Cancer outcomes research in a rural area: a multi-institution partnership model

Disparities in Cancer Stage Outcomes by Catchment Areas for a Comprehensive Cancer Center

Importance

The National Cancer Institute comprehensive cancer centers (CCCs) lack spatial and temporal evaluation of their self-designated catchment areas.

Objective

To identify disparities in cancer stage at diagnosis within and outside a CCC's catchment area across a 10-year period using spatial and statistical analyses.

Design, Setting, and Participants

This cross-sectional, population-based study conducted between 2010 and 2019 utilized cancer registry data for the Johns Hopkins Sidney Kimmel CCC (SKCCC). Eligible participants included patients with cancer in the contiguous US who received treatment for cancer, a diagnosis of cancer, or both at SKCCC. Patients were geocoded to zip code tabulation areas (ZCTAs). Individual-level variables included sociodemographic characteristics, smoking and alcohol use, treatment type, cancer site, and insurance type. Data analysis was performed between March and July 2023.

Exposures

Distance between SKCCC and ZCTAs were computed to generate a catchment area of the closest 75% of patients and outer zones in 5% increments for comparison.

Main Outcomes and Measures

The primary outcome was cancer stage at diagnosis, defined as early-stage, late-stage, or unknown stage. Multinomial logistic regression was used to determine associations of catchment area with stage at diagnosis.

Results

This study had a total of 94 007 participants (46 009 male [48.94%] and 47 998 female [51.06%]; 30 195 aged 22-45 years [32.12%]; 4209 Asian [4.48%]; 2408 Hispanic [2.56%]; 16 004 non-Hispanic Black [17.02%]; 69 052 non-Hispanic White [73.45%]; and 2334 with other or unknown race or ethnicity [2.48%]), including 47 245 patients (50.26%) who received a diagnosis of early-stage cancer, 19 491 (20.73%) who received a diagnosis of late-stage cancer , and 27 271 (29.01%) with unknown stage. Living outside the main catchment area was associated with higher odds of late-stage cancers for those who received only a diagnosis (odds ratio [OR], 1.50; 95% CI, 1.10-2.05) or only treatment (OR, 1.44; 95% CI, 1.28-1.61) at SKCCC. Non-Hispanic Black patients (OR, 1.16; 95% CI, 1.10-1.23) and those with Medicaid (OR, 1.65; 95% CI, 1.46-1.86) and no insurance at time of treatment (OR, 2.12; 95% CI, 1.79-2.51) also had higher odds of receiving a late-stage cancer diagnosis.

Conclusions and Relevance

In this cross-sectional study of CCC data from 2010 to 2019, patients residing outside the main catchment area, non-Hispanic Black patients, and patients with Medicaid or no insurance had higher odds of late-stage diagnoses. These findings suggest that disadvantaged populations and those living outside of the main catchment area of a CCC may face barriers to screening and treatment. Care-sharing agreements among CCCs could address these issues.

Tools, frameworks and resources to guide global action on strengthening rural health systems: a mapping review

BACKGROUND

Inequities of health outcomes persist in rural populations globally. This is strongly associated with there being less health coverage in rural and underserviced areas. Increasing health care coverage in rural area requires rural health system strengthening, which subsequently necessitates having tools to guide action.

OBJECTIVE

This mapping review aimed to describe the range of tools, frameworks and resources (hereafter called tools) available globally for rural health system capacity building.

METHODS

This study collected peer-reviewed materials published in 15-year period (2005-2020). A systematic mapping review process identified 149 articles for inclusion, related to 144 tools that had been developed, implemented, and/or evaluated (some tools reported over multiple articles) which were mapped against the World Health Organization's (WHO's) six health system building blocks (agreed as the elements that need to be addressed to strengthen health systems).

RESULTS

The majority of tools were from high- and middle-income countries (n = 85, 59% and n = 43, 29%, respectively), and only 17 tools (12%) from low-income countries. Most tools related to the health service building block (n = 57, 39%), or workforce (n = 33, 23%). There were a few tools related to information and leadership and governance (n = 8, 5% each). Very few tools related to infrastructure (n = 3, 2%) and financing (n = 4, 3%). This mapping review also provided broad quality appraisal, showing that the majority of the tools had been evaluated or validated, or both (n = 106, 74%).

