Social determinants of colorectal cancer risk, stage, and survival: a systematic review

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.

Impact of patient, hospital, and operative characteristics relative to social determinants of health: Compliance with National Comprehensive Cancer Network guidelines for colon cancer

BACKGROUND

Despite an established association with improved patient outcomes, compliance with National Comprehensive Cancer Network (NCCN) guidelines remains suboptimal. We sought to assess the effect of patient characteristics (PCs), operative characteristics (OCs), hospital characteristics (HCs), and social determinants of health (SDoH) on noncompliance with NCCN guidelines for colon cancer.

METHODS

Patients treated for stage I to III colon cancer from 2004 to 2017 were identified from the National Cancer Database. Multilevel multivariate regression analysis was performed to identify factors associated with receipt of NCCN-compliant care and quantify the proportion of variance explained by PCs, OCs, HCs, and SDoH.

RESULTS

Among 468,097 patients with colon cancer treated across 1319 hospitals, 1 in 4 patients did not receive NCCN-compliant care (122,170 [26.1%]). On regression analysis, older age (odds ratio [OR], 0.96; 95% CI, 0.96-0.96), female sex (OR, 0.97; 95% CI, 0.96-0.99), Black race (OR, 0.96; 95% CI, 0.94-0.98), higher Charlson-Deyo score (OR, 0.84; 95% CI, 0.82-0.86), tumor stage ≥II (OR, 0.42; 95% CI, 0.40-0.44), and tumor grade ≥ 3 (OR, 0.33; 95% CI, 0.32-0.34) were associated with lower odds of receiving NCCN-compliant care (all P values <.05). Higher hospital volume (OR, 1.02; 95% CI, 1.02-1.03), minimally invasive or robotic surgical approach (OR, 1.26; 95% CI, 1.23-1.29), adequate (≥12) lymph node assessment (OR, 3.46; 95% CI, 3.38-3.53), private insurance status (OR, 1.33; 95% CI, 1.26-1.40), Medicare insurance status (OR, 1.42; 95% CI, 1.35-1.49), and higher educational status (OR, 1.06; 95% CI, 1.02-1.09) were associated with higher odds of receiving NCCN-compliant care (all P values <.05). Overall, PCs contributed 36.5%, HCs contributed 1.3%, and OCs contributed 12.9% to the variation in guideline-compliant care, while SDoH contributed only 3.6% of the variation in receipt of NCCN-compliant care.

CONCLUSION

The variation in NCCN-compliant care among patients with colon cancer was largely attributable to patient- and surgeon-level factors, whereas SDoH were associated with a smaller proportion of the variation.

Deprivation and Rurality Mediate Income Inequality's Association with Colorectal Cancer Outcomes

INTRODUCTION

Income inequality is associated with poor health outcomes, but its association with colorectal cancer is not well-studied. The authors aimed to determine the association between income inequality and colorectal cancer incidence/mortality in U.S. counties, and hypothesized that this association was mediated by deprivation.

METHODS

The authors performed a cross-sectional study of U.S. counties from 2015-2019 using statewide cancer registries and the Centers for Disease Control and Prevention WONDER database. Generalized linear negative binomial regression was performed in 2024 to estimate the association between Gini coefficient (income inequality) and colorectal cancer incidence/mortality using incidence rate ratios (IRRs) for the entire cohort and stratified by rurality.

RESULTS

A total of 697,981 colorectal cancer cases were diagnosed in the 5-year study period. On adjusted regression, for every 0.1 higher Gini coefficient, there was an 11% higher risk of both colorectal cancer incidence and mortality (IRR 1.11, 95%CI 1.03,1.19 and IRR 1.11, 95%CI 1.05, 1.18 respectively). The association between income inequality and incidence/mortality peaked in more rural counties, however there was not an overall dose-dependent relationship between rurality and these associations. Deprivation mediated the association between income inequality and colorectal cancer incidence (indirect effect B coefficient 0.088, p<0.001) and mortality (B coefficient 0.088, p<0.001). The magnitude and direction of the direct, indirect, and total effects differed in each rurality strata.

CONCLUSIONS

Much of income inequality's association with colorectal cancer outcomes operates through deprivation. Rural counties have a stronger association between higher income inequality and higher mortality, which works in tandem with deprivation.

Multilevel analysis of social determinants of advanced stage colorectal cancer diagnosis

The advanced stage at diagnosis of colorectal cancer (CRC) may be related to individual factors, socioeconomic conditions, and healthcare service availability. The objective of the study was to analyze the prevalence of advanced stage CRC at the time of diagnosis and its association with individual, contextual, socioeconomic, and healthcare service indicators. An observational, cross-sectional study was conducted, analyzing cases of malignant neoplasms of the colon and rectum in individuals of both sexes, aged between 18 and 99 years, diagnosed between 2010 and 2019 in Brazil (n = 69,047). Data were collected from the Hospital Cancer Registry (HCR), Atlas of Human Development in Brazil, and from the National Registry of Health Institutions (NRHI). A Multilevel Poisson Regression model with random intercept was used. The prevalence of advanced stage CRC at diagnosis was 65.6%. Advanced stage was associated with older age groups prevalence ratio (PR) 4.40 and younger age groups (PR 1.84), low Human Development Index (HDI) (PR 1.22), and low density of family health strategy teams (PR 1.10). The study highlights the unequal distribution of social determinants of health in the diagnosis CRC in Brazil, revealing the need to evaluate and redirect public policies aimed at improving early detection and prevention of CRC in the country.

Investigating the role of county-level colorectal cancer screening rates on stage at diagnosis of colorectal cancer in rural Georgia

BACKGROUND

To examine the impact of county-level colorectal cancer (CRC) screening rates on stage at diagnosis of CRC and identify factors associated with stage at diagnosis across different levels of screening rates in rural Georgia.

METHODS

We performed a retrospective analysis utilizing data from 2004 to 2010 Surveillance, Epidemiology, and End Results Program. The 2013 United States Department of Agriculture rural-urban continuum codes were used to identify rural Georgia counties. The 2004-2010 National Cancer Institute small area estimates for screening behaviors were applied to link county-level CRC screening rates. Descriptive statistics and multinominal logistic regressions were performed.

RESULTS

Among 4,839 CRC patients, most patients diagnosed with localized CRC lived in low screening areas; however, many diagnosed with regionalized and distant CRC lived in high screening areas (p-value = 0.009). In multivariable analysis, rural patients living in high screening areas were 1.2-fold more likely to be diagnosed at a regionalized and distant stage of CRC (both p-value < 0.05). When examining the factors associated with stage at presentation, Black patients who lived in low screening areas were 36% more likely to be diagnosed with distant diseases compared to White patients (95% CI, 1.08-1.71). Among those living in high screening areas, patients with right-sided CRC were 38% more likely to have regionalized disease (95% CI, 1.09-1.74).

CONCLUSION

Patients living in high screening areas were more likely to have a later stage of CRC in rural Georgia.

IMPACT

Allocating CRC screening/treatment resources and improving CRC risk awareness should be prioritized for rural patients in Georgia.

From Base Pairs to City Squares: Comprehensive Precision Oncology for the Future

SUMMARY

An increased understanding of the role of the social determinants of health in cancer prevention, cancer care, and outcomes can lead to their integration into genetics and genomics as well as informing interventions and clinical trials, creating a comprehensive precision oncology framework.

Social Vulnerability Index and Survivorship after Colorectal Cancer Resection

BACKGROUND

Race and socioeconomic status incompletely identify patients with colorectal cancer (CRC) at the highest risk for screening, treatment, and mortality disparities. Social vulnerability index (SVI) was designed to delineate neighborhoods requiring greater support after external health stressors, summarizing socioeconomic, household, and transportation barriers by census tract. SVI is implicated in lower cancer center use and increased complications after colectomy, but its influence on long-term prognosis is unknown. Herein, we characterized relationships between SVI and CRC survival.

STUDY DESIGN

Patients undergoing resection of stage I to IV CRC from January 2010 to May 2023 within an academic health system were identified. Clinicopathologic characteristics were abstracted using institutional National Cancer Database and NSQIP. Addresses from electronic health records were geocoded to SVI. Overall survival and cancer-specific survival were compared using Kaplan-Meier and Cox proportional hazards methods.

RESULTS

A total of 872 patients were identified, comprising 573 (66%) patients with colon tumor and 299 (34%) with rectal tumor. Patients in the top SVI quartile (32%) were more likely to be Black (41% vs 13%, p < 0.001), carry less private insurance (39% vs 48%, p = 0.02), and experience greater comorbidity (American Society of Anesthesiologists physical status III: 86% vs 71%, p < 0.001), without significant differences by acuity, stage, or CRC therapy. In multivariable analysis, high SVI remained associated with higher all-cause (hazard ratio 1.48, 95% CI 1.12 to 1.96, p < 0.01) and cancer-specific survival mortality (hazard ratio 1.71, 95% CI 1.10 to 2.67, p = 0.02).

