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Dona AC, Jewett PI, Henning-Smith C, Ahmed RL, Wei ML, Lazovich D, Vogel RI. Rural-Urban Differences in Sun Exposure and Protection Behaviors in the United States. Cancer Epidemiol Biomarkers Prev 2024; 33:608-615. [PMID: 38227023 PMCID: PMC10990774 DOI: 10.1158/1055-9965.epi-23-1264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/13/2023] [Accepted: 01/11/2024] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Evidence regarding whether rural residence is a risk factor for skin cancer is mixed. We compared sun exposure and protection behaviors between rural and urban residents by ethno-racial group in the United States. METHODS We analyzed data from three (2013-2018) National Health and Nutrition Examination Survey cycles. We compared self-reported sun exposure and protection measures (sunburn, time spent outside, sunscreen use, wearing long sleeves, staying in shade) by rural-urban residential status using survey-weighted logistic regression models stratified by ethno-racial group, adjusting for age, sex, income, education, body mass index, and smoking. RESULTS Hispanic rural versus urban residents more often reported sunburns in the past year [41.6% vs. 31.2%, adjusted OR (aOR): 1.46 (1.15-1.86)]. White rural versus urban residents more often spent 2+ hours outside on workdays [42.9% vs. 29.1%, aOR: 1.60 (1.27-2.01)] and non-workdays [72.2% vs. 64.8%, aOR: 1.45 (1.12-1.88)] and less often used sunscreen [26.0% vs. 35.1%, aOR: 0.74 (0.59-0.93)] and stayed in the shade [21.7% vs. 26.7%, aOR: 0.72 (0.57-0.89)]. Black rural versus urban residents stayed in the shade less often [31.6% vs. 43.9%, aOR: 0.60 (0.39-0.91)] but less often spent 2+ hours outside on non-workdays [47.6% vs. 56.8%, aOR: 0.67 (0.51-0.90)]. CONCLUSIONS Across all ethno-racial groups included, rural residents reported greater sun risk behaviors than urban residents, with some nuances by ethno-racial identity, suggesting rural residence is a potential risk factor for skin cancer. IMPACT Sun protection promotion programs should consider rural-urban settings while also accounting for ethno-racial identities.
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Affiliation(s)
- Allison C. Dona
- Medical School, University of Minnesota, Minneapolis, MN, USA
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Patricia I. Jewett
- Department of Obstetrics, Gynecology and Women’s Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA
- Department of Medicine, Division of Hematology and Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Carrie Henning-Smith
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Rehana L. Ahmed
- Department of Dermatology, University of Minnesota, Minneapolis, MN, USA
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | - Maria L. Wei
- Department of Dermatology, University of California, San Francisco, San Francisco, CA, USA; Dermatology Service, San Francisco VA Health Care System, San Francisco, CA, USA
| | - DeAnn Lazovich
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
- Department of Dermatology, University of Minnesota, Minneapolis, MN, USA
| | - Rachel I. Vogel
- Department of Obstetrics, Gynecology and Women’s Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA
- Department of Dermatology, University of Minnesota, Minneapolis, MN, USA
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Dona AC, Jewett P, Henning-Smith C, Ahmed RL, Lazovich D, Vogel RI. Rural-urban differences in meeting of physical activity recommendations by sun exposure and protection behaviors in the United States. Prev Med 2024; 181:107919. [PMID: 38408648 PMCID: PMC10947812 DOI: 10.1016/j.ypmed.2024.107919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/11/2024] [Accepted: 02/23/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE To examine associations between sun protection behaviors and physical activity (PA) by rural and urban residence in the United States. METHODS We analyzed data from the National Health and Nutrition Examination Survey (2013-2018), restricting to participants ages 20-59 with sun behavior data. Sunburns, sun exposure, and sun protection measures were dichotomized (yes/no): ≥1 sunburn in the past year, 2+ hour outside during workdays or non-workdays, and never/rarely/sometimes using sunscreen, wearing long sleeves, and staying in the shade. Meeting PA recommendations (yes/no) was defined as ≥150 min of vigorous/moderate or ≥ 75 min vigorous PA per week. Associations between sun behaviors and PA were analyzed using logistic regression models, which accounted for survey-weights and potential confounders, and stratified by rural-urban status. RESULTS Rural and urban individuals meeting PA recommendations had greater odds of spending 2+ hour outside during workdays (OR: 2.26 [1.88, 2.74] and 3.95 [2.72, 5.73]) and non-workdays (OR: 2.06 [1.78, 2.38] and 3.33 [2.47, 4.46]). Among urban residents, odds of staying in the shade were lower among those who met PA recommendations (OR: 0.78 [0.66, 0.92]). We did not observe differences in sunburns or other sun behaviors by PA status, regardless of rurality. CONCLUSIONS Meeting PA recommendations was associated with greater sun exposure in both rural and urban populations. Additional exercise location (indoors/outside) data is needed to inform PA and skin cancer prevention interventions to reduce unintended increases in sun exposure and reductions in PA, respectively, especially among rural populations.
