Racial disparities in healthy behaviors and cancer screening among breast cancer survivors and women without cancer: National Health Interview Survey 2005

Examining cancer screening disparities by race/ethnicity and insurance groups: A comparison of 2008 and 2018 National Health Interview Survey (NHIS) data in the United States

BACKGROUND

Pervasive differences in cancer screening among race/ethnicity and insurance groups presents a challenge to achieving equitable healthcare access and health outcomes. However, the change in the magnitude of cancer screening disparities over time has not been thoroughly examined using recent public health survey data.

METHODS

A retrospective cross-sectional analysis of the 2008 and 2018 National Health Interview Survey (NHIS) database focused on breast, cervical, and colorectal cancer screening rates among race/ethnicity and insurance groups. Multivariable logistic regression models were used to assess the relationship between cancer screening rates, race/ethnicity, and insurance coverage, and to quantify the changes in disparities in 2008 and 2018, adjusting for potential confounders.

RESULTS

Colorectal cancer screening rates increased for all groups, but cervical and mammogram rates remained stagnant for specific groups. Non-Hispanic Asians continued to report consistently lower odds of receiving cervical tests (OR: 0.42, 95% CI: 0.32-0.55, p<0.001) and colorectal cancer screening (OR: 0.55, 95% CI: 0.42-0.72, p<0.001) compared to non-Hispanic Whites in 2018, despite significant improvements since 2008. Non-Hispanic Blacks continued to report higher odds of recent cervical cancer screening (OR: 1.98, 95% CI: 1.47-2.68, p<0.001) and mammograms (OR: 1.32, 95% CI: 1.02-1.71, p<0.05) than non-Hispanic Whites in 2018, consistent with higher odds observed in 2008. Hispanic individuals reported improved colorectal cancer screening over time, with no significant difference compared to non-Hispanics Whites in 2018, despite reporting lower odds in 2008. The uninsured status was associated with significantly lower odds of cancer screening than private insurance for all three cancers in 2008 and 2018.

CONCLUSION

Despite an overall increase in breast and colorectal cancer screening rates between 2008 and 2018, persistent racial/ethnic and insurance disparities exist among race/ethnicity and insurance groups. These findings highlight the importance of addressing underlying factors contributing to disparities among underserved populations and developing corresponding interventions.

Racial/ethnic disparities in use of surveillance mammogram among breast cancer survivors: a systematic review

BACKGROUND

Increasing number of breast cancer survivors in the USA have led to greater focus on the long-term health outcomes and surveillance care among these women. However limited evidence exists of use of surveillance mammography among breast cancer survivors and how it varies across racial/ethnic groups.

METHODS

We conducted a systematic review of the literature to explore disparities in use of surveillance mammogram among women breast cancer survivors by searching for relevant studies published between 2000 and 2020 from Medline (Ovid), PubMed (National Library of Medicine), and PsycINFO (Ovid) bibliographic databases. Two authors independently screened titles, abstracts, and full texts of all articles that reported surveillance mammography use across racial/ethnic groups. Data on study design, screening eligibility, sample size, operational definition, and/or measure of the use of a surveillance mammogram among breast cancer survivors and the association between race/ethnicity and use of a surveillance mammogram were summarized in the evidence tables.

RESULTS

We identified 1544 records from the three databases, and 30 studies examined the use of surveillance mammograms among breast cancer survivors across race/ethnic groups. Of these, 21 provided adjusted estimates of racial/ethnic disparities in use of surveillance mammograms, and 15 of these reported statistically significant disparities. In summary, most studies reported that non-white women (mainly Blacks and Hispanics) were less likely to receive a timely surveillance mammogram compared to White.

CONCLUSION

This study extends the evidence of racial/ethnic disparities beyond completion of initial treatment by finding similar disparities in receipt of surveillance mammograms among breast cancer survivors.

IMPLICATION FOR CANCER SURVIVORS

Our findings identify a need to improve efforts to increase post-treatment use of surveillance mammography among racial/ethnic minority women to reduce these gaps and improve overall clinical and quality of life outcomes.

Physical activity barriers and resources among black women with a history of breast and endometrial cancer: a systematic review

Physical inactivity is a significant public health problem among black women. However, there is limited evidence regarding barriers to physical activity and the availability of opportunities to engage in physical activity, specifically for posttreatment black women with a history of cancer.

