Advancing Health Equity in Cancer Survivorship: Opportunities for Public Health

Survivorship after adolescent and young adult cancer: models of care, disparities, and opportunities

Survivors of adolescent and young adult (AYA; age 15-39 years at diagnosis) cancer are a growing population with the potential to live for many decades after treatment completion. Survivors of AYA cancer are at risk for adverse long-term outcomes including chronic conditions, secondary cancers, impaired fertility, poor psychosocial health and health behaviors, and financial toxicity. Furthermore, survivors of AYA cancer from racially minoritized and low socioeconomic status populations experience disparities in these outcomes, including lower long-term survival. Despite these known risks, most survivors of AYA cancer do not receive routine survivorship follow-up care, and research on delivering high-quality, evidence-based survivorship care to these patients is lacking. The need for survivorship care was initially advanced in 2006 by the Institute of Medicine. In 2019, the Quality of Cancer Survivorship Care Framework (QCSCF) was developed to provide an evidence-based framework to define key components of optimal survivorship care. In this commentary focused on survivors of AYA cancer, we apply the QCSCF framework to describe models of care that can be adapted for their unique needs, multilevel factors limiting equitable access to care, and opportunities to address these factors to improve short- and long-term outcomes in this vulnerable population.

Advancing health equity in cancer survivorship research: National Institutes of Health 2017-2022 portfolio review

BACKGROUND

Communities and researchers have called for a paradigm shift from describing health disparities to a health equity research agenda that addresses structural drivers. Therefore, we examined whether the cancer survivorship research portfolio has made this shift.

METHODS

We identified grants focused on populations experiencing health disparities from the National Institutes of Health (NIH) Cancer Survivorship Research Portfolio (N = 724), Fiscal Years 2017-2022. Grant characteristics were abstracted, drivers of health disparities were mapped onto the levels and domains of influence, and opportunities for future research were identified.

RESULTS

A total of 147 survivorship grants focused on health disparities were identified, of which 73.5% of grants focused on survivors from racial and ethnic minoritized groups, 25.9% living in rural areas, 24.5% socioeconomically disadvantaged, and 2.7% sexual and gender minority groups. Study designs were 51.0% observational; 82.3% of grants measured or intervened on at least 1 individual-level of influence compared to higher levels of influence (32.7% interpersonal, 41.5% institutional and community, and 12.2% societal). Behavioral and health care system domains of influence were commonly represented, especially at the individual level (47.6% and 36.1%, respectively). Less frequently represented was the physical and built environment (12.2%).

CONCLUSIONS

NIH-funded cancer survivorship research on health disparities is still focused on individual level of influence. However, the proportion of grants examining structural and social drivers as well as the mechanisms that drive disparities in health care and health outcomes among cancer survivors have increased over time. Gaps in funded research on specific populations, cancer types, and focus areas of survivorship science were identified and warrant priority.

Voices of Black men: reflecting on prostate cancer survivorship care plans

PURPOSE

This study addresses the critical issue of survivorship care for Black prostate cancer survivors. The aim was to explore their awareness of survivorship care plans to improve prostate cancer care and survivorship within this high-risk group.

METHODS

Utilizing a thematic analysis approach, we conducted in-depth interviews focused on analyzing post-treatment experiences of Black prostate cancer survivors by applying interpretive explanations to data collected from participants.

RESULTS

Participants reported a significant gap in survivorship care plan communication post-treatment, as these plans were seldom discussed. Survivors highlighted the adoption of post-treatment strategies and self-education as means to enhance their comprehension of the survivorship process. Black survivors demonstrated an intrinsic motivation, after feeling "discarded," to find suitable resources to enhance their survivorship care for a better quality of life.

CONCLUSION

The prioritization of post-treatment care for Black prostate cancer survivors is important. By offering comprehensive post-treatment education, improving symptom transparency, and establishing safe spaces for open discussion, the quality of life of Black survivors may be substantially improved.

IMPLICATIONS FOR CANCER SURVIVORS

There is a pressing need for dynamic post-treatment care coordination tailored to Black prostate cancer survivors. A lack of crucial post-treatment education for this population that experiences disproportionate burden of prostate cancer may exacerbate cancer health disparities. Addressing this care coordination gap may improve support systems, survivor well-being, and better cancer outcomes.

