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Maciel CB, Busl KM. Neuro-oncologic Emergencies. Continuum (Minneap Minn) 2024; 30:845-877. [PMID: 38830073 DOI: 10.1212/con.0000000000001435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Neuro-oncologic emergencies have become more frequent as cancer remains one of the leading causes of death in the United States, second only to heart disease. This article highlights key aspects of epidemiology, diagnosis, and management of acute neurologic complications in primary central nervous system malignancies and systemic cancer, following three thematic classifications: (1) complications that are anatomically or intrinsically tumor-related, (2) complications that are tumor-mediated, and (3) complications that are treatment-related. LATEST DEVELOPMENTS The main driver of mortality in patients with brain metastasis is systemic disease progression; however, intracranial hypertension, treatment-resistant seizures, and overall decline due to increased intracranial burden of disease are the main factors underlying neurologic-related deaths. Advances in the understanding of tumor-specific characteristics can better inform risk stratification of neurologic complications. Following standardized grading and management algorithms for neurotoxic syndromes related to newer immunologic therapies is paramount to achieving favorable outcomes. ESSENTIAL POINTS Neuro-oncologic emergencies span the boundaries of subspecialties in neurology and require a broad understanding of neuroimmunology, neuronal hyperexcitability, CSF flow dynamics, intracranial compliance, and neuroanatomy.
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Pool A, Kuna EM, Anderson-Mellies A, Kreis A, Marable M, Fraley C, Pacheco D, Green AL. Medical Record Level-Evaluation of Impact of Demographic and Socioeconomic Factors on Pediatric Neuro-Oncology Outcomes at Children's Hospital Colorado. RESEARCH SQUARE 2024:rs.3.rs-3849043. [PMID: 38260550 PMCID: PMC10802725 DOI: 10.21203/rs.3.rs-3849043/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Purpose A medical record-level cohort study to investigate demographic and socioeconomic factors influencing treatment, timing of care, and survival outcomes in pediatric patients diagnosed with central nervous system (CNS) tumors. Methods Using electronic health records of patients at Children's Hospital Colorado from 1986-2020, we identified 898 patients treated for CNS tumors. The primary outcomes of interest were 5-year survival, timing of diagnosis, and treatment. Multivariable logistic regression and Cox regression were used to identify covariates associated with our outcomes of interest. Results We found that age, race, tumor type, diagnosis year, and social concerns influenced receipt and timing of treatment. Age, race, patient rural vs. urban residence, and tumor impacted survival outcomes. Time to presentation and treatment were significantly different between White and minority patients. American Indian/Alaska Native and Black patients were less likely to receive chemo compared to White patients (OR 0.28, 0.93 p = 0.037, < 0.001). Patients with 3 + social concerns were more likely to survive after 5 years than children with no or unknown social concerns (OR 1.84, p = 0.011). However, with an adjusted hazards ratio, children with 2 social concerns were less likely to survive to 5 years than children with no or unknown concerns (OR 0.58, p = 0.066). Conclusions Demographic and socioeconomic factors influence timing of care and survival outcomes in pediatric patients with CNS tumors. Minority status, age, social factors, rural, and urban patients experience differences in care. This emphasizes the importance of considering these factors and addressing disparities to achieve equitable care.
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Delavar A, Wali AR, Santiago-Dieppa DR, Al Jammal OM, Kidwell RL, Khalessi AA. Racial and ethnic disparities in brain tumour survival by age group and tumour type. Br J Neurosurg 2022; 36:705-711. [PMID: 35762526 DOI: 10.1080/02688697.2022.2090507] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE The extent to which racial/ethnic brain tumour survival disparities vary by age is not very clear. In this study, we assess racial/ethnic brain tumour survival disparities overall by age group and type. METHODS Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) 18 registries for US-based individuals diagnosed with a first primary malignant tumour from 2007 through 2016. Cox proportional hazards regression was used to compute adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between race/ethnicity and brain tumour survival, stratified by age group and tumour type. RESULTS After adjusting for sex, socioeconomic status, insurance status, and tumour type, non-Hispanic (NH) Blacks (HR: 1.26; 95% CI: 1.02-1.55), NH Asian or Pacific Islanders (HR: 1.29; 95% CI: 1.01-1.66), and Hispanics (any race) (HR: 1.28; 95% CI: 1.09-1.51) all showed a survival disadvantage compared with NH Whites for the youngest age group studied (0-9 years). Furthermore, NH Blacks (HR: 0.88; 95% CI: 0.91-0.97), NH Asian or Pacific Islanders (HR: 0.84; 95% CI: 0.77-0.92), and Hispanics (any race) (HR: 0.91; 95% CI: 0.85-0.97) all showed a survival advantage compared with NH Whites for the 60-79 age group. Tests for interactions showed significant trends, indicating that racial/ethnic survival disparities disappear and even reverse for older age groups (P < 0.001). This reversal appears to be driven by poor glioblastoma survival among NH Whites (P < 0.001). CONCLUSION Disparities in brain tumour survival among minorities exist primarily among children and adolescents. NH White adults show worse survival than their minority counterparts, which is possibly driven by poor glioblastoma biology.