CONCLUSIONS

High SVI was independently associated with poorer prognosis after CRC resection beyond the perioperative period. Acknowledging needs for multi-institutional evaluation and elaborating causal mechanisms, neighborhood-level vulnerability may inform targeted outreach in CRC care.

Social Determinants of Health and the Link to Colorectal Cancer Outcomes

OPINION  STATEMENT: Colorectal cancer (CRC) remains the second most deadly cancer in the United States, behind only lung cancer. Despite improvements in incidence due to screening and mortality in part due to better treatments, there are some groups that have not seen these promising changes. American Indian/Alaska Native and non-Hispanic Black individuals, certain geographic regions, and lower socioeconomic groups have all been shown to have worse CRC outcomes. A significant body of evidence has linked these disparities in outcomes to social determinants of health (SDH). SDH are defined by the WHO as "the non-medical factors that influence health outcomes." These factors include but are not limited to income, education, social support, neighborhood of residence, and access to healthcare. Individuals who are negatively impacted by SDH have been shown to have a higher incidence of CRC. These individuals are also less likely to receive adequate CRC screening, are less likely to receive appropriate treatment, and have increased CRC mortality. Interventions that target different SDH domains have been shown to lead to increased rates of CRC screening and receipt of appropriate treatment while simultaneously improving CRC mortality. The aim of this review is to highlight the connection between SDH and CRC outcomes while also exploring interventions that target SDH and thereby improve CRC outcomes.

Colorectal cancer survival disparities in the five regions of Georgia

BACKGROUND/OBJECTIVE

The objective of this study was to examine 5-year colorectal cancer survival rates. We also determined whether demographics, tumor characteristics, and treatment modality were associated with 5-year CRC survival in the Clayton, West Central, East Central, Southeast, and Northeast Georgia regions because the significant higher CRC mortality rates in these regions in comparison to the overall rates in the State of Georgia.

METHODS

We conducted a retrospective cohort analysis using data from the 1975-2016 Surveillance, Epidemiology, and End Results program aggregated CRC patients to these five regions. Five-year CRC survival was calculated and stratified by the five regions of Georgia, using the Kaplan-Meier method with log-rank test. Cox proportional hazard regression was used to examine the mentioned association in these five regions.

RESULTS

Among 11,023 CRC patients, 5-year CRC survival was lowest in Clayton (65.9%) compared to the West Central (69.0%), East Central (68.2%), Southeast (70.5%), and Northeast regions (69.5%) (p-value = 0.02). In multivariable analysis, greater risk of CRC death was found in the Clayton region compared to the West Central (HR, 1.12; 95%, 1.00-1.25) region when adjusting for demographics, tumor characteristics, and treatment modality. Among Clayton Georgians, age of 75+ years (HR, 2.13; 95%, 1.56-2.89), grade 3 & 4 tumors (HR, 2.22; 95%, 1.64-3.00), and distant stage (HR, 20.95; 95%, 15.99-27.45) were negatively associated with CRC survival.

CONCLUSION

We observed place-based differences in CRC survival with significantly lower survival rates in the Clayton region. Factors associated with higher risk of CRC death include older age at diagnosis, high-grade tumors, and distant stage CRC among Clayton Georgians. Our study provides important evidence to all relevant stakeholders in furthering the development of culturally tailored CRC screening interventions aimed at CRC early detection and improved outcomes.

Treatments and prognostic factors for bone and soft tissue sarcoma in non-urban areas in Japan

BACKGROUND

Although bone and soft tissue sarcoma is recognized as a rare cancer that originates throughout the body, few comprehensive reports regarding it have been published in Japan.

PATIENTS AND METHODS

Bone and soft tissue sarcomas were tabulated from the Cancer Registries at eight university hospitals in the Chugoku-Shikoku region. Prognostic factors in cases were extracted in a single facility and have been analyzed.

RESULTS

From 2016 to 2019, 3.4 patients with bone and soft tissue sarcomas per a general population of 100,000 were treated at eight university hospitals. The number of patients who underwent multidisciplinary treatment involving collaboration among multiple clinical departments has been increasing recently. In the analysis carried out at a single institute (Ehime University Hospital), a total of 127 patients (male/female: 54/73) with an average age of 67.0 y (median 69.5) were treated for four years, with a 5-year survival rate of 55.0%. In the analysis of prognostic factors by multivariate, disease stage and its relative treatment, renal function (creatinine), and a patient's ability of self-judgment, and a patient's mobility and physical capability were associated with patient prognosis regarding bone and soft tissue sarcomas. Interestingly, age did not affect the patient's prognosis (> 70 vs ≦ 70).

CONCLUSIONS

Physical and social factors may affect the prognosis of patients with bone and soft tissue sarcomas, especially those living in non-urban areas.

Social Determinants of Health Associated With the Need for Urgent Versus Elective Cholecystectomy at an Urban, Safety-Net Hospital

Background: Benign gallstone disease is the most frequent indication for cholecystectomy in the United States. Many patients present with complicated disease requiring urgent interventions, which increases morbidity and mortality. We investigated the association between individual and population-level social determinants of health (SDoH) with urgent versus elective cholecystectomy. Patients and Methods: All patients undergoing cholecystectomy (2014-2021) for benign gallstone disease were included. Demographic and clinical data were linked to population-level SDoH characteristics using census tracts. Data were analyzed using descriptive and inferential statistics. Results: A total of 3,197 patients met inclusion criteria; 1,913 (59.84%) underwent urgent cholecystectomy, 1,204 (37.66%) underwent emergent cholecystectomy, and 80 (2.5%) underwent interval cholecystectomy. On multinomial logistic regression, patients who were older (relative risk [RR], 1.010; p < 0.001), black (RR, 1.634; p = 0.008), and living in census tracts with a higher percent of poverty (RR, 0.017; p = 0.021) had a higher relative risk of presenting for urgent cholecystectomy. Patients who were female (RR, 0.462; p < 0.001), had a primary care provider (PCP; RR, 0.821; p = 0.018), and lived in census tracts with low supermarket access (RR, 0.764; p = 0.038) had a lower relative risk of presenting for urgent cholecystectomy. Only age (RR, 1.066; p < 0.001), female gender (RR, 0.227; p < 0.001), and having a PCP (RR, 1.984; p = 0.034) were associated with presentation for interval cholecystectomy. Conclusions: Patients who were older, black, and living in census tracts with high poverty levels had a higher relative risk of presenting for urgent cholecystectomy at our institution, whereas females and patients with PCPs were more likely to undergo elective cholecystectomy. Improved access to primary care and surgical clinics for all patients at safety-net hospitals may result in improved outcomes in the management of benign gallstone disease by increasing diagnosis and treatment in the elective setting.

Relative predictive value of sociodemographic factors for chronic diseases among All of Us participants: a descriptive analysis

BACKGROUND

Although sociodemographic characteristics are associated with health disparities, the relative predictive value of different social and demographic factors remains largely unknown. This study aimed to describe the sociodemographic characteristics of All of Us participants and evaluate the predictive value of each factor for chronic diseases associated with high morbidity and mortality.

METHODS

We performed a cross-sectional analysis using de-identified survey data from the All of Us Research Program, which has collected social, demographic, and health information from adults living in the United States since May 2018. Sociodemographic data included self-reported age, sex, gender, sexual orientation, race/ethnicity, income, education, health insurance, primary care provider (PCP) status, and health literacy scores. We analyzed the self-reported prevalence of hypertension, coronary artery disease, any cancer, skin cancer, lung disease, diabetes, obesity, and chronic kidney disease. Finally, we assessed the relative importance of each sociodemographic factor for predicting each chronic disease using the adequacy index for each predictor from logistic regression.

RESULTS

Among the 372,050 participants in this analysis, the median age was 53 years, 59.8% reported female sex, and the most common racial/ethnic categories were White (54.0%), Black (19.9%), and Hispanic/Latino (16.7%). Participants who identified as Asian, Middle Eastern/North African, and White were the most likely to report annual incomes greater than $200,000, advanced degrees, and employer or union insurance, while participants who identified as Black, Hispanic, and Native Hawaiian/Pacific Islander were the most likely to report annual incomes less than $10,000, less than a high school education, and Medicaid insurance. We found that age was most predictive of hypertension, coronary artery disease, any cancer, skin cancer, diabetes, obesity, and chronic kidney disease. Insurance type was most predictive of lung disease. Notably, no two health conditions had the same order of importance for sociodemographic factors.

CONCLUSIONS

Age was the best predictor for the assessed chronic diseases, but the relative predictive value of income, education, health insurance, PCP status, race/ethnicity, and sexual orientation was highly variable across health conditions. Identifying the sociodemographic groups with the largest disparities in a specific disease can guide future interventions to promote health equity.

