Left behind: cancer disparities in the developed world

Housing instability and psychological distress in African American cancer survivors: findings from the Detroit Research on Cancer Survivors study

PURPOSE

As health care systems seek to screen for and address housing instability in patient populations, robust evidence linking unstable housing to patient-reported outcomes is needed. Housing instability may increase psychological distress in cancer survivors, potentially more so among African American cancer survivors who are also likely to experience disproportionate burden of housing instability. The purpose of this analysis was to estimate associations between housing instability and psychological distress in African Americans diagnosed with cancer.

METHODS

We included survey responses from 2875 African American cancer survivors in the Detroit Research on Cancer Survivors (ROCS) study. We examined how housing instability at enrollment, using an item adapted from the Health Leads Screening Toolkit, related to psychological distress at enrollment, using Patient Reported Outcomes Measurement System (PROMIS) 4-item anxiety and depression short forms. Linear regression models adjusted for sociodemographic factors were used to estimate associations overall and stratified by stage at diagnosis.

RESULTS

Approximately 12% of participants reported being unstably housed. Housing instability was associated with significant differences in PROMIS scores for both anxiety (difference: 6.79; 95% CI: 5.57-8.01) and depression (difference: 6.16; 95% CI: 4.99-7.34). We did not find meaningful differences stratifying by disease stage.

CONCLUSION

Housing instability was experienced by over a tenth of this cohort of African American cancer survivors and was related to statistically and clinically meaningful differences in psychological distress even following adjustment for sociodemographics.

IMPLICATIONS FOR CANCER SURVIVORS

These findings provide evidence supporting screening of housing instability in cancer survivors, especially those from medically underserved populations.

The association between lung cancer stigma and race: A descriptive correlational study

BACKGROUND

Stigma is a formidable burden for survivors of lung cancer that can reduce the quality of life (QOL), resulting in physical, social and psychological challenges. This study investigates associations between stigma and depression, QOL and demographic and health-related characteristics, including race.

DESIGN

An adapted conceptual model derived from the Cataldo Lung Cancer Stigma Scale guided this descriptive correlation study assessing stigma in African American and Caucasian survivors of lung cancer. Self-reported, written surveys measuring depression, QOL, lung cancer stigma and demographics were administered. Statistical analysis was conducted to assess associations between stigma and depression, stigma and QOL and stigma and race, while adjusting for demographic characteristics.

RESULTS

Participants (N = 56) included 30 Caucasian and 26 African American survivors of lung cancer recruited from a cancer registry of an American College of Surgeons-accredited programme, a survivors' support club and an ambulatory oncology practice in the southeastern United States. Statistical analysis yielded (1) a significant moderate positive association between depression and lung cancer stigma; (2) a significant moderate negative association between QOL and lung cancer stigma; and (3) significant relationships between race and lung cancer stigma, specifically higher degree of stigma among African Americans compared to Caucasians.

CONCLUSION

Stigma affects many aspects of survivors' lives. Healthcare professionals need to consider how health-related stigma may further complicate the physical burdens, psychological distresses and social challenges that accompany the disease, especially among African American survivors. Additional enquiry and interventions are needed to assist with mitigating the negative effects of stigma on survivors and their family members and friends.

PATIENT OR PUBLIC CONTRIBUTION

Fifty-six survivors of lung cancer participated in this descriptivecorrelation study. They completed written surveys measuring depression, QOL, and lung cancer stigma, plus an investigator-developed demographic information form.

Addressing disparities and challenges in underserved patient populations with metastatic breast cancer in Europe

People with metastatic breast cancer face many challenges and disparities in obtaining optimal cancer care. These challenges are accentuated in underserved patient populations across Europe, who are less likely to receive quality healthcare for reasons including socioeconomic inequalities, educational or cultural status, or geographic location. While there are many local and national initiatives targeted to address these challenges, there remains a need to reduce disparities and improve access to healthcare to improve outcomes, with a focus on multidisciplinary stakeholder engagement. In October 2019, a range of experts in metastatic breast cancer, including healthcare professionals, patient representatives, policymakers and politicians, met to discuss and prioritize the critical needs of underserved patient populations with metastatic breast cancer in Europe. Six key challenges faced by these communities were identified: the need for amplification of the metastatic breast cancer patient voice, better and wider implementation of high-quality guidelines for metastatic breast cancer, more collaboration between stakeholders, tailored support for patients from different cultural and ethnic backgrounds, improved data sharing, and work-related issues. The Expert Panel then conceived and discussed potential actionable goals to address each key challenge. Their conclusions present a set of interrelated approaches to address the different challenges and could serve as the basis for concerted improvement of the lives of patients with metastatic breast cancer in Europe.