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Affiliation(s)
- Arash Delavar
- Department of Neurological Surgery, University of California, San Diego La Jolla, CA, USA
| | - Arvin R Wali
- Department of Neurological Surgery, University of California, San Diego La Jolla, CA, USA
| | | | - Omar M Al Jammal
- Department of Neurological Surgery, University of California, San Diego La Jolla, CA, USA
| | - Reilly L Kidwell
- Department of Neurological Surgery, University of California, San Diego La Jolla, CA, USA
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California, San Diego La Jolla, CA, USA
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Tran YH, Coven SL, Park S, Mendonca EA. Social determinants of health and pediatric cancer survival: A systematic review. Pediatr Blood Cancer 2022; 69:e29546. [PMID: 35107854 PMCID: PMC8957569 DOI: 10.1002/pbc.29546] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 11/11/2021] [Accepted: 12/07/2021] [Indexed: 11/07/2022]
Abstract
Despite treatment advancements and improved survival, approximately 1800 children in the United States will die of cancer annually. Survival may depend on nonclinical factors, such as economic stability, neighborhood and built environment, health and health care, social and community context, and education, otherwise known as social determinants of health (SDoH). Extant literature reviews have linked socioeconomic status (SES) and race to disparate outcomes; however, these are not inclusive of all SDoH. Thus, we conducted a systematic review on associations between SDoH and survival in pediatric cancer patients. Of the 854 identified studies, 25 were included in this review. In addition to SES, poverty and insurance coverage were associated with survival. More studies that include other SDoH, such as social and community factors, utilize prospective designs, and conduct analyses with more precise SDoH measures are needed.
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Affiliation(s)
- Yvette H. Tran
- Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana, USA,Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Scott L. Coven
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA,Riley Children’s Hospital, Indianapolis, Indiana, USA
| | - Seho Park
- Department Biostatistics and Health Data Sciences, Indiana University School of Medicine, Indianapolis, Indiana, USA,Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Eneida A. Mendonca
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA,Department Biostatistics and Health Data Sciences, Indiana University School of Medicine, Indianapolis, Indiana, USA,Regenstrief Institute, Inc., Indianapolis, Indiana, USA
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Oigman G, Osorio DS, Ferman S, Stanek JR, Aversa do Souto A, Christiani MMC, Magalhaes DMA, Finlay JL, Vianna DA. Epidemiological characteristics and survival outcomes of children with medulloblastoma treated at the National Cancer Institute (INCA) in Rio de Janeiro, Brazil. Pediatr Blood Cancer 2022; 69:e29274. [PMID: 34767315 DOI: 10.1002/pbc.29274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 07/16/2021] [Accepted: 07/19/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Medulloblastoma (MB),the most common malignant brain tumor of childhood has survival outcomes exceeding 80% for standard-risk and 60% for high-risk patients in high-income countries (HICs). These results have not been replicated in low- and middle-income countries (LMICs), where 80% of children with cancer live. METHODS This is a retrospective review of 114 children aged 3-18 years diagnosed with MB from 1997 to 2016 at National Cancer Institute (INCA). Sociodemographic, clinical, and treatment data were extracted from the medical records and summarized descriptively. Overall survival (OS) and progression-free survival (PFS) were calculated using the Kaplan-Meier method. RESULTS The male-to-female ratio was 1.32 and the median age at diagnosis was 8.2 years. Headache (83%) and nausea/vomiting (78%) were the most common presenting symptoms. Five-year OS was 59.1% and PFS was 58.4%. The OS for standard-risk and high-risk patients was 69% and 53%, respectively. The median time to diagnosis interval was 50.5 days and the median time from surgery to radiation therapy initiation was 50.4 days. Patients who lived >40 km from INCA fared better (OS = 68.2% vs. 51.1%, p = .032). Almost 20% of families lived below the Brazilian minimum wage. Forty-five patients (35%) had metastatic disease at admission. Gross total resection was achieved in 57% of the patitents. CONCLUSIONS Although there are considerable barriers to deliver effective MB treatment in countries like Brazil, the OS seen in the present study demonstrates that good outcomes are not only feasible but can and should be increased with appropriate interventions.