Racial disparities in the relationship of regional socioeconomic status and colorectal cancer survival in the five regions of Georgia

INTRODUCTION

The study's purpose was to examine 5-year colorectal cancer (CRC) survival rates between White and Black patients. We also determined whether regional socioeconomic status (SES) is associated with CRC survival between White and Black patients in the Clayton, West Central, East Central, Southeast, and Northeast Georgia public health districts.

METHODS

We performed a retrospective cohort analysis using data from the 1975 to 2016 Surveillance, Epidemiology, and End Results program. The 2015 United States Department of Agriculture Economic Research Services county typology codes were used to identify region-level SES with persistent poverty, low employment, and low education. Kaplan-Meier method and Cox proportional hazard regression were performed.

RESULTS

Among 10,876 CRC patients (31.1% Black patients), 5-year CRC survival rates were lower among Black patients compared to White patients (65.4% vs. 69.9%; p < 0.001). In multivariable analysis, White patients living in regions with persistent poverty had a 1.1-fold increased risk of CRC death (HR, 1.12; 95% CI, 1.00-1.25) compared to those living in non-persistent poverty regions. Among Black patients, those living in regions with low education were at a 1.2-fold increased risk of CRC death (HR, 1.19; 95% CI, 1.01-1.40) compared to those living in non-low education regions.

DISCUSSION AND CONCLUSIONS

Black patients demonstrated lower CRC survival rates in Georgia compared to their White counterparts. White patients living in regions with persistent poverty, and Black patients living in regions with low education had an increased risk of CRC death. Our findings provide important evidence to all relevant stakeholders in allocating health resources aimed at CRC early detection and prevention and timely referral for CRC treatment by considering the patient's regional SES in Georgia.

Machine Learning as a Tool for Early Detection: A Focus on Late-Stage Colorectal Cancer across Socioeconomic Spectrums

PURPOSE

To assess the efficacy of various machine learning (ML) algorithms in predicting late-stage colorectal cancer (CRC) diagnoses against the backdrop of socio-economic and regional healthcare disparities.

METHODS

An innovative theoretical framework was developed to integrate individual- and census tract-level social determinants of health (SDOH) with sociodemographic factors. A comparative analysis of the ML models was conducted using key performance metrics such as AUC-ROC to evaluate their predictive accuracy. Spatio-temporal analysis was used to identify disparities in late-stage CRC diagnosis probabilities.

RESULTS

Gradient boosting emerged as the superior model, with the top predictors for late-stage CRC diagnosis being anatomic site, year of diagnosis, age, proximity to superfund sites, and primary payer. Spatio-temporal clusters highlighted geographic areas with a statistically significant high probability of late-stage diagnoses, emphasizing the need for targeted healthcare interventions.

CONCLUSIONS

This research underlines the potential of ML in enhancing the prognostic predictions in oncology, particularly in CRC. The gradient boosting model, with its robust performance, holds promise for deployment in healthcare systems to aid early detection and formulate localized cancer prevention strategies. The study's methodology demonstrates a significant step toward utilizing AI in public health to mitigate disparities and improve cancer care outcomes.

County-level colorectal cancer screening rates on colorectal cancer survival in the state of Georgia: Does county-level rurality matter?

PURPOSE

Investigating CRC screening rates and rurality at the county-level may explain disparities in CRC survival in Georgia. Although a few studies examined the relationship of CRC screening rates, rurality, and/or CRC outcomes, they either used an ecological study design or focused on the larger population.

METHODS

We conducted a retrospective analysis utilizing data from the 2004-2010 Surveillance, Epidemiology, and End Results Program. The 2013 United States Department of Agriculture rural-urban continuum codes and 2004-2010 National Cancer Institute small-area estimates for screening behaviors were used to identify county-level rurality and CRC screening rates. Kaplan-Meier method and Cox proportional hazard regression were performed.

RESULTS

Among 22,160 CRC patients, 5-year CRC survival rates were lower among CRC patients living in low screening areas in comparison with intermediate/high areas (69.1% vs. 71.6% /71.3%; p-value = 0.030). Patients living in rural high-screening areas also had lower survival rates compared to non-rural areas (68.2% vs. 71.8%; p-value = 0.009). Our multivariable analysis demonstrated that patients living in intermediate (HR, 0.91; 95% CI, 0.85-0.98) and high-screening (HR, 0.92; 95% CI, 0.85-0.99) areas were at 8%-9% reduced risk of CRC death. Further, non-rural CRC patients living in intermediate and high CRC screening areas were 9% (HR, 0.91; 95% CI, 0.83-0.99) and 10% (HR, 0.90; 95% CI, 0.82-0.99) less likely to die from CRC.

CONCLUSIONS

Lower 5-year survival rates were observed in low screening and rural high-screening areas. Living in intermediate/high CRC screening areas was negatively associated with the risk of CRC death. Particularly, non-rural patients living in intermediate/high-screening areas were 8%-9% less likely to die from CRC. Targeted CRC screening resources should be prioritized for low screening and rural communities.

Insurance Status is Associated With Recurrence in Cutaneous Head and Neck Squamous Cell Carcinoma

OBJECTIVE

To identify socioeconomic factors influencing the presentation and outcomes of cutaneous head and neck squamous cell carcinoma (cHNSCC).

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary academic medical center with comprehensive cancer center.

METHODS

Patients treated for cHNSCC at a single institution between 2008 and 2022 were included. Demographic, socioeconomic data and disease characteristics were obtained from medical record abstraction. Outcome measures included tumor stage, number of distinct primaries, recurrence, and disease-related death. χ2 and Mann-Whitney tests were implemented to evaluate clinicopathologic distributions across disease stages. Survival analyses were performed using Cox regression and Kaplan-Meier analysis.

RESULTS

A total of 346 patients met the inclusion criteria. The median age at presentation and length of follow-up was 70.8 and 3.1 years, respectively. The majority of the cohort was white, male, and English-speaking. 13.3% of patients were underinsured and 27.5% were immunosuppressed. Patients who presented with advanced disease were more likely to be underinsured (21.7% vs 9.6%, P = .006) and have a history of homelessness (8.5% vs 2.1%, P = .014). Immunosuppressed patients were more likely to be underinsured (P = .009). Insurance status (1.97 [1.06-3.66], P = .032) and immune status (2.35 [1.30-4.26], P = .005) were independently associated with worse recurrence-free survival.

CONCLUSION

Socioeconomic factors that influence access to care, such as insurance status, are associated with cHNSCC disease stage and disease recurrence. These factors may impose barriers that delay diagnosis and treatment. This may result in worse disease-related outcomes and greater treatment-associated morbidity for certain patients.

How is equity captured for colorectal, breast and cervical cancer incidence and screening in the Republic of Ireland: A review

Introduction

Organised screening reduces the incidence and late-stage diagnosis of cancer. However, participation in screening is not consistent across populations. Variations can be measured using demographic factors on place of residence, race/ethnicity, occupation, gender/sex, religion, education, socio-economic position (SEP), and social capital (PROGRESS-Plus stratifiers). The Republic of Ireland has screening programmes for colorectal, breast, and cervical cancer but assessment of screening participation and cancer incidence is inconsistent. The review aimed to evaluate the use of stratifiers in breast, cervical and colorectal cancer incidence and screening literature, and assess variations in incidence and screening participation across subgroups in Ireland.

Methods

PubMed was searched systematically and grey literature was identified via Google, Google Scholar, Lenus (Irish Health Research repository), and The Irish Longitudinal Study of Aging (TILDA) in June 2022. Studies were included if they captured stratifiers alongside incidence or screening participation data of the three cancers.

Results

Thirty-six studies and reports were included. Place of residence, SEP, sex, and age were most frequently captured. Incidence and screening participation varied by age, place of residence, SEP, and sex.

Discussion

PROGRESS-Plus is a useful equity lens to review health literature. Cancer incidence and screening participation studies lacked a comprehensive equity lens resulting in difficulties in identifying inequities and non-attenders. Place of residence, SEP and ethnicity should be prioritised in monitoring inequities. Integrating unique health identifiers should improve monitoring and enable evidence-based population-specific interventions to promote screening. Collaboration with community organisations would support engagement with vulnerable populations when data is limited.

Association of educational attainment with cancer mortality in a national cohort study of black and white adults: A mediation analysis

Background

Low educational attainment is associated with excess cancer mortality. However, the mechanisms driving this association remain unknown.

Methods

Using data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, we evaluated the associations of participant and parental/caregiver education with cancer mortality using Cox proportional hazards models, adjusting for socio-demographic characteristics and health conditions. We used principal components analysis to generate indices of measures representing the social determinants of health (SDOH) and health behaviors. We used structural equation modeling to determine if the association between educational attainment and cancer mortality was mediated by these domains.