CONCLUSION

This mapping review provides evidence that there is a breadth of tools available for health system strengthening globally along with some gaps where no tools were identified for specific health system building blocks. Furthermore, most tools were developed and applied in HIC/MIC and it is important to consider factors that influence their utility in LMIC settings. It may be important to develop new tools related to infrastructure and financing. Tools that have been positively evaluated should be made available to all rural communities, to ensure comprehensive global action on rural health system strengthening.

The Population Burden of Cancer: Research Driven by the Catchment Area of a Cancer Center

Cancer centers, particularly those supported by the National Cancer Institute, are charged with reducing the cancer burden in their catchment area. However, methods to define both the catchment area and the cancer burden are diverse and range in complexity often based on data availability, staff resources, or confusion about what is required. This article presents a review of the current literature identifying 4 studies that have defined various aspects of the cancer burden in a defined geographical area and highlights examples of how some cancer centers and other health institutions have defined their catchment area and characterized the cancer burden within it. We then present a detailed case study of an approach applied by the University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center to define its catchment area and its population cancer burden. We cite examples of how the Cancer Center research portfolio addresses the defined cancer burden. Our case study outlines a systematic approach to using publicly available data, such as cancer registry data, that are accessible by all cancer centers. By identifying gaps and formulating future research directions based on the needs of the population within the catchment area, epidemiologic studies and other types of cancer research can be directed to the population served. This review can help guide cancer centers in developing an approach to defining their own catchment area as mandated and applying research findings to this defined population.

Evidence-Based Cancer Survivorship Activities for Comprehensive Cancer Control

INTRODUCTION

One of six priorities of CDC's National Comprehensive Cancer Control Program (NCCCP) is to address the needs of cancer survivors within the local population served by individually funded states, tribes, and territories. This report examines cancer survivorship activities implemented in five NCCCP grantees, which have initiated evidence-based activities outlined in A National Action Plan for Cancer Survivorship: Advancing Public Health Strategies (NAP).

METHODS

NCCCP action plans, submitted annually to CDC, from 2010 to 2014 were reviewed in February 2015 to assess implementation of cancer survivorship activities and recommended strategies consistent with the NAP. Four state-level and one tribal grantee with specific activities related to one of each of the four NAP strategies were chosen for inclusion. Brief case reports describing the initiation and impact of implemented activities were developed in collaboration with each grantee program director.

RESULTS

New Mexico, South Carolina, Vermont, Washington state, and Fond Du Lac Band of Lake Superior Chippewa programs each implemented activities in surveillance and applied research; communication, education, and training; programs, policies, and infrastructure; and access to quality care and services.

CONCLUSIONS

This report provides examples for incorporating cancer survivorship activities within Comprehensive Cancer Control programs of various sizes, demographic makeup, and resource capacity. New Mexico, South Carolina, Vermont, Washington state, and Fond Du Lac Band developed creative cancer survivorship activities that meet CDC recommendations. NCCCP grantees can follow these examples by implementing evidence-based survivorship interventions that meet the needs of their specific populations.

Evolution of a CDC Public Health Research Agenda for Low-Risk Prostate Cancer

Men with prostate cancer face difficult choices when selecting a therapy for localized prostate cancer. Comparative data from controlled studies are lacking and clinical opinions diverge about the benefits and harms of treatment options. Consequently, there is limited guidance for patients regarding the impact of treatment decisions on quality of life. There are opportunities for public health to intervene at several decision-making points. Information on typical quality of life outcomes associated with specific prostate cancer treatments could help patients select treatment options. From 2003 to present, the Division of Cancer Prevention and Control at CDC has supported projects to explore patient information-seeking behavior post-diagnosis, caregiver and provider involvement in treatment decision making, and patient quality of life following prostate cancer treatment. CDC's work also includes research that explores barriers and facilitators to the presentation of active surveillance as a viable treatment option and promotes equal access to information for men and their caregivers. This article provides an overview of the literature and considerations that initiated establishing a prospective public health research agenda around treatment decision making. Insights gathered from CDC-supported studies are poised to enhance understanding of the process of shared decision making and the influence of patient, caregiver, and provider preferences on the selection of treatment choices. These findings provide guidance about attributes that maximize patient experiences in survivorship, including optimal quality of life and patient and caregiver satisfaction with information, treatment decisions, and subsequent care.