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Affiliation(s)
- Gabriela Oigman
- Division of Pediatric Oncology, National Cancer Institute, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Diana S Osorio
- Division of Hematology, Oncology, and BMT, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Sima Ferman
- Division of Pediatric Oncology, National Cancer Institute, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Joseph R Stanek
- Division of Hematology, Oncology, and BMT, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | | | - Marcio M C Christiani
- Division of Neurosurgery, National Cancer Institute, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Denise M A Magalhaes
- Division of Radiation Oncology, National Cancer Institute, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jonathan L Finlay
- Division of Hematology, Oncology, and BMT, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Denizar A Vianna
- Internal Medicine Department, State University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
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Beltrami A, Hilliard A, Green AL. Demographic and socioeconomic disparities in pediatric cancer in the United States: Current knowledge, deepening understanding, and expanding intervention. Cancer Epidemiol 2021; 76:102082. [PMID: 34923289 DOI: 10.1016/j.canep.2021.102082] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 01/19/2023]
Abstract
While survival of pediatric cancer has improved greatly over the past 40 years, demographic and socioeconomic disparities have meant that some groups have not benefitted as much from these advances. We conducted a rapid review to summarize literature on demographic and socioeconomic disparities in outcomes of childhood cancer, starting in 2000. We find that unequal outcomes have been noted for many of these groups across hematologic malignancies, central nervous system tumors, and other solid tumors, although occasional studies have noted absence of disparities for particular at-risk groups and diseases, and gaps in understanding of disparities for some cancer subtypes and groups still exist. These include disparities in duration of overall survival, risk of death, more extensive disease at presentation, and differences/delays in treatment. Black race, Hispanic ethnicity, lack of private insurance, and adolescent/young adult age are most often associated with these poorer outcomes. We then delve into documented and theorized causes of these disparities, including impaired access to care and clinical trials, differences in cancer biology, treatment non-adherence, language barriers, and implicit racial bias. Here, it is clear that socioeconomic factors account for a large proportion of disparities seen, although not all, and that the causes of disparities are complex and interconnected and still need to be better understood. Finally, in an effort to shift emphasis to addressing disparities, we review interventions against disparities that have been studied in childhood cancer patients and other populations, including improving clinical trial representation, communication, health literacy, and family navigation. We suggest ways forward in disparity mitigation toward a goal of achieving equitable cancer outcomes for all children.
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Affiliation(s)
- Alina Beltrami
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States; Department of Biological Sciences, University of Denver, Denver, CO, United States
| | - Alexandra Hilliard
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States; Department of Biological Sciences, University of Denver, Denver, CO, United States
| | - Adam L Green
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States; Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO, United States.
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Haizel-Cobbina J, Chen JW, Belete A, Dewan MC, Karekezi C. The landscape of neuro-oncology in East Africa: a review of published records. Childs Nerv Syst 2021; 37:2983-2992. [PMID: 34468839 DOI: 10.1007/s00381-021-05344-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/23/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Primary central nervous system (CNS) tumors represent an important and growing cause of worldwide morbidity and mortality. There are global variations in the reported case burden of CNS tumors, with high-income countries reporting a higher incidence of cases than low- and middle-income countries. Variations are attributed to differences in access to care, diagnostic capacity, risk exposure, and under-reporting in LMICs. This study aims to review existing literature on the distribution of primary CNS tumors and neuro-oncologic care, and the contribution of scientists and institutions to neuro-oncologic research across 18 East African countries over the last 5 decades. METHOD A search was conducted using OVID Medline and PubMed databases to identify relevant East African neuro-oncologic studies published over the last 50 years. RESULTS The authors reviewed 36 neuro-oncology articles published across 8 of 18 East African countries. Kenya represented the highest number of published articles; ten countries queried yielded zero publications. A total of 2006 cases from all age groups were represented in published literature consisting of a wide spectrum of CNS tumors. One-third of reported cases were pediatric. Meningioma formed the largest proportion (43.3%) followed by glioma (33.7%). Sixty-seven percent of publications gave an overview of clinical care received by patients with most patients not receiving comprehensive neuro-oncologic care. CONCLUSION The modest collection of neuro-oncology publications from East Africa shows that the case diversity of primary CNS tumors in East Africa is comparable to the rest of the world. There is, however, poorer access to neurosurgical care and adjuvant therapy. Multidisciplinary efforts from clinicians, researchers, and healthcare agencies are needed to quantify and address the requisite neuro-oncology needs in this region.
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Affiliation(s)
- Joseline Haizel-Cobbina
- Vanderbilt Institute of Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey W Chen
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Michael C Dewan
- Vanderbilt Institute of Global Health, Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Claire Karekezi
- Department of Surgery, Neurosurgery Unit, Rwanda Military Hospital, Kigali, Rwanda
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Namin S, Zhou Y, Neuner J, Beyer K. Neighborhood Characteristics and Cancer Survivorship: An Overview of the Current Literature on Neighborhood Landscapes and Cancer Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:7192. [PMID: 34281129 PMCID: PMC8297243 DOI: 10.3390/ijerph18137192] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/21/2021] [Accepted: 07/02/2021] [Indexed: 12/18/2022]
Abstract
There is a growing literature on the association between neighborhood contexts and cancer survivorship. To understand the current trends and the gaps in the literature, we aimed to answer the following questions: To what degree, and how, has cancer survivorship research accounted for neighborhood-level effects? What neighborhood metrics have been used to operationalize neighborhood factors? To what degree do the neighborhood level metrics considered in cancer research reflect neighborhood development as identified in the Leadership for Energy and Environmental Design for Neighborhood Development (LEED-ND) guidelines? We first conducted a review guided by PRISMA extension for scoping review of the extant literature on neighborhood effects and cancer survivorship outcomes from January 2000 to January 2021. Second, we categorized the studied neighborhood metrics under six main themes. Third, we assessed the findings based on the LEED-ND guidelines to identify the most relevant neighborhood metrics in association with areas of focus in cancer survivorship care and research. The search results were scoped to 291 relevant peer-reviewed journal articles. Results show that survivorship disparities, primary care, and weight management are the main themes in the literature. Additionally, most articles rely on neighborhood SES as the primary (or only) examined neighborhood level metric. We argue that the expansion of interdisciplinary research to include neighborhood metrics endorsed by current paradigms in salutogenic urban design can enhance the understanding of the role of socioecological context in survivorship care and outcomes.