Results

Among 30,177 REGARDS participants included in this analysis, 3798 (12.6%) had less than a high school degree. In fully adjusted models, those without a high school education experienced about 50% greater risk of death than high school graduates and higher (White participants HR: 1.47; 95% CI: 1.23, 1.76 and Black HR: 1.54; 95% CI: 1.33, 1.79). There was evidence of a modest mediation effect for the association between education and cancer mortality by the SDOH domain score (White total effect HR: 1.25; 95% CI: 1.18, 1.33, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.21; 95% CI: 1.14, 1.28 and Black total effect HR: 1.24; 95% CI: 1.18, 1.29, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.19; 95% CI: 1.14, 1.24). There was no evidence of mediation by the health behaviors score. No significant associations were found for female caregiver/mother's or male caregiver/father's education (N = 13,209).

Conclusions

In conclusion, participant education was strongly associated with cancer mortality, and this association was partially mediated by the SDOH domain score.

Associations between experience of stressful life events and cancer prevalence in China: results from the China Kadoorie Biobank study

BACKGROUND

Studies examining the relationships of stressful life events and cancer yielded inconsistent findings, while relevant evidence in mainland China is scarce. The current study sought to determine whether experience of stressful life events was associated with cancer prevalence in Chinese population.

METHODS

We used cross-sectional data from the China Kadoorie Biobank study which that recruited 0.5 million Chinese adults aged 30 to 79 from 2004 to 2008. Logistic regression models were used to estimate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for cancer associated with stressful life events reported at baseline.

RESULTS

Among the 461,696 participants included in this analysis, 2,122 (0.46%) had self-reported cancer with the mean (SD) age was 57.12 (9.71) years. Compared to those without any stressful life event, participants who experienced 1 and 2 or more events had significantly higher odds of cancer, with the ORs of 1.80 (95% CI: 1.58-2.05) and 3.05 (2.18-4.28). For categories of work-, family-, and personal-related events, the OR of cancer was 1.48 (1.07-2.05), 2.06 (1.80-2.35), and 1.65 (1.17-2.33), respectively. Regarding the specific stressful life events, loss of income/living on debt, major conflict within family, death/major illness of other close family member, and major injury/traffic accident were significantly associated with increased odds of cancer, with the ORs of 2.64 (1.81-3.86), 1.73 (1.20-2.50), 2.36 (2.05-2.72), and 2.11 (1.43-3.13).

CONCLUSION

Our findings suggested that experiences of cumulative and specific stressful life events were significantly associated with increased cancer prevalence in Chinese population.

Colorectal Cancer: Disease Process, Current Treatment Options, and Future Perspectives

Colorectal cancer (CRC) is one of the deadliest malignancies in the US, ranking fourth after lung, prostate, and breast cancers, respectively, in general populations. It continues to be a menace, and the incidence has been projected to more than double by 2035, especially in underdeveloped countries. This review seeks to provide some insights into the disease progression, currently available treatment options and their challenges, and future perspectives. Searches were conducted in the PubMed search engine in the university's online library. The keywords were "Colorectal Cancer" AND "disease process" OR "disease mechanisms" OR "Current Treatment" OR "Prospects". Selection criteria were original articles published primarily during the period of 2013 through 2023. Abstracts, books and documents, and reviews/systematic reviews were filtered out. Of over 490 thousand articles returned, only about 800 met preliminary selection criteria, 200 were reviewed in detail, but 191 met final selection criteria. Fifty-one other articles were used due to cross-referencing. Although recently considered a disease of lifestyle, CRC incidence appears to be rising in countries with low, low-medium, and medium social demographic indices. CRC can affect all parts of the colon and rectum but is more fatal with poor disease outcomes when it is right-sided. The disease progression usually takes between 7-10 years and can be asymptomatic, making early detection and diagnosis difficult. The CRC tumor microenvironment is made up of different types of cells interacting with each other to promote the growth and proliferation of the tumor cells. Significant advancement has been made in the treatment of colorectal cancer. Notable approaches include surgery, chemotherapy, radiation therapy, and cryotherapy. Chemotherapy, including 5-fluorouracil, irinotecan, oxaliplatin, and leucovorin, plays a significant role in the management of CRC that has been diagnosed at advanced stages. Two classes of monoclonal antibody therapies have been approved by the FDA for the treatment of colorectal cancer: the vascular endothelial growth factor (VEGF) inhibitor, e.g., bevacizumab (Avastin®), and the epidermal growth factor receptor (EGFR) inhibitor, e.g., cetuximab (Erbitux®) and panitumumab (Verbitix®). However, many significant problems are still being experienced with these treatments, mainly off-target effects, toxic side effects, and the associated therapeutic failures of small molecular drugs and the rapid loss of efficacy of mAb therapies. Other novel delivery strategies continue to be investigated, including ligand-based targeting of CRC cells.

"It's Probably Just Hemorrhoids": A Qualitative Exploration of the Lived Experiences and Perceptions of Long-term Survivors of Early-Onset Colorectal Cancer

BACKGROUND

Colorectal cancer among adults aged <50 years [early-onset colorectal cancer (EOCRC)] is projected to be the leading cause of cancer-related death by 2030. Although evidence-based guidelines for colorectal cancer screening now recommend beginning screening at age 45, the needs of many at-risk young adults are potentially being overlooked. Unanswered questions also remain regarding the effects of EOCRC on quality-of-life and psychosocial outcomes. This qualitative study explored the lived experiences and perceptions of a sample of adult EOCRC survivors in the United States through one-on-one interviews.

METHODS

An EOCRC advocate survivor team member led 27 structured virtual interviews using a 10-question interview guide. Data were analyzed using a 9-step inductive approach.

RESULTS

Participants were geographically diverse. Most were women (66.6%) who self-identified as non-Hispanic White (85.2%). The mean age at interview was 40.19 ± 5.99; at diagnosis, 33.93 ± 5.90. Six overarching themes emerged: signs and symptoms, risk factors, system-level factors, quality of life, social support, and reflection.

CONCLUSIONS

The specific needs of individuals in this younger population of patients with colorectal cancer should be considered during treatment and future interventions and throughout survivorship.

IMPACT

While the reasons for the increasing incidence of EOCRC are currently unknown, the lived experiences and perceptions of EOCRC survivors noted in this study highlight specific needs of this population that can inform educational materials, comprehensive care, future research, and policy change.

Associations of Albumin and BMI with Colorectal Cancer Risk in the Southern Community Cohort Study: a Prospective Cohort Study

BACKGROUND

Obesity may increase colorectal cancer (CRC) risk through mechanisms of increased inflammation. Although BMI is the most used adiposity indicator, it may less accurately measure adiposity in Black populations. Herein, we investigate associations between BMI, low albumin as an inflammation biomarker, and CRC risk in a racially diverse cohort.

METHODS

Participant data arise from 71,141 participants of the Southern Community Cohort Study, including 724 incident CRC cases. Within the cohort, 69% are Black. Blood serum albumin concentrations, from samples taken at enrollment, were available for 235 cases and 567 controls. Controls matched by age, sex, and race were selected through incidence density sampling. Cox proportional hazards calculated BMI and CRC risk associations (hazard ratios [HRs]; 95% confidence intervals [CIs]. Conditional logistic regression calculated albumin and CRC risk associations (odds ratios [ORs]; 95%CIs).

RESULTS

Underweight, but not overweight or obese, compared to normal BMI was associated with increased CRC risk (HR:1.75, 95%CI:1.00-3.09). Each standard deviation increase of albumin was associated with decreased CRC risk, particularly for those who self-identified as non-Hispanic Black (OR: 0.56, 95%CI:0.34-0.91), or female (OR:0.54, 95%CI:0.30-0.98), but there was no evidence for interaction by these variables (p-interactions > 0.05). Moreover, albumin concentration was lower in Black than White participants. Mediation analysis suggested that the relation between albumin and CRC was not mediated by BMI.

CONCLUSIONS

Null associations of overweight/obesity with CRC risk demonstrates limited utility of BMI, especially among Black populations. Low albumin may indicate CRC risk. In Black individuals, albumin may better predict adiposity related risks than BMI.

Impact of COVID-19 on older adults with cancer and their caregivers' cancer treatment experiences study: The ICE-OLD study

The COVID-19 pandemic and health services impacts related to physical distancing posed many challenges for older adults with cancer. The goal of this study was to examine the impact of the pandemic on cancer treatment plans and cancer treatment experiences of older adults (ie, aged 65 years and older) and their caregiver' experiences of caring for older adults during the pandemic to highlight gaps in care experienced. In this multi-centre qualitative study guided by an interpretive descriptive research approach we interviewed older adults diagnosed with cancer and caregivers caring for them. Participants were recruited via cancer treatment centres in the provinces of British Columbia and Ontario (Vancouver and Toronto), Canada, and through an online ad sent out through patient advocacy organization newsletters. Interviews were recorded and transcribed verbatim and data were analyzed using an interpretive thematic analysis approach. A total of 27 individuals (17 older adults, 52.9% female; 10 caregivers, 90% female) participated in interviews lasting on average 45 minutes. Older adults with cancer described many impacts and pressures created by the pandemic on their cancer experiences, though they generally felt that the pandemic did not impact treatment decisions made and access to care. We grouped our findings into two main themes with their accompanying sub-themes, related to: (1) alterations in the individual and dyadic cancer experience; and (2) navigating health and cancer systems during the pandemic. The additional stressors the pandemic placed on older adults during their treatment and decision-making process and their caregivers expose the need to create or avail additional supports for future disruptions in care.