Logistic burdens of cancer care: A qualitative study

Cancer treatment often creates logistic conflicts with everyday life priorities; however, these challenges and how they are subjectively experienced have been largely unaddressed in cancer care. Our goal was to describe time and logistic requirements of cancer care and whether and how they interfered with daily life and well-being. We conducted interviews with 20 adults receiving cancer-directed treatment at a single academic cancer center. We focused on participants' perception of the time, effort, and energy-intensiveness of cancer care activities, organization of care requirements, and preferences in how to manage the logistic burdens of their cancer care. Participant interview transcripts were analyzed using an inductive thematic analysis approach. Burdens related to travel, appointment schedules, healthcare system navigation, and consequences for relationships had roots both at the system-level (e.g. labs that were chronically delayed, protocol-centered rather than patient-centered bureaucratic requirements) and in individual circumstances (e.g. greater stressors among those working and/or have young children versus those who are retired) that determined subjective burdensomeness, which was highest among patients who experienced multiple sources of burdens simultaneously. Our study illustrates how objective burdens of cancer care translate into subjective burden depending on patient circumstances, emphasizing that to study burdens of care, an exclusive focus on objective measures does not capture the complexity of these issues. The complex interplay between healthcare system factors and individual circumstances points to clinical opportunities, for example helping patients to find ways to meet work and childcare requirements while receiving care.

Multimorbidity clusters in adults 50 years or older with and without a history of cancer: National Health Interview Survey, 2018

BACKGROUND

Multimorbidity is increasing among adults in the United States. Yet limited research has examined multimorbidity clusters in persons aged 50 years and older with and without a history of cancer. An increased understanding of multimorbidity clusters may improve the cancer survivorship experience for survivors with multimorbidity.

METHODS

We identified 7580 adults aged 50 years and older with 2 or more diseases-including 811 adults with a history of primary breast, colorectal, cervical, prostate, or lung cancer-from the 2018 National Health Interview Survey. Exploratory factor analysis identified clusters of multimorbidity among cancer survivors and individuals without a history of cancer (controls). Frequency tables and chi-square tests were performed to determine overall differences in sociodemographic characteristics, health-related characteristics, and multimorbidity between groups.

RESULTS

Cancer survivors reported a higher prevalence of having 4 or more diseases compared to controls (57% and 38%, respectively). Our analysis identified 6 clusters for cancer survivors and 4 clusters for controls. Three clusters (pulmonary, cardiac, and liver) included the same diseases for cancer survivors and controls.

CONCLUSIONS

Diseases clustered differently across adults ≥ 50 years of age with and without a history of cancer. Findings from this study may be used to inform clinical care, increase the development and dissemination of multilevel public health interventions, escalate system improvements, and initiate innovative policy reform.

Population simulation modeling of disparities in US breast cancer mortality

BACKGROUND

Populations of African American or Black women have persistently higher breast cancer mortality than the overall US population, despite having slightly lower age-adjusted incidence.

METHODS

Three Cancer Intervention and Surveillance Modeling Network simulation teams modeled cancer mortality disparities between Black female populations and the overall US population. Model inputs used racial group-specific data from clinical trials, national registries, nationally representative surveys, and observational studies. Analyses began with cancer mortality in the overall population and sequentially replaced parameters for Black populations to quantify the percentage of modeled breast cancer morality disparities attributable to differences in demographics, incidence, access to screening and treatment, and variation in tumor biology and response to therapy.

RESULTS

Results were similar across the 3 models. In 2019, racial differences in incidence and competing mortality accounted for a net ‒1% of mortality disparities, while tumor subtype and stage distributions accounted for a mean of 20% (range across models = 13%-24%), and screening accounted for a mean of 3% (range = 3%-4%) of the modeled mortality disparities. Treatment parameters accounted for the majority of modeled mortality disparities: mean = 17% (range = 16%-19%) for treatment initiation and mean = 61% (range = 57%-63%) for real-world effectiveness.

CONCLUSION

Our model results suggest that changes in policies that target improvements in treatment access could increase breast cancer equity. The findings also highlight that efforts must extend beyond policies targeting equity in treatment initiation to include high-quality treatment completion. This research will facilitate future modeling to test the effects of different specific policy changes on mortality disparities.