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Affiliation(s)
- Sima Namin
- Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (Y.Z.); (K.B.)
| | - Yuhong Zhou
- Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (Y.Z.); (K.B.)
| | - Joan Neuner
- General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
| | - Kirsten Beyer
- Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (Y.Z.); (K.B.)
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Puthenpura V, Canavan ME, Poynter JN, Roth M, Pashankar FD, Jones BA, Marks AM. Racial/ethnic, socioeconomic, and geographic survival disparities in adolescents and young adults with primary central nervous system tumors. Pediatr Blood Cancer 2021; 68:e28970. [PMID: 33704901 PMCID: PMC8221084 DOI: 10.1002/pbc.28970] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/15/2021] [Accepted: 02/04/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Disparities in survival by race/ethnicity, socioeconomic status (SES), and geography in adolescent and young adult (AYA) patients with central nervous system (CNS) tumors have not been well studied. PROCEDURE A retrospective cohort study utilizing the Surveillance, Epidemiology, and End Results (SEER) database was conducted for AYA patients diagnosed with primary CNS tumors. Adjusted hazard ratios (aHR) were calculated using a multivariate Cox proportional hazard model to evaluate the association between race/ethnicity, SES, rurality, and hazard of death. RESULTS All minority groups showed an increased hazard of death with greatest disparities in the high-grade glioma cohort. Lower SES was associated with an increased hazard of death in non-Hispanic White (NHW) patients (aHR 1.12; 95% confidence interval [CI] 1.01-1.24), non-Hispanic Black (NHB) patients (aHR 1.34; 95% CI 1.00-1.80), and patients aged 25-29 years (aHR 1.29; 95% CI 1.07-1.55). Mediation analysis showed an indirect effect of SES on the effect of race/ethnicity on the hazard of death only among NHB patients, with SES accounting for 33.7% of the association between NHB and hazard of death. Rurality was associated with an increased hazard of death for patients in the lowest SES tertile (aHR 1.31; 95% CI 1.08-1.59) and NHW patients (aHR 1.20; 95% CI 1.08-1.34). CONCLUSIONS Patients identified as a racial/ethnic minority, patients with a lower SES, and patients residing in rural areas had an increased hazard of death. Further studies are needed to understand and address the biological, psychosocial, societal, and economic factors that impact AYA neuro-oncology patients at highest risk of experiencing poorer outcomes.
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Affiliation(s)
- Vidya Puthenpura
- Section of Pediatric Hematology and Oncology, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Maureen E Canavan
- Department of Internal Medicine, Cancer Outcomes and Public Policy and Effectiveness Research (COPPER), Yale School of Medicine, New Haven, Connecticut, USA
| | - Jenny N Poynter
- Division of Epidemiology and Clinical Research, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael Roth
- Department of Pediatrics Patient Care, Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farzana D Pashankar
- Section of Pediatric Hematology and Oncology, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Beth A Jones
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Asher M Marks
- Section of Pediatric Hematology and Oncology, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
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Aristizabal P, Winestone LE, Umaretiya P, Bona K. Disparities in Pediatric Oncology: The 21st Century Opportunity to Improve Outcomes for Children and Adolescents With Cancer. Am Soc Clin Oncol Educ Book 2021; 41:e315-e326. [PMID: 34061564 PMCID: PMC9126642 DOI: 10.1200/edbk_320499] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Adult cancer disparities have been documented for decades and continue to persist despite clinical advancements in cancer prevention, detection, and treatment. Pediatric cancer survival has improved significantly in the United States for the past 5 decades to over 80%; however, disparate outcomes among children and adolescents with cancer still affect many populations in the United States and globally, including racial and ethnic minorities, populations with low socioeconomic status, and residents of underserved areas. To achieve equitable outcomes for all children and adolescents with cancer, it is imperative that concerted multilevel approaches be carried out to understand and address health disparities and to ensure access to high-quality cancer care. Addressing social determinants of health, such as removing barriers to health care access and ensuring access to social supports, can reduce pediatric cancer disparities. Nevertheless, public health policy, health system interventions, and innovative delivery of evidence-based services are critically needed. Partnerships among patients, caregivers, and health care providers, and among health care, academic, and governmental institutions, have a pivotal role in reducing cancer disparities and improving outcomes in the 21st century.