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Affiliation(s)
- Allison C Dona
- Medical School, University of Minnesota, Minneapolis, MN, USA; Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Patricia Jewett
- Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA; Department of Medicine, Division of Hematology and Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Carrie Henning-Smith
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - Rehana L Ahmed
- Department of Dermatology, University of Minnesota, Minneapolis, MN, USA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | - DeAnn Lazovich
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | - Rachel I Vogel
- Department of Obstetrics, Gynecology and Women's Health, Division of Gynecologic Oncology, University of Minnesota, Minneapolis, MN, USA; Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA.
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Domínguez Bueso DL, González Ruiz LM, Mondragón Márquez LI, Liu JJ. Skin cancer survivorship and sun protection behaviors in the United States. PHOTODERMATOLOGY, PHOTOIMMUNOLOGY & PHOTOMEDICINE 2024; 40:e12933. [PMID: 38288776 DOI: 10.1111/phpp.12933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/08/2023] [Accepted: 11/12/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Skin cancer survivors are more vulnerable to subsequent skin cancers and other malignancies, but previous studies have not examined in detail their sun protection behavior prevalence by sociodemographic factors. We aimed to understand the sociodemographic disparities in the prevalence of three important types of sun protection behaviors: using sunscreen, seeking shade, and wearing protective clothing, among skin cancer survivors and those without skin cancer history. METHODS We used the 2015 U.S. National Health Interview Survey to analyze 29,523 participants, of which 772 were skin cancer survivors and 28,751 were those without skin cancer history. We assessed overall and specific sun protection behavior prevalence based on using sunscreen, seeking shade, and wearing protective clothing. Weighted Poisson regression was used to estimate prevalence ratios. RESULTS Melanoma and nonmelanoma skin cancer survivors had similar overall sun protection behavior (p > .05). Among all skin cancer survivors, 36.0% infrequently used sunscreen, 50.2% infrequently wore protective clothing, 47.8% infrequently sought shade, and 30.0% lacked frequent overall sun protection, which significantly differed from those without skin cancer history (p < .0001). The prevalence of frequent overall sun protection behavior was lower for those who were younger at survey, males, less educated, single or never married, or lived in poverty, regardless of their skin cancer history (p < .01). CONCLUSIONS By identifying subpopulations with higher prevalence of infrequent sun protection among those with or without skin cancer history, our findings may encourage efforts to reduce sociodemographic disparities in sun protection behaviors and promote primary and tertiary skin cancer prevention.