Local Social Vulnerability as a Predictor for Cancer-Related Mortality Among US Counties

Substantial gaps in national healthcare spending and disparities in cancer mortality rates are noted across counties in the US. In this cross-sectional analysis, we investigated whether differences in local county-level social vulnerability impacts cancer-related mortality. We linked county-level age-adjusted mortality rates (AAMR) from the Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research database, to county-level Social Vulnerability Index (SVI) from the CDC Agency for Toxic Substances and Disease Registry. SVI is a metric comprising 15 social factors including socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. AAMRs were compared between least and most vulnerable counties using robust linear regression models. There were 4 107 273 deaths with an overall AAMR of 173 per 100 000 individuals. Highest AAMRs were noted in older adults, men, non-Hispanic Black individuals, and rural and Southern counties. Highest mortality risk increases between least and most vulnerable counties were noted in Southern and rural counties, individuals aged 45-65, and lung and colorectal cancers, suggesting that these groups may face highest risk for health inequity. These findings inform ongoing deliberations in public health policy at the state and federal level and encourage increased investment into socially disadvantaged counties.

Association of emotional support with quality of life, mental health, and survival in older adults with gastrointestinal malignancies-Results from the CARE registry

BACKGROUND

Emotional support (ES) is the most frequently reported support need among older adults with cancer. Yet, the association of ES with cancer outcomes is largely unknown. This study examined the association of ES with health-related quality of life (HRQoL), mental health, and survival among older adults with gastrointestinal (GI) malignancies.

METHODS

We included newly diagnosed older adults (≥60 years) with GI cancer undergoing self-reported geriatric assessment at their first clinic visit. ES was measured using an adaptation of the Medical Outcomes Study (dichotomized adequate ES vs. inadequate ES). Outcomes included physical and mental HRQoL, anxiety, depression, and survival. Multivariable linear regression evaluated the association between ES and HRQoL scores. Multivariable logistic regression evaluated the association of ES with anxiety and depression. All models were adjusted for age at geriatric assessments, race, sex, and cancer type/stage.

RESULTS

795 participants were included. Median patient age was 68 years (IQR: 64-74), 58% were male, and most cancers were either colorectal (37.9%) or pancreatic (30.8%). Most (77.6%) had adequate ES. Patients with inadequate ES were more likely to be Black (31.5 vs. 20.8%, p = 0.005), disabled (24.1 vs. 10.4%, p < 0.001), widowed/divorced (54.2 vs. 24.8%, p < 0.001) and had lower physical and mental HRQoL t-scores (Physical β: -3.35, 95% CI: -5.25, -1.46; Mental β: -2.46, 95% CI: -4.11, -0.81) and higher odds of depression (aOR: 2.22, CI: 1.34-3.69). This study found no difference between those with adequate ES versus inadequate ES in the proportion of deaths within 1 year of diagnosis (24.3% vs. 24.2%, p = 0.966), or within 2 years of diagnosis (32.4% vs. 33.2%, p = 0.126).

CONCLUSIONS

Older adults with inadequate ES have worse physical and mental HRQoL and higher odds of depression compared to those with adequate ES.

Impact of taxes and warning labels on red meat purchases among US consumers: A randomized controlled trial

BACKGROUND

Policies to reduce red meat intake are important for mitigating climate change and improving public health. We tested the impact of taxes and warning labels on red meat purchases in the United States. The main study question was, will taxes and warning labels reduce red meat purchases?

METHODS AND FINDINGS

We recruited 3,518 US adults to participate in a shopping task in a naturalistic online grocery store from October 18, 2021 to October 28, 2021. Participants were randomized to one of 4 conditions: control (no tax or warning labels, n = 887), warning labels (health and environmental warning labels appeared next to products containing red meat, n = 891), tax (products containing red meat were subject to a 30% price increase, n = 874), or combined warning labels + tax (n = 866). We used fractional probit and Poisson regression models to assess the co-primary outcomes, percent, and count of red meat purchases, and linear regression to assess the secondary outcomes of nutrients purchased. Most participants identified as women, consumed red meat 2 or more times per week, and reported doing all of their household's grocery shopping. The warning, tax, and combined conditions led to lower percent of red meat-containing items purchased, with 39% (95% confidence interval (CI) [38%, 40%]) of control participants' purchases containing red meat, compared to 36% (95% CI [35%, 37%], p = 0.001) of warning participants, 34% (95% CI [33%, 35%], p < 0.001) of tax participants, and 31% (95% CI [30%, 32%], p < 0.001) of combined participants. A similar pattern was observed for count of red meat items. Compared to the control, the combined condition reduced calories purchased (-312.0 kcals, 95% CI [-590.3 kcals, -33.6 kcals], p = 0.027), while the tax (-10.4 g, 95% CI [-18.2 g, -2.5 g], p = 0.01) and combined (-12.8 g, 95% CI [-20.7 g, -4.9 g], p = 0.001) conditions reduced saturated fat purchases; no condition affected sodium purchases. Warning labels decreased the perceived healthfulness and environmental sustainability of red meat, while taxes increased perceived cost. The main limitations were that the study differed in sociodemographic characteristics from the US population, and only about 30% to 40% of the US population shops for groceries online.

CONCLUSIONS

Warning labels and taxes reduced red meat purchases in a naturalistic online grocery store. Trial Registration: http://www.clinicaltrials.gov/ NCT04716010.

The prevalence of chronic and episodic loneliness and social isolation from a longitudinal survey

Loneliness and social isolation, experienced more long-term, has been shown to increase mortality and lead to poorer health outcomes in specific cohorts. However, it is unclear what the prevalence of chronic loneliness and social isolation is, and which demographic groups are most at risk of reporting more chronic forms. A psychometrically validated classification system was used to identify people who met criteria for episodic and chronic loneliness and social isolation using the Household Income and Labour Dynamics in Australia (HILDA) survey waves 14-18. The prevalence of loneliness (overall 34%; 21% episodic, 13% chronic) far exceeded that of social isolation (overall 17%; 13% episodic, 4% chronic). There was consistency in the demographic characteristics (from age, sex, household type, income) of those who experienced loneliness and social isolation. However, people with a long-term health condition had an elevated risk of episodic loneliness (AOR 1.24, 95% CI 1.11-1.39) and a markedly higher risk of chronic loneliness (AOR 2.01, 95% CI 1.76-2.29), compared with those without a long-term health condition. Loneliness, both episodic and chronic subtypes, is more prevalent than social isolation. However, both chronic loneliness and social isolation remains neglected and poorly targeted within current practice and policy.

A Survey of Cancer Risk Behaviors, Beliefs, and Social Drivers of Health in New Hampshire and Vermont

Compared with urban areas, rural areas have higher cancer mortality and have experienced substantially smaller declines in cancer incidence in recent years. In a New Hampshire (NH) and Vermont (VT) survey, we explored the roles of rurality and educational attainment on cancer risk behaviors, beliefs, and other social drivers of health. In February-March 2022, two survey panels in NH and VT were sent an online questionnaire. Responses were analyzed by rurality and educational attainment. Respondents (N = 1,717, 22%) mostly lived in rural areas (55%); 45% of rural and 25% of urban residents had high school education or less and this difference was statistically significant. After adjustment for rurality, lower educational attainment was associated with smoking, difficulty paying for basic necessities, greater financial difficulty during the COVID-19 pandemic, struggling to pay for gas (P < 0.01), fatalistic attitudes toward cancer prevention, and susceptibility to information overload about cancer prevention. Among the 33% of respondents who delayed getting medical care in the past year, this was more often due to lack of transportation in those with lower educational attainment (21% vs. 3%, P = 0.02 adjusted for rurality) and more often due to concerns about catching COVID-19 among urban than rural residents (52% vs. 21%; P < 0.001 adjusted for education). In conclusion, in NH/VT, smoking, financial hardship, and beliefs about cancer prevention are independently associated with lower educational attainment but not rural residence. These findings have implications for the design of interventions to address cancer risk in rural areas.

Significance

In NH and VT, the finding that some associations between cancer risk factors and rural residence are more closely tied to educational attainment than rurality suggest that the design of interventions to address cancer risk should take educational attainment into account.