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Affiliation(s)
- Paula Aristizabal
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of California San Diego/Peckham Center for Cancer and Blood Disorders, Rady Children’s Hospital San Diego, San Diego, CA
- Population Sciences, Disparities and Community Engagement, University of California San Diego Moores Cancer Center, La Jolla, CA
| | - Lena E. Winestone
- Department of Pediatrics, Division of Allergy, Immunology, and Blood & Marrow Transplantation, University of California San Francisco Benioff Children’s Hospitals, San Francisco, CA
- University of California San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | - Puja Umaretiya
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kira Bona
- Department of Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Maternal and perinatal factors are associated with risk of pediatric central nervous system tumors and poorer survival after diagnosis. Sci Rep 2021; 11:10410. [PMID: 34001927 PMCID: PMC8129132 DOI: 10.1038/s41598-021-88385-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 04/06/2021] [Indexed: 11/09/2022] Open
Abstract
Central nervous system (CNS) tumors are the most common solid tumors in children. Findings on the role of maternal and perinatal factors on the susceptibility or outcome of these tumors are inconclusive. Therefore, we investigated the association between these early-life factors, risk, and survival of pediatric CNS tumors, using data from one of the world’s largest and most diverse cancer registries. Information on pediatric CNS tumor cases (n = 1950) for the period 1995–2011 was obtained from the Texas Cancer Registry. Birth certificate controls were frequency-matched on birth year at a ratio of 10:1 for the same period. Evaluated maternal and perinatal variables were obtained from birth records. Unconditional logistic regression was used to generate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for etiological factors. Additionally, Cox proportional hazards regression was employed to assess adjusted hazard ratios (HRs) and 95% CIs for survival factors. The results indicated that Hispanic and non-Hispanic black mothers were less likely to have children with CNS tumors compared to non-Hispanic white mothers (OR 0.88 [95% CI 0.78–0.98] P-value = 0.019; OR 0.79 [95% CI 0.67–0.93 P-value = 0.004], respectively). Infants born large for gestational age (OR 1.26 [95% CI 1.07–1.47] P-value = 0.004) and those delivered pre-term (OR 1.19 [95% CI 1.04–1.38] P-value = 0.013) showed an increased risk of CNS tumors. Infants born by vaginal forceps or vacuum delivery had a higher risk of CNS tumors compared to those born by spontaneous vaginal delivery (OR 1.35 [95% CI 1.12–1.62] P-value = 0.002). Additionally, offspring of Hispanic and non-Hispanic black mothers showed a higher risk of death (HR 1.45 [95% CI 1.16–1.80] P-value = 0.001; HR 1.53 [95% CI 1.12–2.09] P-value = 0.008, respectively). Infants born by cesarean had a higher risk of death compared to those delivered vaginally (HR 1.28 [95% CI 1.05–1.57] P-value = 0.016). These findings indicate the important role of maternal and perinatal characteristics in the etiology and survival of these clinically significant malignancies.
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Racial and ethnic disparities among children with primary central nervous system tumors in the US. J Neurooncol 2021; 152:451-466. [PMID: 33774801 DOI: 10.1007/s11060-021-03738-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Primary central nervous system (CNS) tumors are among the most common and lethal types of cancer in children. However, the existence of health disparities in CNS tumors by race or ethnicity remains poorly understood. This systematic review sought to determine whether racial and ethnic disparities in incidence, healthcare access, and survival exist among pediatric patients diagnosed with CNS tumors. METHODS A search of MEDLINE, Embase, CINAHL, Web of Science, and Scopus was conducted. Inclusion criteria selected for studies published between January 1, 2005 and July 15, 2020 that focused on pediatric populations in the US, evaluated for potential differences based on racial or ethnic backgrounds, and focused on CNS tumors. A standardized study form was used to collect study information, population of interest, research design, and quality of analysis, sample size, participant demographics, pathology evaluated, and incidence or outcomes observed. RESULTS A total of 30 studies were inlcuded. Studies suggest White children may be more likely to be diagnosed with a CNS tumor and Hispanic children to present with advanced-stage disease and have worse outcomes. The degree of influence derived from socioeconomic factors is unclear. This review was limited by few available studies that included race and ethnicity as a variable, the overlap in databases used, and unclear categorization of race and ethnicity. CONCLUSIONS This review identified notable and at times contradicting variations in racial/ethnic disparities among children with CNS tumors, suggesting that the extent of these disparities remains largely unknown and prompts further research to improve health equity.