Bridging the "Know-Do" Gaps in Five Non-Communicable Diseases Using a Common Framework Driven by Implementation Science

According to the United Nations High-Level Meeting 2018, five non-communicable diseases (NCDs) including cardiovascular diseases, chronic respiratory diseases, diabetes mellitus, cancer, and mental health conditions accounted for two-thirds of global deaths. These five NCDs share five common risk factors including tobacco use, unhealthy diets, physical inactivity, alcohol use, and air pollution. Low- and middle-income countries (LMICs) face larger burden of NCDs than high-income countries (HICs), due to differences in ecological, technological, socioeconomic and health system development. Based on high-level evidence albeit mainly from HICs, the burden caused by NCDs can be reduced by affordable medicines and best practices. However, "know-do" gaps, ie, gaps between what we know in science and what we do in practice, has limited the impact of these strategies, especially in LMICs. Implementation science advocates the use of robust methodologies to evaluate sustainable solutions in health, education and social care aimed at informing practice and policies. In this article, physician researchers with expertise in NCDs reviewed the common challenges shared by these five NCDs with different clinical courses. They explained the principles of implementation science and advocated the use of an evidence-based framework to implement solutions focusing on early detection, prevention and empowerment, supplemented by best practices in HICs and LMICs. These successful stories can be used to motivate policymakers, payors, providers, patients and public to co-design frameworks and implement context-relevant, multi-component, evidence-based practices. In pursuit of this goal, we propose partnership, leadership, and access to continuing care as the three pillars in developing roadmaps for addressing the multiple needs during the journey of a person with or at risk of these five NCDs. By transforming the ecosystem, raising awareness and aligning context-relevant practices and policies with ongoing evaluation, it is possible to make healthcare accessible, affordable and sustainable to reduce the burden of these five NCDs.

Collaborative depression care sensitive to the needs of underserved patients with cancer: Feasibility, acceptability and outcomes

PURPOSE

A single-arm trial evaluated the feasibility, acceptability, and outcomes of COPE-D, a collaborative care intervention for underserved cancer patients with depression.

METHODS

Bilingual (Spanish and English) care managers provided counseling and/or medication management in consultation with physicians. Outcomes were treatment improvement (≥ 5-point reduction in PHQ-9), treatment response (≥ 50% reduction in PHQ-9), suicidal ideation resolution, and changes in depression (PHQ-9), anxiety (GAD-2), sleep disturbance (PSQI), global mental and physical health (PROMIS), social isolation (PROMIS), and qualitative feedback.

RESULTS

193 patients consented to participate. 165 initiated and 141 completed treatment, with 65% and 56% achieving treatment improvement and response, respectively. Outcomes did not differ by ethnicity (31% Hispanic), cancer stage (71% stages III-IV), income, or education. Suicidal ideation, depression, anxiety, sleep disturbance, and social isolation also improved. Qualitative feedback was largely positive.

CONCLUSION

COPE-D improved depression and quality of life among underserved patients, with acceptable retention rates.

Embedding lifestyle interventions into cancer care: has telehealth narrowed the equity gap?

Lifestyle interventions targeting energy balance (ie, diet, exercise) are critical for optimizing the health and well-being of cancer survivors. Despite their benefits, access to these interventions is limited, especially in underserved populations, including older people, minority populations and those living in rural and remote areas. Telehealth has the potential to improve equity and increase access. This article outlines the advantages and challenges of using telehealth to support the integration of lifestyle interventions into cancer care. We describe 2 recent studies, GO-EXCAP and weSurvive, as examples of telehealth lifestyle intervention in underserved populations (older people and rural cancer survivors) and offer practical recommendations for future implementation. Innovative approaches to the use of telehealth-delivered lifestyle intervention during cancer survivorship offer great potential to reduce cancer burden.

Disparities in the use of assisted reproductive technologies after breast cancer: a population-based study

PURPOSE

Equitable access to oncofertility services is a key component of cancer survivorship care, but factors affecting access and use remain understudied.

METHODS

To describe disparities in assisted reproductive technology (ART) use among women with breast cancer in California, we conducted a population-based cohort study using linked oncology, ART, and demographic data. We identified women age 18-45 years diagnosed with invasive breast cancer between 2000 and 2015. The primary outcome was ART use-including oocyte/embryo cryopreservation or embryo transfer-after cancer diagnosis. We used log-binomial regression to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) to identify factors associated with ART use.

RESULTS

Among 36,468 women with invasive breast cancer, 206 (0.56%) used ART. Women significantly less likely to use ART were age 36-45 years at diagnosis (vs. 18-35 years: PR = 0.17, 95% CI 0.13-0.22); non-Hispanic Black or Hispanic (vs. non-Hispanic White: PR = 0.31, 95% CI 0.21-0.46); had at least one child (vs. no children: adjusted PR [aPR] = 0.39, 95% CI 0.25-0.60); or lived in non-urban areas (vs. urban: aPR = 0.28, 95% CI 0.10-0.75), whereas women more likely to use ART lived in high-SES areas (vs. low-/middle-SES areas: aPR = 2.93, 95% CI 2.04-4.20) or had private insurance (vs. public/other insurance: aPR = 2.95, 95% CI 1.59-5.49).