Evaluating Work Impairment as a Source of Financial Toxicity in Cancer Healthcare and Negative Impacts on Health Status

How the socioeconomic factors intersect for a particular patient can determine their susceptibility to financial toxicity, what costs they will encounter during treatment, the type and quality of their care, and the potential work impairments they face. The primary goal of this study was to evaluate financial factors leading to worsening health outcomes by the cancer subtype. A logistic model predicting worsening health outcomes while assessing the most influential economic factors was constructed by the University of Michigan Health and Retirement Study. A forward stepwise regression procedure was implemented to identify the social risk factors that impact health status. Stepwise regression was done on data subsets based on the cancer types of lung, breast, prostate, and colon cancer to determine whether significant predictors of worsening health status were different or the same across cancer types. Independent covariate analysis was also conducted to cross-validate our model. On the basis of the model fit statistics, the two-factor model has the best fit, that is, the lowest AIC among potential models of 3270.56, percent concordance of 64.7, and a C-statistics of 0.65. The two-factor model used work impairment and out-of-pocket costs, significantly contributing to worsening health outcomes. Covariate analysis demonstrated that younger patients with cancer experienced more financial burdens leading to worsening health outcomes than elderly patients aged 65 years and above. Work impairment and high out-of-pocket costs were significantly associated with worsening health outcomes among cancer patients. Matching the participants who need the most financial help with appropriate resources is essential to mitigate the financial burden.

Significance

Among patients with cancer, work impairment and out-of-pocket are the two primary factors contributing to adverse health outcomes. Women, African American or other races, the Hispanic population, and younger individuals have encountered higher work impairment and out-of-pocket costs due to cancer than their counterparts.

Factors influencing organised faecal occult blood test screening participation in culturally and linguistically diverse populations: a scoping review

OBJECTIVE

This review aims to provide a comprehensive overview of the literature examining factors influencing participation in organised faecal occult blood test (FOBT) screening programmes in culturally and linguistically diverse populations. This article addresses gaps in the literature by providing a mixed methods review of the multilevel influences on FOBT screening in culturally and linguistically diverse (CALD) populations. This review was guided by the question "What are the factors influencing participation in organised FOBT screening programs in CALD populations?"

STUDY DESIGN

Scoping review.

METHODS

A scoping review methodology was used to summarise the available evidence. A thematic analysis of the included studies was undertaken to identify factors influencing organised FOBT screening participation in CALD populations from the literature.

RESULTS

FOBT screening participation was lower by ethnicity, religion, birthplace and language spoken. Barriers to screening included, faecal aversion, fatalism, fear of cancer, language and literacy barriers, difficulty accessing translated materials and low colorectal screening knowledge and awareness. CALD populations also had lower perceived benefits, susceptibility and cues to action, higher perceived barriers and greater perceived external health locus control than non-CALD populations. Facilitators of screening included positive attitudes to screening, general practitioner recommendations and social support. Group education sessions and narrative-based screening information were found to increase screening participation.

CONCLUSION

This review highlights the range of interrelated factors influencing participation in organised FOBT screening programmes in CALD populations and proposes multicomponent interventions to address low screening uptake. Features of successful community-level interventions should be explored further. Narratives show promise for engaging CALD populations. Accessibility of screening information should be addressed at the system level. Leveraging the general practitioner relationship in promoting FOBT screening programmes may also be an effective strategy to target 'hard-to-reach' populations.

Area-level Socioeconomic Disadvantage and Cancer Survival in Metropolitan Detroit

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPACT

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

Impact of facilitating continued accessibility to cancer care during COVID-19 lockdown on perceived wellbeing of cancer patients at a rural cancer center in Rwanda

During the COVID-19 pandemic in Rwanda, Partners In Health Inshuti Mu Buzima collaborated with the Butaro Cancer Center of Excellence (BCCOE) to mitigate disruptions to cancer care by providing patients with free transportation to treatment sites and medication delivery at patients' local health facilities. We assessed the relationship between facilitated access to care and self-reported wellbeing outcomes. This cross-sectional telephone survey included cancer patients enrolled at BCCOE in March 2020. We used linear regression to compare six dimensions of quality of life (EORTC QLQ-C30), depression (PHQ-9), anxiety (GAD-7), and financial toxicity (COST) among patients who did and did not receive facilitated access to care. We also assessed access to cancer care and whether patient wellbeing and its association with facilitated access to care differed by socioeconomic status. Of 214 respondents, 34.6% received facilitated access to care. Facilitated patients were more likely to have breast cancer and be on chemotherapy. Facilitation was significantly associated with more frequent in-person clinical encounters, improved perceived quality of cancer care, and reduced transportation-related barriers. Facilitated patients had significantly better global health status (β = 9.14, 95% CI: 2.3, 16.0, p <0.01) and less financial toxicity (β = 2.62, 95% CI: 0.2,5.0, p = 0.03). However, over half of patients reported missing or delaying appointment. Patient wellbeing was low overall and differed by patient socioeconomic status, with poor patients consistently showing worse outcomes. Socioeconomic status did not modify the association between facilitated access to care and wellbeing indicators. Further, facilitation did not lead to equitable wellbeing outcomes between richer and poorer patients. Facilitated access to care during COVID-19 pandemic was associated with some improvements in access to cancer care and patient wellbeing. However, cancer patients still experienced substantial disruptions to care and reported low overall levels of wellbeing, with socioeconomic disparities persisting despite facilitated access to care. Implementing more robust, equity-minded facilitation and better patient outreach programs during health emergencies may promote better care and strengthen patient care overall and effect better patients' outcomes.

Exposome approach for identifying modifiable factors for the prevention of colorectal cancer

Previous studies have shown certain exposure factors (such as lifestyle and metabolism) are associated with colorectal cancer (CRC) events. However, the application of the exposome theoretical frame and the extent to which the exposome domain can modulate the risk of CRC remain unknown. Our study aimed to construct valid exposome measurements and examine the relationship between exposome counts and the risk of CRC. This study included 335,370 individuals in the UK Biobank. We used exploratory factor analysis to identify a valid construct of exposome factors. We then summed the exposome counts within each domain. Cox proportional hazard models were used to estimate the hazard ratios and 95% confidence intervals of CRC risk related to the exposome factors and counts. During an 8.69 year median follow-up, 10,702 CRC cases were identified. Five domains were extracted from 12 variables, including ecosystem, lifestyle, tobacco and alcohol use, social economics, and social support. The Cox model results showed that the ecosystem was positively related to the reduced CRC risk (HR = 0.970; 95% CI 0.952-0.989). Similar results were also found among the domains of healthy lifestyles (HR = 0. 889; 95% CI 0.871-0.907), and no tobacco and alcohol use (HR = 0.892; 95% CI 0.876-0.909). The disadvantageous social economic (HR = 1.081; 95% CI 1.058-1.105) and insufficient social support domains (HR = 1.036; 95% CI 1.017-1.056) were associated with an increased risk of CRC. Similar risk trends were also observed across the exposome count groups with CRC incidence. Our findings suggest that certain exposure domains are related to the incidence of CRC. Ecosystem, lifestyle, and social factors can be incorporated into prediction models to identify individuals at high risk of CRC.

Racism, xenophobia, and discrimination: mapping pathways to health outcomes

Despite being globally pervasive, racism, xenophobia, and discrimination are not universally recognised determinants of health. We challenge widespread beliefs related to the inevitability of increased mortality and morbidity associated with particular ethnicities and minoritised groups. In refuting that racial categories have a genetic basis and acknowledging that socioeconomic factors offer incomplete explanations in understanding these health disparities, we examine the pathways by which discrimination based on caste, ethnicity, Indigeneity, migratory status, race, religion, and skin colour affect health. Discrimination based on these categories, although having many unique historical and cultural contexts, operates in the same way, with overlapping pathways and health effects. We synthesise how such discrimination affects health systems, spatial determination, and communities, and how these processes manifest at the individual level, across the life course, and intergenerationally. We explore how individuals respond to and internalise these complex mechanisms psychologically, behaviourally, and physiologically. The evidence shows that racism, xenophobia, and discrimination affect a range of health outcomes across all ages around the world, and remain embedded within the universal challenges we face, from COVID-19 to the climate emergency.

Exploring the Impact of Language Concordance on Cancer Communication

PURPOSE

Patients with cancer who have limited English proficiency are more likely to experience inequities in cancer knowledge, timely care, and access to clinical trials. Matching patients with language-concordant clinicians and working with professional interpreters can effectively reduce language-related disparities, but little data are available regarding the impact of language-concordant interactions in oncology care. This study aimed to assess the use of the Roter Interaction Analysis System (RIAS) in language-concordant and -discordant interactions for patients with non-English language preference presenting for an initial oncology visit at four New York City hospitals.

METHODS

We used the RIAS, a validated tool for qualitative coding and quantitative analysis, to evaluate interactions between 34 patients and 16 clinicians. The pairings were stratified into dyads: English language-concordant (n = 12); professionally interpreted (n = 11); partially language-concordant (n = 4, partially bilingual clinicians who communicated in Spanish and/or used ad hoc interpreters); and Spanish language-concordant (n = 7). A trained Spanish-speaking coder analyzed the recordings using established RIAS codes.