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Adel Fahmideh M, Scheurer ME. Pediatric Brain Tumors: Descriptive Epidemiology, Risk Factors, and Future Directions. Cancer Epidemiol Biomarkers Prev 2021; 30:813-821. [PMID: 33653816 DOI: 10.1158/1055-9965.epi-20-1443] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/23/2020] [Accepted: 02/23/2021] [Indexed: 11/16/2022] Open
Abstract
Brain tumors are the most common solid tumors in children and remain a significant contributor to death by disease in this population. Pediatric brain tumors (PBT) are broadly classified into two major categories: glial and neuronal tumors. Various factors, including tumor histology, tumor location, and demographics, influence the incidence and prognosis of this heterogeneous group of neoplasms. Numerous epidemiologic studies have been conducted to identify genetic and environmental risk factors for these malignancies. Thus far, the only established risk factors for PBTs are exposure to ionizing radiation and some rare genetic syndromes. However, relatively consistent evidence of positive associations for birth defects, markers of fetal growth, advanced parental age, maternal dietary N-nitroso compounds, and exposure to pesticides have been reported. The genetic variants associated with susceptibility to PBTs were predominantly identified by a candidate-gene approach. The identified genetic variants belong to four main pathways, including xenobiotic detoxification, inflammation, DNA repair, and cell-cycle regulation. Conducting large and multi-institutional studies is warranted to systematically detect genetic and environmental risk factors for different histologic subtypes of PBTs. This, in turn, might lead to a better understanding of etiology of PBTs and eventually developing risk prediction models to prevent these clinically significate malignancies.
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Affiliation(s)
- Maral Adel Fahmideh
- Department of Medicine, Section of Epidemiology and Population Sciences, Baylor College of Medicine, Houston, Texas. .,Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas.,Center for Epidemiology and Population Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Michael E Scheurer
- Department of Medicine, Section of Epidemiology and Population Sciences, Baylor College of Medicine, Houston, Texas.,Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas.,Center for Epidemiology and Population Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas.,Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas
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14
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Haizel-Cobbina J, Spector LG, Moertel C, Parsons HM. Racial and ethnic disparities in survival of children with brain and central nervous tumors in the United States. Pediatr Blood Cancer 2021; 68:e28738. [PMID: 32970937 DOI: 10.1002/pbc.28738] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite improvements in overall survival for pediatric cancers, treatment disparities remain for racial/ethnic minorities compared to non-Hispanic Whites; however, the impact of race on treatment outcomes for pediatric brain and central nervous system (CNS) tumors in the United States is not well known. METHODS We included 8713 children aged 0-19 years with newly diagnosed primary brain and CNS tumors between 2000 and 2015 from the Census Tract-level SES and Rurality Database developed by Surveillance, Epidemiology, and End Results (SEER) Program. We used chi-square tests to assess differences in sociodemographic, cancer, and treatment characteristics by race/ethnicity and Kaplan-Meier curves and Cox proportional hazards models to examine differences in 10-year survival, adjusting for these characteristics. RESULTS Among 8713 patients, 56.75% were non-Hispanic White, 9.59% non-Hispanic Black, 25.46% Hispanic, and 8.19% from "other" racial/ethnic groups. Median unadjusted survival for all pediatric brain tumors was 53 months, but varied significantly by race/ethnicity with a median survival of 62 months for non-Hispanic Whites, 41 months for non-Hispanic Blacks, and 40 months for Hispanic and other. Multivariable analyses demonstrated minority racial groups still had significantly higher hazard of death than non-Hispanic Whites; Hispanic (adjusted hazard ratio [aHR] 1.25 [1.18-1.31]); non-Hispanic Black (aHR 1.12 [1.04-1.21]); other (aHR 1.22 [1.12-1.32]). Results were consistent when stratified by tumor histology. CONCLUSION We identified disparities in survival among racial/ethnic minorities with pediatric brain and CNS tumors, with Hispanic patients having the highest risk of mortality. Eliminating these disparities requires commitment toward promoting heath equity and personalized cancer treatment.
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Affiliation(s)
| | - Logan G Spector
- Division of Pediatric Epidemiology and Clinical Research, University of Minnesota, Minneapolis, Minnesota
| | - Christopher Moertel
- Division of Pediatric Hematology and Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Helen M Parsons
- Division of Health Policy and Management, University of Minnesota, Minneapolis, Minnesota
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15
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Bonkowsky JL, deVeber G, Kosofsky BE. Pediatric Neurology Research in the Twenty-First Century: Status, Challenges, and Future Directions Post-COVID-19. Pediatr Neurol 2020; 113:2-12. [PMID: 32979654 DOI: 10.1016/j.pediatrneurol.2020.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND The year 2020 marked a fundamental shift in the pediatric neurology field. An impressive positive trajectory of advances in patient care and research faced sudden global disruptions by the coronavirus disease 2019 pandemic and by an international movement protesting racial, socioeconomic, and health disparities. The disruptions revealed obstacles and fragility within the pediatric neurology research mission. However, renewed commitment offers unique opportunities for the pediatric neurology research community to enhance and prioritize research directions for the coming decades. METHODS The Research Committee of the Child Neurology Society evaluated the challenges and opportunities facing the pediatric neurology research field, including reviewing published literature, synthesizing publically available data, and conducting a survey of pediatric neurologists. RESULTS We identified three priority domains for the research mission: funding levels, active guidance, and reducing disparities. Funding levels: to increase funding to match the burden of pediatric neurological disease; to tailor funding mechanisms and strategies to support clinical trial efforts unique to pediatric neurology; and to support investigators across their career trajectory. Active guidance: to optimize infrastructure and strategies, to leverage novel therapeutics, enhance data collection, and improve inclusion of children in clinical trials. Reducing disparities: to reduce health disparities in children with neurological disease, to develop proactive measures to enhance workforce diversity and inclusion, and increase avenues to balance work-life obligations for investigators. CONCLUSIONS In this uniquely challenging epoch, the pediatric neurology research community has a timely and important mission to re-engage the public and government, advancing the health of children with neurological conditions.