Non-small cell lung cancer treatment receipt and survival among African-Americans and whites in a rural area

Data on racial disparities among lung cancer patients in rural areas are scarce. We examined differences in treatment receipt and survival among African-American (AA) and Non-Hispanic White (NHW) non-small cell lung cancer (NSCLC) patients residing in Southwest Georgia (SWGA)-a primarily rural 33-county area; population 700,000. Medical records for 934 SWGA NSCLC patients diagnosed in 2001-2003 were used to extract information on age, race, marital status, insurance coverage, comorbidities, and treatment. Information pertaining to socioeconomic status, urban/rural residence, and survival was obtained from the cancer registry. Multivariable logistic regression analyses examined the relation of various patient and disease characteristics to receipt of tumor-directed therapy. Cox regression models were used to assess determinants of survival. Treatment receipt was associated with age, marital status, comorbidities, and disease stage in most analyses. No associations were observed between race and either surgery [odds ratio (OR) 0.83, 95% confidence interval (CI) 0.49-1.39] or radiation (OR 0.72; 95% CI 0.52-1.00). NHW patients were more likely to receive no treatment at all (OR 1.50, 95% CI 1.01-2.23). There was no racial difference in survival (hazard ratio = 1.07, 95% CI 0.90-1.26). Effects of insurance and treatment on survival were most pronounced within 6 months post-diagnosis, but were attenuated over time. We found no evidence of racial disparities in survival and, in some analyses, a decreased likelihood of treatment receipt among NHW NSCLC patients compared to AA. The results from SWGA stand in contrast to studies that applied different methodologies and were conducted elsewhere.

Elderly breast and colorectal cancer patients' clinical course: patient and contextual influences

BACKGROUND

The social and medical environments that surround people are each independently associated with their cancer course. The extent to which these characteristics may together mediate patients' cancer care and outcomes is not known.

METHODS

Using multilevel methods and data, we studied elderly breast and colorectal cancer patients (level I) within urban social (level II: ZIP code tabulation area) and health care (level III: hospital service area) contexts. We sought to determine (1) which, if any, observable social and medical contextual attributes were associated with patient cancer outcomes after controlling for observable patient attributes, and (2) the magnitude of residual variation in patient cancer outcomes at each level.

RESULTS

Numerous patient attributes and social area attributes, including poverty, were associated with unfavorable patient cancer outcomes across the full clinical cancer continuum for both cancers. Health care area attributes were not associated with patient cancer outcomes. After controlling for observable covariates at all 3 levels, there was substantial residual variation in patient cancer outcomes at all levels.

CONCLUSIONS

After controlling for patient attributes known to confer risk of poor cancer outcomes, we find that neighborhood socioeconomic disadvantage exerts an independent and deleterious effect on residents' cancer outcomes, but the area supply of the specific types of health care studied do not. Multilevel interventions targeted at cancer patients and their social areas may be useful. We also show substantial residual variation in patient outcomes across social and health care areas, a finding potentially relevant to traditional small area variation research methods.

Using a participatory evaluation design to create an online data collection and monitoring system for New Mexico's Community Health Councils

We present the collaborative development of a web-based data collection and monitoring plan for thirty-two county councils within New Mexico's health council system. The monitoring plan, a key component in our multiyear participatory statewide evaluation process, was co-developed with the end users: representatives of the health councils. Guided by the Institute of Medicine's Community, Health Improvement Process framework, we first developed a logic model that delineated processes and intermediate systems-level outcomes in council development, planning, and community action. Through the online system, health councils reported data on intermediate outcomes, including policy changes and funds leveraged. The system captured data that were common across the health council system, yet was also flexible so that councils could report their unique accomplishments at the county level. A main benefit of the online system was that it provided the ability to assess intermediate, outcomes across the health council system. Developing the system was not without challenges, including creating processes to ensure participation across a large rural state; creating shared understanding of intermediate outcomes and indicators; and overcoming technological issues. Even through the challenges, however, the benefits of committing to using participatory processes far outweighed the challenges.