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Affiliation(s)
| | - Liza M González Ruiz
- International Health Program, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Jason J Liu
- International Health Program, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Yu SY, Hirsch A, Zaslavsky O, Cochrane BB. Risk factors and early prevention of skin cancer in rural older outdoor workers: A scoping review. Geriatr Nurs 2023; 54:37-45. [PMID: 37703688 DOI: 10.1016/j.gerinurse.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/15/2023]
Abstract
Skin cancer risk increases with age and prolonged exposure to ultraviolet radiation (UVR), particularly in rural geographical locations and for individuals with light skin complexions. However, the impact of UVR-induced skin cancer risk and sun-protective behaviors in rural older populations working outdoors has yet to be explored. A scoping review was conducted to fill this gap, with 12 articles meeting the inclusion criteria of aged 50 years and older among rural outdoor workers. Skin cancer risk factors, prevention strategies, and barriers to sun-protective behaviors were summarized for each study. The scoping review addressed some key differences in age-related effects of UVR among rural older outdoor workers compared to studies among adults in general. Findings have policy and research implications that highlight the need to design feasible preventive strategies to reduce rural disparities in cancer care and enhance access to preventive services for this high-risk population.
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Affiliation(s)
- Shih-Yin Yu
- School of Nursing, University of Washington, Seattle, WA.
| | - Anne Hirsch
- School of Nursing, University of Washington, Seattle, WA; Department of Child, Family and Population Health Nursing, University of Washington, Seattle, WA
| | - Oleg Zaslavsky
- School of Nursing, University of Washington, Seattle, WA; Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA
| | - Barbara B Cochrane
- School of Nursing, University of Washington, Seattle, WA; Department of Child, Family and Population Health Nursing, University of Washington, Seattle, WA
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Stump TK, Fastner S, Jo Y, Chipman J, Haaland B, Nagelhout ES, Wankier AP, Lensink R, Zhu A, Parsons B, Grossman D, Wu YP. Objectively-Assessed Ultraviolet Radiation Exposure and Sunburn Occurrence. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5234. [PMID: 37047850 PMCID: PMC10094127 DOI: 10.3390/ijerph20075234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/09/2023] [Accepted: 03/15/2023] [Indexed: 06/19/2023]
Abstract
Ultraviolet radiation (UVR) exposure is the primary modifiable risk factor for melanoma. Wearable UVR sensors provide a means of quantifying UVR exposure objectively and with a lower burden than self-report measures used in most research. The purpose of this study was to evaluate the relationship between detected UVR exposure and reported sunburn occurrence. In this study, a UVR monitoring device was worn by 97 parent-child dyads during waking hours for 14 days to measure instantaneous and accumulated UVR exposure. The results showed that the participants' total UVR exposure was associated with reported sunburn after adjusting for Fitzpatrick skin type and geographic location. It was observed that one standard erythemal dose (SED) increase in the participants' daily total UVR exposure was associated with reported sunburn (an odds ratio (OR) of 1.26 with a 95% CI of 1.13 and 1.41, and p < 0.001 for parents and an OR of 1.28 with a 95% CI of 1.12 and 1.47, and p < 0.001 for children). A one-SED increase in the participants' UVR exposure from 10 am to 4 pm was also associated with reported sunburn (an OR of 1.31 with a 95% CI of 1.15 and 1.49, and p < 0.001 for parents and an OR of 1.33 with a 95% CI of 1.12 and 1.59, and p = 0.001 for children). We found that elevated UVR exposure recordings measured by the UVR sensor were associated with reported sunburn occurrence. Future directions for wearable UVR sensors may include their use as an intervention tool to support in-the-moment sunburn prevention.