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Affiliation(s)
- Joshua L Bonkowsky
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah; Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah.
| | - Gabrielle deVeber
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Barry E Kosofsky
- Department of Pediatrics, New York-Presbyterian/Weill Cornell Medicine, New York, New York
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16
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Wang X, Ojha RP, Partap S, Johnson KJ. The effect of insurance status on overall survival among children and adolescents with cancer. Int J Epidemiol 2020; 49:1366-1377. [DOI: 10.1093/ije/dyaa079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2020] [Indexed: 12/11/2022] Open
Abstract
Abstract
Background
Differences in access, delivery and utilisation of health care may impact childhood and adolescent cancer survival. We evaluated whether insurance coverage impacts survival among US children and adolescents with cancer diagnoses, overall and by age group, and explored potential mechanisms.
Methods
Data from 58 421 children (aged ≤14 years) and adolescents (15–19 years), diagnosed with cancer from 2004 to 2010, were obtained from the National Cancer Database. We examined associations between insurance status at initial diagnosis or treatment and diagnosis stage; any treatment received; and mortality using logistic regression, Cox proportional hazards (PH) regression, restricted mean survival time (RMST) and mediation analyses.
Results
Relative to privately insured individuals, the hazard of death (all-cause) was increased and survival months were decreased in those with Medicaid [hazard ratio (HR) = 1.27, 95% confidence interval (CI): 1.22 to 1.33; and −1.73 months, 95% CI: −2.07 to −1.38] and no insurance (HR = 1.32, 95% CI: 1.20 to 1.46; and −2.13 months, 95% CI: −2.91 to −1.34). The HR for Medicaid vs. private insurance was larger (pinteraction <0.001) in adolescents (HR = 1.52, 95% CI: 1.41 to 1.64) than children (HR = 1.16, 95% CI: 1.10 to 1.23). Despite statistical evidence of PH assumption violation, RMST results supported all interpretations. Earlier diagnosis for staged cancers in the Medicaid and uninsured populations accounted for an estimated 13% and 19% of the survival deficit, respectively, vs. the privately insured population. Any treatment received did not account for insurance-associated survival differences in children and adolescents with cancer.
Conclusions
Children and adolescents without private insurance had a higher risk of death and shorter survival within 5 years following cancer diagnosis. Additional research is needed to understand underlying mechanisms.
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Affiliation(s)
- Xiaoyan Wang
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Rohit P Ojha
- Center for Outcomes Research, JPS Health Network, Fort Worth, TX, USA
- Department of Biostatistics and Epidemiology, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Sonia Partap
- Department of Neurology, Stanford University, Palo Alto, CA, USA
- Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Kimberly J Johnson
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
- Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
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17
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Population-Based Analysis of Demographic and Socioeconomic Disparities in Pediatric CNS Cancer Survival in the United States. Sci Rep 2020; 10:4588. [PMID: 32165703 PMCID: PMC7067886 DOI: 10.1038/s41598-020-61237-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/18/2020] [Indexed: 11/09/2022] Open
Abstract
Previous studies have demonstrated effects of racial and socioeconomic factors on survival of adults with cancer. While less studied in the pediatric population, data exist demonstrating disparities of care and survival in pediatric oncology patients based on socioeconomic and racial/ethnic factors. Brain cancers recently overtook leukemia as the number one cause of childhood cancer fatalities, but demographic and socioeconomic disparities in these tumors have not been adequately studied. We obtained data from the SEER Program of the National Cancer Institute (NCI). We selected patients under 19 years of age with central nervous system (CNS) cancers diagnosed between 2000 and 2015. We included patient demographics, tumor characteristics, treatment, and socioeconomic characteristics as covariates in the analysis. We measured overall survival and extent of disease at diagnosis. We saw that Black and Hispanic patients overall had a higher risk of death than non-Hispanic White patients on multivariable analysis. On stratified analysis, Black and Hispanic patients with both metastatic and localized disease at diagnosis had a higher risk of death compared to White, non-Hispanic patients, although the difference in Black patients was not significant after adjusting for mediating factors. However, our findings on extent of disease at diagnosis demonstrated that neither Black race nor Hispanic ethnicity increased the chance of metastatic disease at presentation when controlling for mediating variables. In summary, racial and ethnic disparities in childhood CNS tumor survival appear to have their roots at least partially in post-diagnosis factors, potentially due to the lack of access to high quality care, leading to poorer overall outcomes.