RESULTS

Spanish language-concordant clinicians had almost two-fold greater number of statements about biomedical information than English language-concordant clinicians. Spanish language-concordant patients had a higher tendency to engage in positive talk such as expressing agreement. The number of partnership/facilitation-related statements was equivalent for English and Spanish language-concordant groups but lower in professionally interpreted and partially language-concordant dyads.

CONCLUSION

Language concordance may facilitate more effective biomedical counseling and therapeutic relationships between oncology clinicians and patients. Future research should further explore the impact of language concordance on cancer-specific health outcomes.

Characteristics of Cancer Survivors Living in Poverty in the United States: Results From the 2020 Behavioral Risk Factor Surveillance System Survey

PURPOSE

There has been increasing concern over the high cost of oncology care and its long-lasting impact on the well-being of cancer survivors.

METHODS

We examined characteristics of impoverished cancer survivors in the United States, including their physical and mental health, using data from the 2020 Behavioral Risk Factor Surveillance System. We used binomial logistic regressions for binary outcome variables, and negative binomial regressions for count variables, to estimate the odds ratios (ORs) and incident rate ratios (IRRs) of the physical, mental, and socioeconomic-related health factors for low-income cancer survivors versus higher-income survivors. We compared the ORs and IRRs for low-income cancer survivors with those of higher income cancer survivors.

RESULTS

There was a two-fold increased odds (adjusted OR, 2.33; 95% CI, 1.86 to 2.91) of having fair/poor health for low-income cancer survivors compared with higher-income cancer survivors. There was an almost two-fold increased odds (adjusted OR, 1.97; 95% CI, 1.50 to 2.59) of not being able to see a doctor among low-income cancer survivors, and a 42% lower odds (adjusted OR, 0.58; 95% CI, 0.39 to 0.86) of having health insurance coverage for low-income cancer survivors compared with higher-income survivors. Incidence rate ratios for physical (IRR, 1.52; 95% CI, 1.31 to 1.75) and mental (IRR, 1.53; 95% CI, 1.26 to 1.86) unhealthy days were significantly higher among low-income cancer survivors compared with nonpoor cancer survivors.

CONCLUSION

Strategies are available to ameliorate financial hardship at multiple levels. Implementation of these strategies is urgently needed.

The association between sociodemographic factors and time to diagnosis for colorectal cancer in northern Sweden

OBJECTIVES

This study examined whether sociodemographic factors, including distance to hospital, were associated with differences in the diagnostic interval and the treatment interval for colorectal cancer in northern Sweden.

METHODS

Data were retrieved from the Swedish cancer register on patients (n = 446) diagnosed in three northern regions during 2017-2018, then linked to data from Statistics Sweden and medical records. Also, Google maps was used to map the distance between patients' place of residence and nearest hospital. The different time intervals were analysed using Mann-Whitney U-test and Cox regression.

RESULTS

Differences in time to diagnosis were found between groups for income and distance to hospital, favouring those with higher income and shorter distance. The unadjusted regression analysis showed higher income to be associated with more rapid diagnosis (HR 1.004, CI 1.001-1.007). This association remained in the fully adjusted model for income (HR 1.004, CI 1.000-1.008), but not for distance. No differences between sociodemographic groups were found in the treatment interval.

CONCLUSION

Higher income and shorter distance to hospital were in the unadjusted models associated with shorter time to diagnosis for patients with CRC in northern Sweden. The association remained for income when adjusting for other variables even though the difference was small.

Sleep pattern, healthy lifestyle and colorectal cancer incidence

Researchers have identified an association between lifestyle factors and colorectal cancer (CRC) risk. This study examined the relationship between sleep patterns and CRC events. 392,252 individuals were sampled from the UK Biobank. Chronotype, sleep duration, insomnia, snoring, and excessive daytime sleepiness were combined to measure a healthy sleep score. A number of healthy sleep factors were defined, along with factors for healthy lifestyle scores. Using Cox proportional hazards regression, computed hazard ratios (HRs) were used to examine the associations between sleep patterns, healthy lifestyles, and the incidence of CRC. Healthy sleep scores were inversely associated with CRC events. The HRs for CRC were 0.90 (95% CI, 0.88-0.92) and 0.95 (95% CI, 0.92-0.98) for a 1-point healthy sleep score increase among males and females. When analyzing sleep components, sleeping 7-8 h/day, no frequent insomnia, no snoring, and no frequent daytime sleepiness were independently associated with a 9%, 14%, 8%, and 14% lower risk of CRC, respectively, whilst healthy lifestyle scores were inversely associated with CRC incidence across all models. Sleep pattern and lifestyle are significantly correlated with CRC risk. The healthier the subject's lifestyle and sleep pattern, the lower their CRC risk.

Establishment of predictive nomogram and web-based survival risk calculator for malignant pleural mesothelioma: A SEER database analysis

Background

Malignant pleural mesothelioma (MPM) is an uncommon condition with limited available therapies and dismal prognoses. The purpose of this work was to create a multivariate clinical prognostic nomogram and a web-based survival risk calculator to forecast patients’ prognoses.

Methods

Using a randomization process, training and validation groups were created for a retrospective cohort study that examined the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015 for individuals diagnosed with MPM (7:3 ratio). Overall survival (OS) and cancer-specific survival (CSS) were the primary endpoints. Clinical traits linked to OS and CSS were identified using Least Absolute Shrinkage and Selection Operator (LASSO) Cox regression analysis, which was also utilized to develop nomogram survival models and online survival risk calculators. By charting the receiver operating characteristic (ROC), consistency index (C-index), calibration curve, and decision curve analysis (DCA), the model’s performance was assessed. The nomogram was used to classify patients into various risk categories, and the Kaplan-Meier method was used to examine each risk group’s survival rate.

Results

The prognostic model comprised a total of 1978 patients. For the total group, the median OS and CSS were 10 (9.4-10.5) and 11 (9.4-12.6) months, respectively. As independent factors for OS and CSS, age, gender, insurance, histology, T stage, M stage, surgery, and chemotherapy were chosen. The calibration graphs demonstrated good concordance. In the training and validation groups, the C-indices for OS and CSS were 0.729, 0.717, 0.711, and 0.721, respectively. Our nomogram produced a greater clinical net benefit than the AJCC 7th edition, according to DCA and ROC analysis. According to the cut-off values of 171 for OS and 189 for CSS of the total scores from our nomogram, patients were classified into two risk groups. The P-value &lt; 0.001 on the Kaplan-Meier plot revealed a significant difference in survival between the two patient groups.

Conclusions

Patient survival in MPM was correctly predicted by the risk evaluation model. This will support clinicians in the practice of individualized medicine.

Research on body image cognition, social support and illness perception in breast cancer patients with different surgical methods

In parallel with the rapid rise in breast cancer incidence, there is also a noticeable rise in the number of patients who experience persistent negative body image cognition after breast cancer surgery. This study aimed to explore the differences in illness perception, social support, and body image cognition among breast cancer patients with different surgical methods, and the correlation, regression, and mediation among the three variables. The Brief Illness Perception Questionnaire (BIPQ), the Social Support Rating Scale (SSRS) and the Body Image Cognition after Breast Cancer Questionnaire (BIBCQ) were used to evaluate breast cancer patients’ illness perception, social support and body image cognition. Data analyses were performed by descriptive statistics, independent samples t-test, analysis of variance (ANOVA), Pearson correlation, and linear regression. The mediation was explored by the PROCESS V3.3. The study found that breast cancer patients undergoing radical mastectomy (RM) and modified radical mastectomy (MRM) demonstrated more negative illness perception, body image cognition, and lower social support compared with the patients receiving nipple-sparing mastectomy (NSM; p < 0.05). The subscale cognitive representation (CR) of BIPQ was strongly positively correlated with BIBCQ (p < 0.05). Illness perception positively predicted body image cognition (p < 0.01), while social support negatively predicted body image cognition. Social support partially mediated illness perception and body image cognition, exhibiting a positive role in post-operative body image cognition.

Explaining regional variations in colon cancer survival in Ontario, Canada: a population-based retrospective cohort study

OBJECTIVES

Regional variation in cancer survival is an important health system performance measurement. We evaluated if regional variation in colon cancer survival may be driven by differences in the patient population, their health and healthcare utilisation, and/or cancer care delivery.

DESIGN

Population-based retrospective cohort study using routinely collected linked health administrative data.

SETTING

Ontario, Canada.

PARTICIPANTS

Patients with colon cancer diagnosed between 1 January 2009 and 31 December 2012.

OUTCOME

Cancer-specific survival was compared across the province's 14 health regions. Using accelerated failure time models, we assessed whether regional survival variations were mediated through differences in case mix, including age, sex, comorbidities, stage at diagnosis and colon subsite, potential marginalisation and/or prediagnosis healthcare.