Perioperative complications and oncological outcomes following radical cystectomy among different racial groups: A long-term, single-center study

INTRODUCTION

Current literature on perioperative and oncological outcomes following radical cystectomy among different racial groups is limited, especially among Hispanics and Asians. The objective of this study was to assess the impact of racial differences on perioperative and oncological outcomes in a large cohort of bladder cancer patients who underwent radical cystectomy.

METHODS

We retrospectively reviewed the records of 3293 patients who underwent radical cystectomy with curative intent at our institution between 1971 and 2017. Based on race, patients were categorized as Hispanic (n=190), Asian (n=145), African American (n=67), and Caucasian (n=2891). Baseline characteristics, pericystectomy complications, and oncological outcomes, including recurrence-free and overall survival, were compared between the racial groups.

RESULTS

Mean patient age was 68±10.6 years. Median followup was 10.28 years. Body masss index and American Society of Anesthesiologists scores were significantly higher in Hispanic and African American population, and smoking incidence was lower in Asian patients. Hispanics presented with significantly higher clinical stage and longer time interval from diagnosis to treatment (mean 85.5 vs. 75.4 days in Caucasians, p<0.001). Overall 90-day complication and readmission rates were higher in Hispanics (41.06% and 18.95%, respectively). Oncological outcomes, however, were comparable between different race groups. In multivariate analysis, pathological nodal status and lymphovascular invasion were independent predictors of oncological outcomes, but race was not.

CONCLUSIONS

In this very large, ethnically diverse patient cohort who underwent radical cystectomy with curative intent, pericystectomy complications were more common in Hispanics; however, race was not an independent predictor of long-term oncological outcome.

The respective parts of incidence and lethality in socioeconomic differences in cancer mortality. An analysis of the French network Cancer registries (FRANCIM) data

Background

To determine relevant public health actions and to guide intervention priorities, it is of great importance to assess the relative contribution of incidence and lethality to social inequalities in cancer mortality.

Methods

The study population comprised 185,518 cases of cancer diagnosed between 2006 and 2009 recorded in the French registries. Survival was known for each patient (endpoint: 30/06/2013). Deprivation was assessed using the European Deprivation Index. We studied the influence of deprivation on mortality, incidence and lethality rates and quantified the respective proportions of incidence and lethality in social inequalities in mortality by calculating attributable deaths.

Results

For cancers with social inequalities both in incidence and lethality, excess mortality in deprived was mainly caused by social inequalities in incidence (e.g. men lung cancer: 87% of excess deaths in the deprived caused by inequalities in incidence). Proportions were more balanced for some cancer sites (e.g. cervical cancer: 56% incidence, 44% lethality). For cancer sites with a higher incidence in the least deprived (e.g. breast cancer), the excess-lethality in deprived leads entirely the higher mortality among the deprived.

Conclusions

Most of the excess mortality in deprived is due to the excess incidence of tobacco-dependent cancers and the excess lethality of screenable cancers.

Palliative Oncologic Care Curricula for Providers in Resource-Limited and Underserved Communities: a Systematic Review

Familiarity with principles of palliative care, supportive care, and palliative oncological treatment is essential for providers caring for cancer patients, though this may be challenging in global communities where resources are limited. Herein, we describe the scope of literature on palliative oncological care curricula for providers in resource-limited settings. A systematic literature review was conducted using PubMed, Embase, Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Med Ed Portal databases, and gray literature. All available prospective cohort studies, case reports, and narratives published up to July 2017 were eligible for review. Fourteen articles were identified and referenced palliative care education programs in Argentina, Uganda, Kenya, Australia, Germany, the USA, or multiple countries. The most common teaching strategy was lecture-based, followed by mentorship and experiential learning involving role play and simulation. Education topics included core principles of palliative care, pain and symptom management, and communication skills. Two programs included additional topics specific to the underserved or American Indian/Alaskan Native community. Only one program discussed supportive cancer care, and no program reported educational content on resource-stratified decision-making for palliative oncological treatment. Five programs reported positive participant satisfaction, and three programs described objective metrics of increased educational or research activity. There is scant literature on effective curricula for providers treating cancer patients in resource-limited settings. Emphasizing supportive cancer care and palliative oncologic treatments may help address gaps in education; increased outcome reporting may help define the impact of palliative care curriculum within resource-limited communities.