CONCLUSION

Women with breast cancer who are socially or economically disadvantaged, or who already had a child, are substantially less likely to use ART after diagnosis. The implementation of policies or programs targeting more equitable access to fertility services for women with cancer is warranted.

Evidence-Based Guidance for Breast Cancer Survivorship

Breast cancer survivorship care includes management of lingering physical symptoms, supports to address the emotional toll exacted by a cancer diagnosis and cancer therapies, monitoring and optimization of cardiac and bone health, general wellness promotion, reproductive health care, surveillance for cancer recurrence, care coordination, and efforts to mitigate health disparities.

Community-based interventions designed to optimize health behaviors among cancer survivors: an integrative systematic review

PURPOSE

The purpose of this review was to synthesize the evidence on community-based health behavior optimization interventions (physical activity, nutrition, weight management) with a focus on cancer survivors at risk for poor health outcomes.

METHODS

This integrative review followed the methods and protocol outlined by the Joanna Briggs Institute Methods Manual for systematic reviews and was reported using PRISMA-Scr. Four databases, namely, PubMed, CINAHL, Web of Science, SportDiscus, were searched in March 2021 to identify articles addressing health behaviors among cancer survivors.

RESULTS

The review included 43 articles describing unique interventions developed through community-based participatory research (CBPR). The majority of community-based interventions were designed to optimize exercise/physical activity (76.7%) exclusively or in combination with nutrition. Non-Hispanic White persons constituted most participants. Most interventions took place as a part of an established community program and recruited from existing community programs to evaluate intervention effects on specific health outcomes. Of the interventions, 88.3% improved at least one outcome measurement.

CONCLUSION

The current studies have built on the strengths and resources of the community using existing programs. There was a lack of diversity in socioeconomic status and racial/ethnic background among participants of most interventions and inputs from partners such as cancer survivors, community, and healthcare organizations. Multiple health behavior interventions with longitudinal studies are needed for racial/ethnic minoritized cancer survivors. Future research should focus on achieving mutual benefits through iterative processes to develop sustainable community/research partnerships, ensuring long-term commitment, and disseminating knowledge gained from CBPR to and by all involved partners to improve health behaviors.

Cancer treatment and survivorship statistics, 2022

The number of cancer survivors continues to increase in the United States due to the growth and aging of the population as well as advances in early detection and treatment. To assist the public health community in better serving these individuals, the American Cancer Society and the National Cancer Institute collaborate triennially to estimate cancer prevalence in the United States using incidence and survival data from the Surveillance, Epidemiology, and End Results cancer registries, vital statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics, and population projections from the US Census Bureau. Current treatment patterns based on information in the National Cancer Database are presented for the most prevalent cancer types by race, and cancer-related and treatment-related side-effects are also briefly described. More than 18 million Americans (8.3 million males and 9.7 million females) with a history of cancer were alive on January 1, 2022. The 3 most prevalent cancers are prostate (3,523,230), melanoma of the skin (760,640), and colon and rectum (726,450) among males and breast (4,055,770), uterine corpus (891,560), and thyroid (823,800) among females. More than one-half (53%) of survivors were diagnosed within the past 10 years, and two-thirds (67%) were aged 65 years or older. One of the largest racial disparities in treatment is for rectal cancer, for which 41% of Black patients with stage I disease receive proctectomy or proctocolectomy compared to 66% of White patients. Surgical receipt is also substantially lower among Black patients with non-small cell lung cancer, 49% for stages I-II and 16% for stage III versus 55% and 22% for White patients, respectively. These treatment disparities are exacerbated by the fact that Black patients continue to be less likely to be diagnosed with stage I disease than White patients for most cancers, with some of the largest disparities for female breast (53% vs 68%) and endometrial (59% vs 73%). Although there are a growing number of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based strategies and equitable access to available resources are needed to mitigate disparities for communities of color and optimize care for people with a history of cancer. CA Cancer J Clin. 2022;72:409-436.