Local breast cancer spatial patterning: a tool for community health resource allocation to address local disparities in breast cancer mortality

Despite available demographic data on the factors that contribute to breast cancer mortality in large population datasets, local patterns are often overlooked. Such local information could provide a valuable metric by which regional community health resources can be allocated to reduce breast cancer mortality. We used national and statewide datasets to assess geographical distribution of breast cancer mortality rates and known risk factors influencing breast cancer mortality in middle Tennessee. Each county in middle Tennessee, and each ZIP code within metropolitan Davidson County, was scored for risk factor prevalence and assigned quartile scores that were used as a metric to identify geographic areas of need. While breast cancer mortality often correlated with age and incidence, geographic areas were identified in which breast cancer mortality rates did not correlate with age and incidence, but correlated with additional risk factors, such as mammography screening and socioeconomic status. Geographical variability in specific risk factors was evident, demonstrating the utility of this approach to identify local areas of risk. This method revealed local patterns in breast cancer mortality that might otherwise be overlooked in a more broadly based analysis. Our data suggest that understanding the geographic distribution of breast cancer mortality, and the distribution of risk factors that contribute to breast cancer mortality, will not only identify communities with the greatest need of support, but will identify the types of resources that would provide the most benefit to reduce breast cancer mortality in the community.

Do socially deprived urban areas have lesser supplies of cancer care services?

PURPOSE

Area social deprivation is associated with unfavorable health outcomes of residents across the full clinical course of cancer from the stage at diagnosis through survival. We sought to determine whether area social factors are associated with the area health care supply.

PATIENTS AND METHODS

We studied the area supply of health services required for the provision of guideline-recommended care for patients with breast cancer and colorectal cancer (CRC) in each of the following three distinct clinical domains: screening, treatment, and post-treatment surveillance. We characterized area social factors in 3,096 urban zip code tabulation areas by using Census Bureau data and the health care supply in the corresponding 465 hospital service areas by using American Hospital Association, American Medical Association, and US Food and Drug Administration data. In two-level hierarchical models, we assessed associations between social factors and the supply of health services across areas.

RESULTS

We found no clear associations between area social factors and the supply of health services essential to the provision of guideline recommended breast cancer and CRC care in urban areas. The measures of health service included the supply of physicians who facilitate screening, treatment, and post-treatment care and the supply of facilities required for the same services.

CONCLUSION

Because we found that the supply of types of health care required for the provision of guideline-recommended cancer care for patients with breast cancer and CRC did not vary with markers of area socioeconomic disadvantage, it is possible that previously reported unfavorable breast cancer and CRC outcomes among individuals living in impoverished areas may have occurred despite an apparent adequate area health care supply.

Black-white differences in receipt and completion of adjuvant chemotherapy among breast cancer patients in a rural region of the US

Recent breast cancer treatment studies conducted in large urban settings have reported racial disparities in the appropriate use of adjuvant chemotherapy. This article presents the first focused evaluation of black-white differences in receipt and completion of chemotherapy for breast cancer in a primarily rural region of the United States. We performed chart abstraction on initial therapy received by 868 women diagnosed with Stages I, IIA, IIB, or IIIA breast cancer in 2001-2003 in southwest Georgia (SWGA). For chemotherapy, information collected included treatment plan, dates of delivery, concordance between therapy planned and received, and date and reasons for end of treatment. The patient's age at diagnosis, race, marital status, insurance coverage, hormone receptor status, comorbidities, socioeconomic status, urban/rural status, treatment site, and distance to the site were also collected. Following univariate analyses, we used multivariable logistic regression modeling to examine the impact of race on the likelihood of (1) receiving chemotherapy and (2) completing planned chemotherapy. For patients terminating chemotherapy prematurely, the reasons were documented. The results showed that the unadjusted black-white difference in receipt of chemotherapy (48.3 vs. 36.0%) was significant, but in the multivariable analysis the black-white odds ratio (OR = 1.18) was not. While the unadjusted black-white difference (92.0 vs. 87.8%) in completing chemotherapy was not significant, in multivariable models black race was positively associated with completing care (p ranging from 0.032 to 0.087 and OR, correspondingly, from 2.16 to 2.64). The impact of race on completing chemotherapy was influenced by marital status, with a significant black-white difference for patients not married (OR = 4.67), but no difference for those married (OR = 1.06). We find compelling racial differences in this largely rural region-with black breast cancer patients receiving or completing chemotherapy at rates that equal or exceed white patients. Further investigation is warranted, both in SWGA and in other rural regions.