PURPOSE

The purpose of this paper was to systematically review, summarize, and synthesize findings on physical activity-related research including barriers, facilitators, and resources for physical activity among posttreatment black women with a history of breast and endometrial cancer.

METHODS

We developed a comprehensive search strategy and conducted searches in the following databases: PsycINFO, Web of Science, Cochrane, PubMed, and Sociological Abstracts. Summary measures were described qualitatively (e.g., themes) and quantitatively (e.g., frequencies).

RESULTS

This review identified 35 eligible articles describing 12 intervention and 23 observational studies. We described intervention preferences (e.g., resistance activities), beliefs about physical activity, and benefits of physical activity for quality of life (e.g., improvements in social wellbeing) in black cancer survivors. In addition, very few studies identified barriers to physical activity (n = 7) and focused on increasing physical activity (n = 12) among black women with a history of cancer. The most common reported barriers among the target population were fatigue, lack of social support, weather, illness/health issues, cost, time constraints, living too far away, and inability/unwillingness to obtain physician clearance, whereas the most common facilitators were faith, other health concerns, and social support.

CONCLUSIONS/IMPLICATIONS

Future studies should target barriers, facilitators, and culturally adapted strategies for physical activity at all levels of influence to develop multi-level interventions to engage and improve physical activity among black women with a history of breast and endometrial cancer.

PROTOCOL REGISTRATION NUMBER

CRD42018110008.

The Affordable Care Act improved health insurance coverage and cardiovascular-related screening rates for cancer survivors seen in community health centers

Background

This study assessed the impact of Affordable Care Act (ACA) Medicaid expansion on health insurance rates and receipt of cardiovascular‐related preventive screenings (body mass index, glycated hemoglobin [HbA1c], low‐density lipoproteins, and blood pressure) for cancer survivors seen in community health centers (CHCs).

Methods

This study identified cancer survivors aged 19 to 64 years with at least 3 CHC visits in 13 states from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE). Via inverse probability of treatment weighting multilevel multinomial modeling, insurance rates before and after the ACA were estimated by whether a patient lived in a state that expanded Medicaid, and changes between a pre‐ACA time period and 2 post‐ACA time periods were assessed.

Results

The weighted estimated sample size included 409 cancer survivors in nonexpansion states and 2650 in expansion states. In expansion states, the proportion of uninsured cancer survivors decreased significantly from 20.3% in 2012‐2013 to 4.5%in 2016‐2017, and the proportion of those with Medicaid coverage increased significantly from 38.8% to 55.6%. In nonexpansion states, there was a small decrease in uninsurance rates (from 33.6% in 2012‐2013 to 22.5% in 2016‐2017). Cardiovascular‐related preventive screening rates increased over time in both expansion and nonexpansion states: HbA1c rates nearly doubled from the pre‐ACA period (2012‐2013) to the post‐ACA period (2016‐2017) in expansion states (from 7.2% to 12.8%) and nonexpansion states (from 9.3% to 16.8%).

Conclusions

This study found a substantial decline in uninsured visits among cancer survivors in Medicaid expansion states. Yet, 1 in 5 cancer survivors living in a state that did not expand Medicaid remained uninsured. Several ACA provisions likely worked together to increase cardiovascular‐related preventive screening rates for cancer survivors seen in CHCs.

The Affordable Care Act (ACA) provides coverage options for cancer survivors seen in community health centers, especially in states that have expanded Medicaid; unfortunately, 1 in 5 cancer survivors living in a state that has not expanded Medicaid coverage eligibility remains uninsured. The ACA Medicaid expansion provision change, likely in tandem with other ACA changes, has also contributed to modest improvements in rates of cardiovascular‐related screenings for cancer survivors.

Factors Influencing Surveillance Mammography Adherence Among Breast Cancer Survivors

PROBLEM IDENTIFICATION

Many breast cancer survivors fail to engage in surveillance mammography to detect new and recurrent cancers. This review identifies factors promoting or inhibiting breast cancer survivors' participation in recommended surveillance mammography.

LITERATURE SEARCH

This integrative review included all English-language studies published from 2000 to 2017, identified in CINAHL®, PsycINFO®, Embase®, and MEDLINE® via PubMed®.