Masculinity Barriers to Ever Completing Colorectal Cancer Screening among American Indian/Alaska Native, Black, and White Men (Ages 45-75)

Disparities in colorectal cancer (CRC) mortality among White, Black, and American Indian/Alaska Native (AIAN) men are attributable to differences in early detection screening. Determining how masculinity barriers influence CRC screening completion is critical for cancer prevention and control. To determine whether masculinity barriers to medical care are associated with lower rates of ever completing CRC screening, a survey-based study was employed from December 2020-January 2021 among 435 White, Black, and AIAN men (aged 45-75) who resided in the US. Logistic regression models were fit to four Masculinity Barriers to Medical Care subscales predicting ever completing CRC screening. For all men, being strong was associated with 54% decreased odds of CRC screening completion (OR 0.46, 95% CI 0.23 to 0.94); each unit increase in negative attitudes toward medical professionals and exams decreased the odds of ever completing CRC screening by 57% (OR 0.43, 95% CI 0.21 to 0.86). Black men who scored higher on negativity toward medical professionals and exams had decreased odds of ever screening. Consideration of masculinity in future population-based and intervention research is critical for increasing men's participation in CRC screening, with more salience for Black men.

A scoping review of interactive and personalized web-based clinical tools to support treatment decision making in breast cancer

The increasing attention on personalized breast cancer care has resulted in an explosion of new interactive, tailored, web-based clinical decision tools for guiding treatment decisions in clinical practice. The goal of this study was to review, compare, and discuss the clinical implications of current tools, and highlight future directions for tools aiming to improve personalized breast cancer care. We searched PubMed, Embase, PsychInfo, Cochrane Database of Systematic Reviews, Web of Science, and Scopus to identify web-based decision tools addressing breast cancer treatment decisions. There was a total of 17 articles associated with 21 unique tools supporting decisions related to surgery, radiation therapy, hormonal therapy, bisphosphonates, HER2-targeted therapy, and chemotherapy. The quality of the tools was assessed using the International Patient Decision Aid Standard instrument. Overall, the tools considered clinical (e.g., age) and tumor characteristics (e.g., grade) to provide personalized outcomes (e.g., survival) associated with various treatment options. Fewer tools provided the adverse effects of the selected treatment. Only one tool was field-tested with patients, and none were tested with healthcare providers. Future studies need to assess the feasibility, usability, acceptability, as well as the effects of personalized web-based decision tools on communication and decision making from the patient and clinician perspectives.

Evaluation of health perceptions and healthcare utilization among population-based female cancer survivors and cancer-free women

PURPOSE

Cancer survivors are more likely to report having a poor health status when compared to the general population. Few studies have focused on the impact of cancer on health status and healthcare utilization/access outcomes among women from medically underserved populations.

METHODS

25,741 women with and without a history of cancer from the National Health and Nutrition Examination Survey from 1999 to 2016 contributed data. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using multivariable logistic regression for associations between cancer status and perceived health and healthcare utilization/access outcomes stratified by race/ethnicity, poverty status, education, and comorbidities.

RESULTS

1,897 (7.0%) women had a history of cancer with breast cancer as the most common (n = 671, 35.7%). While most survivors were non-Hispanic white (69.4%), 13.9% were Hispanic, 12.0% were non-Hispanic Black, and 4.6% were additional racial/ethnic groups. Survivors were 1.32 times more likely to be hospitalized within the last year (95% CI 1.11-1.58) and 1.32 times more likely to see a mental health provider within the last year (95% CI 1.05-1.66) compared to cancer-free women. Race/ethnicity was a significant effect modifier in the association between being a survivor and seeing a mental health provider, with Hispanic survivors having the highest odds (aOR 3.44; 95% CI 2.06-5.74; p-interaction < 0.00).

CONCLUSION

Our study identifies disparities in healthcare utilization among female cancer survivors, highlighting the importance of evaluating these associations among medically underserved populations. These findings can educate healthcare professionals working with these populations to inform gaps in survivorship care utilization/access.

An Update on Survivorship Issues in Lung Cancer Patients

Recent advances in lung cancer therapeutics and screening have led to increased numbers of lung cancer survivors. Most survivors have undergone invasive treatment (surgery, radiation therapy, chemotherapy and/or immunotherapy) and carry a high comorbidity burden. Overall quality of life suffers during the evaluation, treatment and follow-up phase, with the potential for long-term decline. The issues faced by survivors include physical symptoms, emotional distress as well as socioeconomic instability. These issues may lead to poor compliance with recommended follow-up plan. This article provides an up-to-date literature review on the major issues faced by lung cancer survivors and identifies under-recognized problems such as stigma, financial toxicity and sexual dysfunction. Future collaborative efforts are needed to further elucidate the complex issues that affect overall well-being of lung cancer survivors and to develop appropriate interventions in this expanding survivor population.