Development of health-related quality of life and symptoms in patients with advanced cancer in Greenland

A prospective national cohort study assessed the development of health-related quality of life (HRQoL) and symptoms in adult patients undergoing treatment and care for advanced cancer in Greenland. HRQol was examined by EORTC QLQ-C30 version 3.0 questionnaire monthly for 4 months. Changes over time and between-group comparisons were examined. Of 58 patients included in the study, 47% completed the questionnaire four times. Functioning was generally high, and improved social functioning was observed after 1 and 2 months. The highest symptom score was for fatigue followed by pain and nausea/vomiting. A high score for financial problems remained unchanged during the entire period. Patients with higher income had reduced pain intensity (p = .03) and diarrhoea (p = .05) than patients with income below the poverty line. After 1 month, reduction in pain intensity was observed for Nuuk citizens compared with non-Nuuk citizens (p = .05). After 2 months, non-Nuuk citizens reported improved social functioning compared with Nuuk citizens (p = .05). After 3 months, Global Health in Nuuk citizens was improved compared with non-Nuuk citizens (p = .05). An important clinical finding was that patients' needs for support are related to social status, and geographical factors should be taken into account when planning palliative care.

Lifestyle and Dietary Factors and Prostate Cancer Risk: A Multicentre Case-Control Study

This study aims to explore the association between fruit and vegetable intake, high fat, body mass index (BMI) score, physical activity, and the occurrence of prostate cancer among Jordanian men. A case-control study was conducted in three large referral hospitals. The sample included 165 prostate cancer patients in the case group and 177 healthy participants in the control group. The results showed that smoking (odds ratio [OR] = 0.32; 95% confidence interval [CI] = [0.18, 0.57]), a history of prostate infection (OR = 0.21; 95% CI = [0.11, 0.38]), high-fat intake (OR = 0.44; 95% CI = [0.23, 0.85]), and increased mean of BMI (OR = 1.08; 95% CI = [1.02, 1.13]) increased the likelihood of developing prostate cancer. Healthy diet and giving up smoking are recommended, as they may contribute to a reduction in the incidence of prostate cancer. More randomized clinical trials in this area are needed to strengthen the available evidence and reduce the effects of confounding variables.

Ways of knowing on the Internet: A qualitative review of cancer websites from a critical nursing perspective

People diagnosed with cancer typically want information from their doctor or nurse. However, many individuals now turn to the Internet to tackle unmet information needs and to complement healthcare professional information. The purpose of this study was to qualitatively explore the content of commonly searched cancer websites from a critical nursing perspective, as this information is accessible, and allows patients to address their information needs in ways that healthcare professionals cannot. This qualitative examination of websites is informed by Carper's fundamental patterns of knowing and complemented with the critical view to technology espoused by the philosophy of technology. We conducted a review of 20 websites using a two-step interpretive descriptive approach and thematic analysis. We identified the dominant discourse to be focused on empirical information on treatment, prognosis, and cure, and a paucity of sociopolitical, ethical, personal, and esthetic information. In place of holistic, nuanced, and accurate knowledge nurses may provide, patients find predominantly empirical and biomedical information online. Discussion explores and critiques online cancer content, gaps in information, and the importance of information diversity. Implications focus on needed discourse around pervasive technologies and the nursing role in assessing and directing patients to holistic information.

Race and postoperative complications following urologic cancer surgery: An ACS-NSQIP analysis

PURPOSE

Racial disparities in complication rates have been demonstrated for a variety of surgical procedures. We hypothesized that African American (AA) patients experience higher postoperative complication rates than whites following urologic oncology procedures.