RESULTS

The study population included 16 895 patients with colon cancer. There was statistically significant regional variation in cancer-specific survival. Three regions had cancer-specific survival that was between 30% (95% CI 1.03 to 1.65) and 39% (95% CI 1.13 to 1.71) longer and one region had cancer-specific survival that was 26% shorter (95% CI 0.58 to 0.93) than the reference region. For three of these regions, case mix explained between 26% and 56% of the survival variation. Further adjustment for rurality explained 22% of the remaining survival variation in one region. Adjustment for continuity of primary care and the diagnostic interval length explained 10% and 11% of the remaining survival variation in two other regions. Socioeconomic marginalisation, recent immigration and colonoscopy history did not explain colon cancer survival variation.

CONCLUSIONS

Case mix accounted for much of the regional variation in colon cancer survival, indicating that efforts to monitor the quality of cancer care through survival metrics should consider case mix when reporting regional survival differences. Future work should repeat this approach in other settings and other cancer sites considering a broad range of potential mediators.

Race, age, and sex differences on the influence of obesity on colorectal cancer sidedness and mortality: A national cross‐sectional study

BACKGROUND AND OBJECTIVES

Colorectal cancer (CRC) sidedness is recognized as a prognostic factor for survival; left-sided colorectal cancer is associated with better outcomes than right-sided colon cancer (RsCC). We aimed to evaluate the influence of obesity on CRC sidedness and determine how race, age, and sex affect mortality among overweight and obese individuals.

METHODS

A survey-weighted analysis was conducted using data obtained from the National Inpatient Sample between 2016 and 2019.

RESULTS

Of the 24 549 patients with a diagnosis of CRC and a reported body mass index (BMI), 13.6% were overweight and 49.9% were obese. The race distribution was predominantly non-Hispanic Whites (69.7%), followed by Black (15.6%), Hispanic (8.7%), and other race (6.1%). Overweight (BMI: 25-29.9) and obese (BMI: ≥30) individuals were more likely to have RsCC (adjusted OR [aOR] = 1.28; 95% CI: 1.17-1.39, p < 0.001 and aOR = 1.45; 95% CI: 1.37-1.54, p < 0.001, respectively). Obese Black individuals were more likely to have RsCC as compared to their White counterparts (aOR = 1.23; 95% CI: 1.09-1.38).

CONCLUSIONS

Obesity is associated with an increased risk of RsCC. In addition, racial disparities in CRC sidedness and outcomes are most pronounced among obese patients.

Role of Occupation in Shaping Cancer Disparities

Simple Summary

The investigation of cancer disparities is of major importance. In this paper, we address this issue through the occupational point of view, trying to capture how work and its related factors impact on cancer inequalities. The data we provide may increase awareness relevant to cancer control, and stimulate further studies aimed at the identification of the occupational determinants of cancer disparities and the quantification of their role.

Abstract

Cancer occurrence is characterized globally by profound socioeconomic differences. Occupation is a fundamental component of socioeconomic status. In this review, we discuss the role of occupation as a determinant of cancer disparities. First, we address the issue of participation in cancer screening programs based on income, health insurance, occupational status and job title. Second, we review the role of occupation in contributing to disparities by acting as a mediator between cancer and (i) education and (ii) race/ethnicity. Lastly, we analyze data from a multicenter case−control study of lung cancer to calculate the mediating role of occupational exposure to diesel exhaust, silica and welding fumes in the association between education and lung cancer. By addressing the complex paths from occupation to cancer inequalities from multiple points of view, we provide evidence that occupational-related characteristics, such as income, health insurance, unemployment and hazardous exposures impinge on cancer control and outcomes. The increasing awareness of these aspects is fundamental and should lead to public health interventions to avoid inequalities rising from occupational factors.

Understanding geographic and racial/ethnic disparities in mortality from four major cancers in the state of Georgia: a spatial epidemiologic analysis, 1999–2019

We examined geographic and racial variation in cancer mortality within the state of Georgia, and investigated the correlation between the observed spatial differences and county-level characteristics. We analyzed county-level cancer mortality data collected by the Centers for Disease Control and Prevention on breast, colorectal, lung, and prostate cancer mortality among adults (aged ≥ 18 years) in 159 Georgia counties from years 1999 through 2019. Geospatial methods were applied, and we identified hot spot counties based on cancer mortality rates overall and stratified by non-Hispanic white (NH-white) and NH-black race/ethnicity. Among all adults, 5.0% (8 of 159), 8.2% (13 of 159), 5.0% (8 of 159), and 6.9% (11 of 159) of Georgia counties were estimated hot spots for breast cancer, colorectal, lung, and prostate cancer mortality, respectively. Cancer mortality hot spots were heavily concentrated in three major areas: (1) eastern Piedmont to Coastal Plain regions, (2) southwestern rural Georgia area, or (3) northern-most rural Georgia. Overall, hot spot counties generally had higher proportion of NH-black adults, older adult population, greater poverty, and more rurality. In Georgia, targeted cancer prevention strategies and allocation of health resources are needed in counties with elevated cancer mortality rates, focusing on interventions suitable for NH-black race/ethnicity, low-income, and rural residents.

Socioeconomic Status and Distance to Reference Centers for Complex Cancer Diseases: A Source of Health Inequalities? A Population Cohort Study Based on Catalonia (Spain)

The centralization of complex surgical procedures for cancer in Catalonia may have led to geographical and socioeconomic inequities. In this population-based cohort study, we assessed the impacts of these two factors on 5-year survival and quality of care in patients undergoing surgery for rectal cancer (2011–12) and pancreatic cancer (2012–15) in public centers, adjusting for age, comorbidity, and tumor stage. We used data on the geographical distance between the patients’ homes and their reference centers, clinical patient and treatment data, income category, and data from the patients’ district hospitals. A composite ‘textbook outcome’ was created from five subindicators of hospitalization. We included 646 cases of pancreatic cancer (12 centers) and 1416 of rectal cancer (26 centers). Distance had no impact on survival for pancreatic cancer patients and was not related to worse survival in rectal cancer. Compared to patients with medium–high income, the risk of death was higher in low-income patients with pancreatic cancer (hazard ratio (HR) 1.46, 95% confidence interval (CI) 1.15–1.86) and very-low-income patients with rectal cancer (HR 5.14, 95% CI 3.51–7.52). Centralization was not associated with worse health outcomes in geographically dispersed patients, including for survival. However, income level remained a significant determinant of survival.

Disparities in Surgical Timing and Guideline-Adherent Staging Work-Up for Colon Cancer

BACKGROUND

Expedited or delayed surgery for colon cancer without appropriate work-up increases mortality risk. We sought to identify what patient, social, and hospital factors were associated with timely, guideline-adherent work-up for colon cancer.

METHODS

Retrospective analysis of 19,046 patients in the Surveillance, Epidemiology, and End Results (SEER) database linked with Medicare administrative claims who underwent elective surgery for colon cancer between 2010 and 2015 was performed. Primary outcome was receipt of complete preoperative work-up (colonoscopy, imaging, tumor marker evaluation) and timely surgery within 60 days of diagnosis. Patients were stratified into four groups: (1) adherent; (2) early surgery (< 30 days) with incomplete work-up; (3) surgery between 30 and 60 days with incomplete work-up; and (4) late surgery (> 60 days) with/without work-up. Characteristics were compared and multinomial logistic regression was performed.

RESULTS

Overall, 46.2% of patients received adherent care, 33.1% had early surgery and inadequate work-up, 10.3% had appropriately timed surgery but incomplete work-up, and 10.4% underwent late surgery. Multivariable analysis demonstrated that older, female, Black, and unmarried patients as well as patients living in areas with higher rates of poverty were more likely to receive non-adherent care. A greater proportion of patients at teaching hospitals received complete work-up (57.6% vs. 49.5%) but also underwent late surgery (12.4% vs. 8.6%) compared with non-teaching hospitals.

CONCLUSIONS

Patient, societal, and hospital factors impact whether patients receive guideline-adherent colon cancer care. Interventions are needed to improve access to timely and guideline-adherent cancer care as a possible mechanism to combat surgical disparities.

Social determinants of health and pediatric cancer survival: A systematic review

Despite treatment advancements and improved survival, approximately 1800 children in the United States will die of cancer annually. Survival may depend on nonclinical factors, such as economic stability, neighborhood and built environment, health and health care, social and community context, and education, otherwise known as social determinants of health (SDoH). Extant literature reviews have linked socioeconomic status (SES) and race to disparate outcomes; however, these are not inclusive of all SDoH. Thus, we conducted a systematic review on associations between SDoH and survival in pediatric cancer patients. Of the 854 identified studies, 25 were included in this review. In addition to SES, poverty and insurance coverage were associated with survival. More studies that include other SDoH, such as social and community factors, utilize prospective designs, and conduct analyses with more precise SDoH measures are needed.