients belonged to the high rather than the low SES groups (p = .032). From VLS diagnosis to 2018 (1,958.4 total person*years at risk), 22 patients received their first diagnosis of cancer, mainly the skin, breast, and vulva. No significant differences in cancer incidence were found between high/medium-high and low/medium-low SES subjects.

CONCLUSIONS

The fact that more VLS patients belonged to the highest socioeconomic classes may be due to a more frequent diagnosis in those with greater health seeking behavior and resources. An involvement of SES-related factors in VLS pathophysiological background can also be taken into consideration. Both the lack of marked social and economic differences in the study area and the availability of free visits and screening may account for the lack of association between SES and cancer development.

Deprivation and segregation in ovarian cancer survival among African American women: a mediation analysis

PURPOSE

Deprivation and segregation indices are often examined as possible explanations for observed health disparities in population-based studies. In this study, we assessed the role of recognized deprivation and segregation indices specifically as they affect survival in a cohort of self-identified Black women diagnosed with ovarian cancer who enrolled in the African American Cancer Epidemiology Study.

METHODS

Mediation analysis was used to examine the direct and indirect effects between deprivation or segregation and overall survival via a Bayesian structural equation model with Gibbs variable selection.

RESULTS

The results suggest that high socioeconomic status-related indices have an association with increased survival, ranging from 25% to 56%. In contrast, index of concentration at the extremes-race does not have a significant impact on overall survival. In many cases, the indirect effects have very wide credible intervals; consequently, the total effect is not well estimated despite the estimation of the direct effect.

CONCLUSIONS

Our results show that Black women living in higher socioeconomic status neighborhoods are associated with increased survival with ovarian cancer using area-level economic indices such as Yost or index of concentration at the extremes-income. In addition, the Kolak urbanization index has a similar impact and highlights the importance of area-level deprivation and segregation as potentially modifiable social factors in ovarian cancer survival.

Hyperlocal disparities in breast, cervical, and colorectal cancer screening: An ecological study of social vulnerability in Miami-Dade county

Neighborhoods have been identified as important determinants of health-related outcomes, but limited research has assessed the influence of neighborhood context along the cancer continuum. This study used census tract-level data from the United States Census Bureau and Centers for Disease Control and Prevention to characterize Miami-Dade County census tracts (n = 492) into social vulnerability clusters and assess their associated breast, cervical, and colorectal cancer screening participation rates. We identified disparities by social vulnerability cluster in cancer screening participation rates. Further investigation of geographic disparities in social vulnerability and cancer screening participation could inform equity-focused cancer control efforts.

Understanding Health Equity in Public Health Practice in the United States

CONTEXT

Understanding the extent to which equity-focused work is occurring in public health departments (eg, in chronic disease programs) can identify areas of success and what is needed to move the needle on health equity.

OBJECTIVE

The study objective was to characterize the patterns and correlates of equity-related practices in US state and territorial public health practice.

DESIGN

The design was a multimethod (quantitative and qualitative), cross-sectional study.

SETTING

The setting included US state and territorial public health departments.

PARTICIPANTS

Chronic disease prevention practitioners (N = 600) completed self-report surveys in July 2022 through August 2022 (analyzed in September 2022 through December 2022).

MAIN OUTCOME MEASURES

Health equity data were obtained across 4 domains: (1) staff skills, (2) work unit practices, (3) organizational priorities and values, and (4) partnerships and networks.

RESULTS

There was a wide range in self-reported performance across the health equity variables. The highest values (those agreeing and strongly agreeing) were related to staff skills (eg, the ability to describe the causes of inequities [82%]). Low agreement was reported for multiple items, indicating the lack of systems for tracking progress on health equity (32%), the lack of hiring of staff members who represent disadvantaged communities (33%), and limited use of principles for community engagement (eg, sharing decision-making authority with partners [34%]). Qualitative data provided tangible examples showing how practitioners and their agencies are turning an array of health equity concepts into actions.

CONCLUSIONS

There is urgency in addressing health equity and our data suggest considerable room for enhancing health equity practices in state and territorial public health. To support these activities, our findings provide some of the first information on areas of progress, gaps in practice, and where to target technical assistance, capacity building efforts, and accreditation planning.