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18
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Ostrom QT, Truitt G, Gittleman H, Brat DJ, Kruchko C, Wilson R, Barnholtz-Sloan JS. Relative survival after diagnosis with a primary brain or other central nervous system tumor in the National Program of Cancer Registries, 2004 to 2014. Neurooncol Pract 2019; 7:306-312. [PMID: 32537180 DOI: 10.1093/nop/npz059] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background The majority of reported cancer survival statistics in the United States are generated using the National Cancer Institute's publicly available Surveillance, Epidemiology, and End Results (SEER) data, which prior to 2019 represented 28% of the US population (now 37%). In the case of rare cancers or special subpopulations, data sets based on a larger portion of the US population may contribute new insights into these low-incidence cancers. The purpose of this study is to characterize the histology-specific survival patterns for all primary malignant and nonmalignant primary brain tumors in the United States using the Centers for Disease Control and Prevention's National Program of Cancer Registries (NPCR). Methods Survival data were obtained from the NPCR (includes data from 39 state cancer registries, representing 81% of the US population). Relative survival rates (RS) with 95% CI were generated using SEER*Stat 8.3.5 from 2004 to 2014 by behavior, histology, sex, race/ethnicity, and age at diagnosis. Results Overall, there were 488 314 cases from 2004 to 2014. Overall 5-year RS was 69.8% (95% CI = 69.6%-69.9%). Five-year RS was 35.9% (95% CI = 35.6%-36.1%) for malignant and 90.2% (95% CI = 90.1%-90.4%) for nonmalignant tumors. Pilocytic astrocytoma had the longest 5-year RS (94.2%, 95% CI = 93.6%-94.6%) of all glioma subtypes, whereas glioblastoma had the shortest 5-year RS (6.1%, 95% CI = 6.0%-6.3%). Nonmalignant nerve sheath tumors had the longest 5-year RS (99.3%, 95% CI = 99.1%-99.4%). Younger age and female sex were associated with increased survival for many histologies. Conclusions Survival after diagnosis with primary brain tumor varies by behavior, histology, and age. Using such a database that includes more than 80% of the US population may represent national survival patterns.
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Affiliation(s)
- Quinn T Ostrom
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA.,Department of Medicine, Section of Epidemiology and Population Sciences, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Gabrielle Truitt
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA.,Department of Bioethics, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Haley Gittleman
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Daniel J Brat
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
| | - Reda Wilson
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jill S Barnholtz-Sloan
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA.,Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Siegel DA, Li J, Ding H, Singh SD, King JB, Pollack LA. Racial and ethnic differences in survival of pediatric patients with brain and central nervous system cancer in the United States. Pediatr Blood Cancer 2019; 66:e27501. [PMID: 30350913 PMCID: PMC6314020 DOI: 10.1002/pbc.27501] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/30/2018] [Accepted: 09/15/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Brain and central nervous system (CNS) cancer is the leading cause of cancer death among children and adolescents in the United States. Data from earlier studies suggested racial and ethnic differences in survival among pediatric patients with brain tumor. This study examined racial/ethnic difference in survival using national data and considered the effects of demographic and clinical factors. METHODS Using National Program of Cancer Registries data, 1-, 3-, and 5-year relative survival (cancer survival in the absence of other causes of death) was calculated for patients with brain and CNS cancer aged < 20 years diagnosed during 2001-2008 and followed up through 2013. Racial and ethnic differences in survival were measured by sex, age, economic status, stage, anatomic location, and histology. Adjusted racial and ethnic difference in 5-year cancer specific survival was estimated using multivariable Cox regression analysis. RESULTS Using data from 11 302 patients, 5-year relative survival was 77.6% for non-Hispanic white patients, 69.8% for non-Hispanic black patients, and 72.9% for Hispanic patients. Differences in relative survival by race/ethnicity existed within all demographic groups. Based on multivariable analysis, non-Hispanic black patients had a higher risk of death at 5 years after diagnosis compared to non-Hispanic white patients (adjusted hazard ratio = 1.2, 95% confidence interval, 1.1-1.4). CONCLUSIONS Pediatric brain and CNS cancer survival differed by race/ethnicity, with non-Hispanic black patients having a higher risk of death than non-Hispanic white patients. Future investigation of access to care, social and economic barriers, and host genetic factors might identify reasons for disparities in survival.
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Affiliation(s)
- David A. Siegel
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia,Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jun Li
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Helen Ding
- DB Consulting Group, Inc., Atlanta, Georgia
| | - Simple D. Singh
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jessica B. King
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lori A. Pollack
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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