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Affiliation(s)
- Tammy K. Stump
- Department of Dermatology, University of Utah Health Sciences Center, Salt Lake City, UT 84132, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA
| | - Suzanne Fastner
- Department of Dermatology, University of Utah Health Sciences Center, Salt Lake City, UT 84132, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA
| | - Yeonjung Jo
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84108, USA
| | - Jonathan Chipman
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84108, USA
| | - Benjamin Haaland
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84108, USA
| | - Elizabeth S. Nagelhout
- Division of Public Health, Department of Family & Preventive Medicine, University of Utah, Salt Lake City, UT 84108, USA
| | - Ali P. Wankier
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA
| | - Riley Lensink
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA
| | - Angela Zhu
- Department of Pediatrics, University of Utah, Salt Lake City, UT 84113, USA
| | - Bridget Parsons
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA
| | - Douglas Grossman
- Department of Dermatology, University of Utah Health Sciences Center, Salt Lake City, UT 84132, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA
| | - Yelena P. Wu
- Department of Dermatology, University of Utah Health Sciences Center, Salt Lake City, UT 84132, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA
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Wu YP, Parsons B, Jo Y, Chipman J, Haaland B, Nagelhout ES, Carrington J, Wankier AP, Brady H, Grossman D. Outdoor activities and sunburn among urban and rural families in a Western region of the US: Implications for skin cancer prevention. Prev Med Rep 2022; 29:101914. [PMID: 35911574 PMCID: PMC9326324 DOI: 10.1016/j.pmedr.2022.101914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/07/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022] Open
Abstract
Skin cancer risk differs between individuals in rural versus urban communities. Differing skin cancer risk could be due to unique patterns of outdoor activities. Rural versus urban adults and children engage in different outdoor activities. Preventive interventions could target activities with high sunburn risk.
Prevention of skin cancer involves decreasing exposure to ultraviolet radiation (UVR) and avoiding sunburn, especially early in life. Individuals living in urban versus rural areas, as defined by the Rural Urban Commuting Area (RUCA) code classification, have different risks for skin cancer, likely due to differing patterns of outdoor activities and preventive behaviors employed when outdoors. However, few studies have examined differences in outdoor activities between rural and urban individuals and examined this among both adults and children. This study compared the outdoor activities, sun protection strategies, tanning behaviors, and sunburn occurrence of adults and children (n = 97 dyads) in rural versus urban settings in a Western region of the United States. The relationships between outdoor activities and sunburn occurrence were examined in both groups. Analyses employed Barnard’s Exact Test and logistic generalized estimating equations models. Individuals in rural and urban areas reported differences in sun protection strategies used, tanning behaviors, and outdoor activities. Individuals in urban areas more commonly reported use of certain forms of sun protection, such as sunscreen and shade, whereas long pants and skirt wearing were more common for children in rural areas. Individuals in rural areas were more likely than those in urban areas to engage in farm work, yard work, and youth sports. Gender differences in these outcomes were also identified. Skin cancer preventive interventions could be tailored for rural and urban families to target sun protection strategies to outdoor activities and to situations in which sunburns are likely to occur.
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Affiliation(s)
- Yelena P Wu
- Department of Dermatology, University of Utah Health Sciences Center, 30 North 1900 East, 4A330 - Salt Lake City, UT 84132, USA.,Huntsman Cancer Institute, University of Utah, 1950, 2000 Cir of Hope Dr, Salt Lake City, UT 84112, USA
| | - Bridget Parsons
- Huntsman Cancer Institute, University of Utah, 1950, 2000 Cir of Hope Dr, Salt Lake City, UT 84112, USA
| | - Yeonjung Jo
- Department of Population Health Sciences, University of Utah, 295 Chipeta Way, Williams Building, Room 1N410, Salt Lake City, UT 84108, USA
| | - Jonathan Chipman
- Huntsman Cancer Institute, University of Utah, 1950, 2000 Cir of Hope Dr, Salt Lake City, UT 84112, USA.,Department of Population Health Sciences, University of Utah, 295 Chipeta Way, Williams Building, Room 1N410, Salt Lake City, UT 84108, USA
| | - Benjamin Haaland
- Huntsman Cancer Institute, University of Utah, 1950, 2000 Cir of Hope Dr, Salt Lake City, UT 84112, USA.,Department of Population Health Sciences, University of Utah, 295 Chipeta Way, Williams Building, Room 1N410, Salt Lake City, UT 84108, USA