DATA EVALUATION

23 studies met the inclusion criteria and were analyzed and synthesized.

SYNTHESIS

19 factors influencing mammography adherence were identified and organized into a conceptual model with two major categories.

IMPLICATIONS FOR RESEARCH

The new model of predictors of mammography adherence can provide guidance for identifying individuals at greatest risk for nonadherence, as well as development of new interventions to address barriers to regular mammography screening, to promote early detection of new and recurrent cancers and improved survival rates.

Adherence to multiple health behaviours in cancer survivors: a systematic review and meta-analysis

PURPOSE

Multiple health behaviours (not smoking, minimal alcohol consumption, and maintaining a healthy weight by having a healthy diet and regular physical activity) improve quality of life and longevity of cancer survivors. Despite international guidelines, there are no existing reviews that synthesise cancer survivors' adherence to healthy lifestyle recommendations.

METHOD

Five databases (Embase, MEDLINE, PsycINFO, Web of Science, and Google Scholar) were searched for relevant articles published from 2007 until January 2018. Studies reporting adult cancer survivors' adherence to at least two lifestyle behaviours (body mass index, physical activity, smoking, fruit and vegetable intake, fiber intake, red meat intake, caloric intake, sodium intake, and alcohol consumption) based on the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) recommendations were included in the review. The pooled prevalence of adherence to single and multiple behaviours was calculated using a random-effects model. Subgroup analysis (mean years of survival and publication year) was undertaken.

RESULTS

A total of 3322 articles were identified. Of these, 51 studies matched the inclusion criteria, presenting data from 2,620,586 adult cancer survivors. Adherence to single behaviours, which was estimated from studies that assessed at least two health behaviours, was highest for not smoking (PE 87%; 95% CI, 85%, 88%) and low or no alcohol intake (PE 83%; 95% CI, 81%, 86%), and lowest for fiber intake (PE 31%; 95% CI, 21%, 40%). Adherence to multiple healthy behaviours (13 studies), ranged from 7 to 40% (pooled estimate (PE) 23%; 95% CI, 17%, 30%). Recent survivors (< 5-year survival time) had relatively better adherence to multiple behaviours (PE 31%; 95% CI, 27%, 35%) than long-term (> 5 years) survivors (PE 25%; 95% CI, 14%, 36%). Adherence to multiple behaviours improved over time since 2007.

CONCLUSION

Adherence to physical activity, dietary, and multiple lifestyle behaviours recommendations was low amongst cancer survivors. Recent cancer survivors were relatively more adherent to WCRF/AICR recommendations compared to long-term survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Health promotion programs help support healthy lifestyle behaviours of cancer survivors. PROSPERO registration number: CRD42018091663.

Culture, identity, strength and spirituality: A qualitative study to understand experiences of African American women breast cancer survivors and recommendations for intervention development

OBJECTIVE

Despite advancements in cancer treatment, racial disparities in breast cancer survival persist, with African American women experiencing lower survival rates and poorer quality of life than non-Hispanic White women. Using a social cognitive model of restorative well-being as a framework, this qualitative study sought: (a) to examine strength- and culture-related factors associated with African American female breast cancer survivors' cancer coping and post-treatment experiences and (b) to make recommendations for culturally sensitive intervention.

METHODS

Eight focus groups occurred with a total of 40 local African American breast cancer survivors. Focus groups were audiotaped and transcribed verbatim. Framework analyses were used to identify themes. NVivo qualitative analysis software-managed data.

RESULTS

Two major themes emerged from the focus group discussions: (a) God enables breast cancer survivorship and works every day in our lives and (b) the healthiest thing about us is that we are strong African American women. Recommendations for intervention planning and implementation were made towards intervention structure, content development and language framing in a local context.

CONCLUSION

Findings suggest a need for community-based participatory survivorship interventions that are culturally and spiritually consonant and peer-based. Such interventions may respond to the cancer-related and personal needs of the target population.

Healthy behavioral choices and cancer screening in persons living with HIV/AIDS are different by sex and years since HIV diagnosis

PURPOSE

The prevalence of non-AIDS-related malignancies is on the rise among people aging with HIV population, but the evidence on healthy behaviors including cancer screening practices in this population subgroup is extremely limited. Therefore, we investigated the prevalence of healthy behaviors and sex-specific cancer screening among persons living with HIV, by sex and time since HIV diagnosis.