MATERIALS AND METHODS

Patients in American College of Surgeons National Surgical Quality Improvement Program who underwent radical prostatectomy (RP), radical or partial nephrectomy (RN/PN), and radical cystectomy (RC) between 2005 and 2013 were included. Complications were grouped as minor (Clavien I-II), major (Clavien III-IV), or death (Clavien V). A 30-day complication rates and disparities in preoperative comorbidity burden were compared by race. After adjustment for comorbidity burden, multivariable logistic regression was performed to test the association between race and risk of complication.

RESULTS

Of 38,642 patients included in the analysis, 90% were white and 10% were AA. In unadjusted analysis, there were no significant differences in complication rates between AA and white patients for any Clavien grade in the procedures queried (RP: P = 0.07; RN/PN: P = 0.70; RC: P = 0.12). After controlling for a higher comorbidity burden among AA patients, AA race was again not independently associated with 30-day postoperative complications for RP (odds ratio [OR] = 1.08, 95% CI: 0.92-1.29), RN/PN (OR = 0.98, 95% CI: 0.84-1.13), or RC (OR = 1.10, 95% CI: 0.84-1.43).

CONCLUSION

Despite a higher comorbidity burden, AA patients in American College of Surgeons National Surgical Quality Improvement Program are not at increased risk of 30-day postoperative complications following major urologic cancer surgery. These findings suggest that comorbidity burden, as opposed to race, is most strongly associated with the risk of postoperative complications. To minimize perioperative risk, clinicians should strive to preoperatively optimize medical comorbidities in all patients undergoing urologic cancer surgery.

Implementation of evidence-based patient navigation programs

BACKGROUND

Patient navigation refers to a direct patient care role that links patients with clinical providers and their support system and provides individualized support during cancer care, ensuring that patients have access to the knowledge and resources necessary to complete recommended treatment. While most reports have studied the role of patient navigators during the cancer screening or diagnostic process, emerging evidence indicates the benefits of patient navigation during active cancer treatment.

DISCUSSION

Reports in the literature are conflicting on the impact of patient navigation during cancer care and on the benefits to timely or quality care in all populations. Recent sub-analyses of the Patient Navigation Research Program data demonstrated specifically the benefits of targeting patient navigation to the most vulnerable populations, including those with low educational attainment, low income and unstable housing, less social support, multiple comorbidities, and minority race/ethnicity.

CONCLUSION

The implications of the Patient Navigation Research Program are that this resource is best utilized when directed to support the care of patients at locations with known challenges to timely care and for specific patients with risk factors for delays in care, including comorbidities, low educational attainment and low income. Implementation of patient navigation programs requires the following processes: needs assessment, selection of a navigator to meet the community and care needs, supervision and integration of the navigator into clinical processes, and systems support to facilitate the identification and tracking of those patients requiring patient navigation. There is a need for ongoing research on methods to fund and sustain patient navigation programs.

Socio-economic disparities in long-term cancer survival-10 year follow-up with individual patient data

PURPOSE

Reasons for the social gradient in cancer survival are not fully understood yet. Previous studies were often only able to determine the socio-economic status of the patients from the area they live in, not from their individual socio-economic characteristics.

METHODS

In a multi-centre cohort study with 1633 cancer patients and 10-year follow-up, individual socio-economic position was measured using the indicators: education, job grade, job type, and equivalence income. The effect on survival was measured for each indicator individually, adjusting for age, gender, and medical characteristics. The mediating effect of health behaviour (alcohol and tobacco consumption) was analysed in separate models.

RESULTS

Patients without vocational training were at increased risk of dying (rate ratio (RR) 1.5, 95% confidence interval (CI) 1.1-2.2) compared to patients with the highest vocational training; patients with blue collar jobs were at increased risk (RR 1.2; 95% CI 1.0-1.5) compared to patients with white collar jobs; income had a gradual effect (RR for the lowest income compared to highest was 2.7, 95% CI 1.9-3.8). Adding health behaviour to the models did not change the effect estimates considerably. There was no evidence for an effect of school education and job grade on cancer survival.

CONCLUSIONS

Patients with higher income, better vocational training, and white collar jobs survived longer, regardless of disease stage at baseline and of tobacco and alcohol consumption.