| | | | - James Carrington
- School of Medicine, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132, USA
| | - Ali P Wankier
- Huntsman Cancer Institute, University of Utah, 1950, 2000 Cir of Hope Dr, Salt Lake City, UT 84112, USA
| | - Hannah Brady
- Huntsman Cancer Institute, University of Utah, 1950, 2000 Cir of Hope Dr, Salt Lake City, UT 84112, USA
| | - Douglas Grossman
- Department of Dermatology, University of Utah Health Sciences Center, 30 North 1900 East, 4A330 - Salt Lake City, UT 84132, USA.,Huntsman Cancer Institute, University of Utah, 1950, 2000 Cir of Hope Dr, Salt Lake City, UT 84112, USA
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Lewis-Thames MW, Langston ME, Khan S, Han Y, Fuzzell L, Xu S, Moore JX. Racial and Ethnic Differences in Rural-Urban Trends in 5-Year Survival of Patients With Lung, Prostate, Breast, and Colorectal Cancers: 1975-2011 Surveillance, Epidemiology, and End Results (SEER). JAMA Netw Open 2022; 5:e2212246. [PMID: 35587350 PMCID: PMC9121191 DOI: 10.1001/jamanetworkopen.2022.12246] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE Considering reported rural-urban cancer incidence and mortality trends, rural-urban cancer survival trends are important for providing a comprehensive description of cancer burden. Furthermore, little is known about rural-urban differences in survival trends by racial and ethnic groups. OBJECTIVE To examine national rural-urban trends in 5-year cancer-specific survival probabilities for lung, prostate, breast, and colorectal cancers in a diverse sample of racial and ethnic groups. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used an epidemiologic assessment with 1975 to 2016 Surveillance, Epidemiology, and End Results (SEER) data to analyze patients diagnosed no later than 2011. Patients were classified as living in rural and urban counties based on the 2013 Rural-Urban Continuum Codes. MAIN OUTCOMES AND MEASURES The 5-year cancer-specific survival probability of urban and rural patients for each cancer type was estimated by fitting Cox proportional hazard regression models accounting for race, ethnicity, tumor characteristics, and other sociodemographic characteristics. A generalized linear regression model was used to estimate the mean estimated probability of survival for each stratum. Joinpoint regression analysis estimated periods of significant change in survival. RESULTS In this study, data from 3 659 417 patients with cancer (median [IQR] age, 67 [58-76]; 1 918 609 [52.4%] male; 237 815 [6.5%] Hispanic patients; 396 790 [10.8%] Black patients; 2 825 037 [77.2%] White patients) were analyzed, including 888 338 patients with lung cancer (24.3%), 750 704 patients with colorectal cancer (20.5%), 987 826 patients with breast cancer (27.0%) breast, and 1 023 549 patients with prostate cancer (28.0%). There were 430 353 rural patients (11.8%). Overall, there was an equal representation of rural and urban men. Rural patients were likely to be non-Hispanic White individuals, have more cases of distant tumors, and be older. Rural and non-Hispanic Black patients for all cancer types often had shorter survival. From 1975 to 2016, the 5-year lung cancer survival rate was shorter for non-Hispanic Black rural patients in 1975 at 48%, while increasing to 57% for both non-Hispanic Black urban and rural patients in 2011, but still the shortest among all cancer types. In 1975, the longest survival rate was observed in urban Asian and Pacific Islander patients with breast cancer at 86%, and in 2011, the longest survival rate was observed in urban non-Hispanic White patients with XX cancer at 92%. CONCLUSIONS AND RELEVANCE Even after accounting for sociodemographic and tumor characteristics, these findings suggest that non-Hispanic Black patients with cancer are particularly vulnerable to cancer burden, and resources are urgently needed to reverse decades-old survival trends.
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Affiliation(s)
- Marquita W. Lewis-Thames
- Department of Medical Social Science, Center for Community Health, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Marvin E. Langston
- Division of Research, Kaiser Permanente, Northern California, Oakland, California
- Department of Epidemiology and Population Health, Stanford University, Stanford, California
| | - Saira Khan
- Epidemiology Program, College of Health Sciences, University of Delaware, Newark
| | - Yunan Han
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Lindsay Fuzzell
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Shuai Xu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Justin Xavier Moore
- Cancer Prevention, Control, and Population Health Program, Department of Medicine, Augusta University, Augusta, Georgia
- Institute of Preventive and Public Health, Augusta University, Augusta, Georgia
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