METHODS

We included 517 persons living with HIV from the Florida Cohort. Data were obtained from the baseline and follow-up questionnaires, electronic medical records, and Enhanced HIV/AIDS Reporting System. The prevalence of self-reported, age-appropriate cancer screening (anal, colorectal, prostate, breast, and cervical), and healthy behaviors (sustaining healthy body weight, refraining from smoking and alcohol and engaging in physical activity) was compared by sex and years since HIV diagnosis (≤ 13 vs. > 13 years).

RESULTS

In the analyses by sex, females were more likely to be obese than males (56.5% vs. 22.2%, p < 0.0001). Distribution of healthy behaviors did not differ by time since diagnosis among males and females. In the analysis of age-appropriate screening among males, 64.8% never had an anal Pap-smear, 36.2% never had a colonoscopy, and 38.9% never had prostate cancer screening. In the analysis of age-appropriate screening among females, 50.0% never had an anal Pap-smear, 46.5% never had a colonoscopy, 7.9% never had a cervical Pap-smear, and 12.7% never had a mammogram. The difference in anal Pap-smear by sex was statistically significant (p < 0.0001). Among males, the age-adjusted prevalence of never having a colonoscopy was higher in those who had HIV for ≤ 13 years (50.8% vs. 30.6%, p = 0.03).

CONCLUSION

The prevalence of selected healthy behaviors and cancer screening differed by sex and/or years since HIV diagnosis suggesting a need for tailored cancer prevention efforts among persons living with HIV via long-term sex-specific interventions.

Factors Associated with Adherence to Preventive Breast Cancer Screenings among Middle-aged African American Women

Medical and other health professionals recommend biyearly screening for breast cancer for women 40-74 years of age. However, the breast cancer screening rate of African American women aged 45 and up is lower than that of other ethnicities. The present study intended to identify factors impacting African American women's participation in breast cancer screening. This study is a longitudinal secondary data analysis of 3,911 African American participants of the Study of Women's Health Across the Nation. By using Systems Model of Clinical Preventive Care, multinomial logistic regression was applied to explore the likelihood of having breast cancer screenings (breast exam and/or mammogram) associating with predisposing factors, enabling factors, referencing factors, and situational factors. Participants with older age, with higher education, having a healthcare provider for female health, in far distance, and with a cancer(s) were significantly more likely to adhere to the recommendations of breast cancer screenings. However, participants who did not have time to visit doctors, did not trust the physicians, and who smoked regularly were significantly less likely to adhere to the recommendations of breast cancer screenings. Implications for policy and practice are discussed.

Longitudinal social cognitive influences on physical activity and sedentary time in Hispanic breast cancer survivors

OBJECTIVE

This study evaluated the effect of two home-based exercise interventions (one culturally adapted and one standard) on changes in social cognitive theory (SCT) variables, physical activity (PA), and sedentary time (ST), and determined the association between changes in SCT variables and changes in PA and ST in Hispanic breast cancer survivors.

METHOD

Project VIVA! was a 16-week randomized controlled pilot study to test the effectiveness and feasibility of a culturally adapted exercise intervention for Mexican American and Puerto Rican breast cancer survivors in Houston, Texas and San Juan, Puerto Rico, respectively. Women (N = 89) completed questionnaires on SCT variables, PA, and ST and were then randomized to a 16-week culturally adapted exercise program, a non-culturally adapted standard exercise intervention or a wait-list control group. Multiple regression models were used to determine associations between changes in SCT variables and changes in PA and ST.

RESULTS

Participants were in their late 50s (58.5 ± 9.2 years) and obese (31.0 ± 6.5 kg/m2 ). Women reported doing roughly 34.5 min/day of PA and spending over 11 h/day in sedentary activities. Across groups, women reported significant increases in exercise self-efficacy and moderate-intensity, vigorous-intensity, and total PA from baseline to follow-up (p < 0.05). Increased social support from family was associated with increases in vigorous-intensity PA. Increases in social modeling were associated with increases in moderate-intensity and total PA and with decreases in ST from baseline to follow-up (p < 0.05).