The contribution of prognostic factors to socio-demographic inequalities in breast cancer survival in Victoria, Australia

BACKGROUND

Breast cancer survival in Australia varies according to socio-economic status (SES) and between rural and urban places of residence. Part of this disparity may be due to differences in prognostic factors at the time of diagnosis.

METHODS

Women with invasive breast cancer diagnosed from 2008 until 2012 (n = 14,165) were identified from the Victorian Cancer Registry and followed up for 5 years, with death from breast cancer or other causes recorded. A prognostic score, based on stage at diagnosis, cancer grade, whether the cancer was detected via screening, reported comorbidities and age at diagnosis, was constructed for use in a mediation analysis.

RESULTS

Five-year breast cancer mortality for women with breast cancer who were in the lowest quintile of SES (10.3%) was almost double that of those in the highest quintile (5.7%). There was a small survival advantage (1.7% on average, within each socio-economic quintile) of living in inner-regional areas compared with major cities. About half of the socio-economic disparity was mediated by prognostic factors, particularly stage at diagnosis and the presence of comorbidities. The inner-regional survival advantage was not due to differences in prognostic factors.

CONCLUSIONS

Part of the socio-economic disparity in breast cancer survival could be addressed by earlier detection in, and improved general health for, more disadvantaged women. Further research is required to identify additional causes of socio-economic disparities as well as the observed inner-regional survival advantage.

The effect of social determinants of health on utilization of surgical treatment for hepatocellular carcinoma patients

BACKGROUND

A paucity of data exists on how social determinants of health (SDOH) influence treatment for Hepatocellular carcinoma (HCC). We investigated associations between SDOH (healthcare access, education, social/community context, economic stability, and built/neighborhood environment) and receipt of surgery.

METHODS

The Pennsylvania Liver Cancer Registry was linked with neighborhood SDOH from the American Community Survey. Multilevel logistic regression models with patient and neighborhood SDOH variables were developed.

RESULTS

Of 9423 HCC patients, 2393 were stage I. Only 36.3% of stage I patients received surgery. Black patients had significantly lower odds of surgery vs Whites (OR = 0.73; p < 0.01), but not after adjustments for SDOH. All 5 SDOH domains were associated with odds of surgery overall; 2 domains were associated in Stage I patients, social context (e.g., racial concentration, p = 0.03) and insurance access (p < 0.01).

CONCLUSIONS

SDOH impact utilization of surgery for HCC. Findings can guide healthcare professionals to create programs for populations at risk for poor liver cancer outcomes.

Social determinants of health impact mortality from HCC and cholangiocarcinoma: a population-based cohort study

BACKGROUND AND AIMS

The social determinants of health can pose barriers to accessing cancer screening and treatment and have been associated with cancer mortality. However, it is not clear whether area deprivation is independently associated with mortality in HCC and cholangiocarcinoma when controlling for individual-level social determinants of health.

APPROACH AND RESULTS

The cohort included individuals over 18 years old diagnosed with HCC (N=3460) or cholangiocarcinoma (N=781) and reported to the Indiana State Cancer Registry from 2009 to 2017. Area disadvantage was measured using the social deprivation index (SDI). SDI was obtained by linking addresses to the American Community Survey. Individual social determinants of health included race, ethnicity, sex, marital status, and insurance type. The primary outcome was mortality while controlling for SDI and individual social determinants of health by means of Cox proportional hazard modeling. In HCC, living in a neighborhood in the fourth quartile of census-track SDI (most deprived) was associated with higher mortality (HR: 1.14, 95% CI, 1.003-1.30, p=0.04) than living in a first quartile SDI neighborhood. Being uninsured (HR: 1.64, 95% CI, 1.30-2.07, p<0.0001) and never being married (HR: 1.31, 95% CI, 1.15-1.48, p<0.0001) were also associated with mortality in HCC. In cholangiocarcinoma, SDI was not associated with mortality.

CONCLUSIONS

Social deprivation was independently associated with mortality in HCC but not cholangiocarcinoma. Further research is needed to better understand how to intervene on both area and individual social determinants of health and develop interventions to address these disparities.