CONCLUSIONS

Hispanic cancer survivors benefit from PA interventions that focus on increasing social support from family and friends and social modeling. Copyright © 2015 John Wiley & Sons, Ltd.

Racial and Ethnic Differences in Dietary Intake, Physical Activity, and Body Mass Index (BMI) Among Cancer Survivors: 2005 and 2010 National Health Interview Surveys (NHIS)

INTRODUCTION

This paper reports racial/ethnic differences in mean dietary and alcohol intake, physical activity, and body mass index (BMI) among cancer survivors and examines adherence to the American Cancer Society and the US Dietary Guidelines for Americans.

METHODS

Data are from the cross-sectional 2005 and 2010 National Health Interview Surveys (NHIS). The total sample of cancer survivors (N = 3367) included non-Hispanic Whites (NHW; N = 2698), non-Hispanic Blacks (NHBs; N = 379), and Hispanics (N = 290). We compared mean reported dietary intake, moderate/vigorous physical activity, and BMI among racial/ethnic groups. Predicted marginals and multivariate logistic regression analysis were used to compare prevalence of non-adherence with recommendations among groups.

RESULTS

Among the three racial/ethnic groups, Hispanics had the highest mean intake of vegetables, fiber, and calcium (p = 0.0003; p < 0.0001; p = 0.001). In the logistic regression model adjusting for sociodemographic covariates, smoking and BMI, Hispanics had lower non-adherence to fiber guidelines (OR = 0.38; CI = 0.24-0.58) than NHWs. NHBs had significantly higher non-adherence to vegetable guidelines (OR = 1.63; CI = 1.07-2.47). NHBs and Hispanics had lower non-adherence with alcohol guidelines than NHWs (OR = 0.35 and 0.38; CI = 0.18-0.69 and 0.19-0.76, respectively). NHBs and Hispanics were more likely to be overweight/obese (OR = 1.66 and 1.57; CI = 1.24-2.23 and CI = 1.11-2.21, respectively).

CONCLUSIONS

There are racial/ethnic differences in certain health behaviors of cancer survivors. However, non-adherence to guidelines is high in all three racial/ethnic groups. Achieving the recommended guidelines for diet, physical activity, and a healthy BMI is a concern for all cancer survivors, indicating the need for intervention among this growing group of at-risk individuals.

Risk Factors, Preventive Practices, and Health Care Among Breast Cancer Survivors, United States, 2010

INTRODUCTION

We compared behavioral risk factors and preventive measures among female breast cancer survivors, female survivors of other types of cancers, and women without a history of cancer. Survivorship health care indicators for the 2 groups of cancer survivors were compared.

METHODS

Using data from the 2010 Behavioral Risk Factor Surveillance System, we calculated the proportion of women with risk factors and their engagement in preventive practices, stratified by cancer status (cancer survivors or women with no history of cancer), and compared the proportions after adjusting for sociodemographic characteristics.

RESULTS

A significantly higher proportion of breast cancer survivors had mammography in the previous year (79.5%; 95% confidence interval [CI], 76.0%-83.0%) than did other cancer survivors (68.1%; 95% CI, 65.6%-70.7%) or women with no history of cancer (66.4%; 95% CI, 65.5%-67.3%). Breast cancer survivors were also more likely to have had a Papanicolaou (Pap) test within the previous 3 years than women with no history of cancer (89.4%; 95% CI, 85.9%-93.0 vs 85.1%; 95% CI, 84.4%-85.8%) and a colonoscopy within the previous 10 years (75.4%; 95% CI, 71.7%-79.0%) than women with no history of cancer (60.0%; 95% CI, 59.0%-61.0%). Current smoking was significantly lower among survivors of breast cancer (10.3%; 95% CI, 7.4%-13.2%) than other cancer survivors (20.8%; 95% CI, 18.4%-23.3%) and women with no history of cancer (18.3%; 95% CI, 17.5%-19.1%). After adjusting for sociodemographic characteristics, we found that breast cancer survivors were significantly more likely to have had mammography, a Pap test, and colonoscopy, and less likely to be current smokers.

CONCLUSION

Breast cancer survivors are more likely to engage in cancer screening and less likely to be current smokers than female survivors of other types of cancer or women with no history of cancer.