The Occupational Participation of Latinx Cancer Survivors and Their Family Caregivers Living in Survivorship: A Qualitative Exploration Informed by Multiple Stakeholders

The purpose of this study was to examine the lived experiences of Latinx cancer survivors and their family caregivers during survivorship. Eighteen semi-structured interviews were conducted with a variety of stakeholders including Latinx cancer survivors (n = 8), their family caregivers (n = 5), and cancer care providers (n = 5). Data were analyzed thematically to describe occupational participation. Latinx families lived in political, economic, language, and social contexts that facilitated and hindered their well-being. Survivors simultaneously experienced occupational deprivation and posttraumatic growth. To promote occupational justice, occupational therapy practitioners and researchers are called to partner with Latinx survivors and their families to facilitate skills needed for everyday participation.

Racial Differences in the Influence of Health Care System Factors on Informal Support for Cancer Care Among Black and White Breast and Lung Cancer Survivors

This retrospective, secondary qualitative analysis investigates whether health system factors influence social support among Black and white breast and lung cancer survivors and racial differences in support. These data come from race- and cancer-stratified focus groups (n = 6) and interviews (n = 2) to inform a randomized controlled trial utilizing antiracism and community-based participatory research approaches. Findings indicate social support was helpful for overcoming treatment-related challenges, including symptom management and patient-provider communication; racial differences in support needs and provision were noted. Resources within individual support networks reflect broader sociostructural factors. Reliance on family/friends to fill gaps in cancer care may exacerbate racial disparities.

Virtual care models for cancer survivorship

Virtual care models for cancer survivorship are needed to support patients living with the chronic effects of cancer treatment, while increasing health system capacity. Characteristics that may be critical to their success have not been adequately studied. This scoping review summarizes previous efforts to virtualize survivorship care to inform future innovations in the field. Four databases were searched for articles published before January 2020, and 24 articles that met selection criteria were included in this analysis. Rationale for pursuing virtual models of care shared two common objectives: (1) the need for sustainable survivorship care, and (2) the opportunity to improve survivorship outcomes. Breast cancer (N = 10) and prostate cancer (N = 4) were the most targeted cancers for virtual survivorship care. The implemented technologies included web platforms (N = 15), telephone calls (N = 12), and smartphone or tablet applications (N = 5). A variety of healthcare professionals were effectively involved in the provision of virtual care. Future virtual care models may benefit from integrating with existing health systems and services, repurposing common technologies, involving allied health professionals, and engaging patients and caregivers from diverse communities in the design of virtual services.

Transgender individuals' cancer survivorship: Results of a cross-sectional study

BACKGROUND

Transgender individuals' cancer prevalence and transgender cancer survivors' health needs have received scarce attention. The current study compared transgender and cisgender individuals' cancer prevalence and described the health needs of transgender cancer survivors.

METHODS

The authors used Behavioral Risk Factor Surveillance System data on 95,800 cisgender and transgender individuals who self-reported a cancer diagnosis. Using multiple logistic regression, they estimated cancer prevalence and calculated odds ratios with 95% confidence intervals of physical, psychological, overall health, and health behaviors of transgender survivors compared with cisgender survivors.

RESULTS

After adjusting for confounders, transgender men had a significantly higher (>2-fold) number of cancer diagnoses compared with cisgender men, but not cisgender women. Cancer prevalence among gender nonconforming individuals and transgender women was not significantly different from that of cisgender men and cisgender women. Gender nonconforming survivors had significantly greater physical inactivity, heavy episodic alcohol use, and depression compared with cisgender men and cisgender women. Transgender men survivors were significantly more likely to report poor physical health and greater medical comorbidities and were less likely to report smoking compared with cisgender men and cisgender women. Transgender women survivors were significantly more likely to report diabetes compared with cisgender men and cisgender women and were more likely to report cardiovascular disease compared with cisgender women.

CONCLUSIONS

Clinicians should be aware of the higher prevalence of cancer among transgender men and a potential survivorship bias among transgender individuals. Transgender survivors have considerable variation in their risk profile. Clinicians and health services can target gender nonconforming survivors' depression and health behaviors to improve survival and should address the complex comorbidities of transgender men and transgender women.

La qualité de vie à la suite à d’une cystoprostatectomie totale chez les hommes: perception des patients tunisiens

Introduction

La cystoprostatectomie totale (CPT) entraîne souvent des changements dans la qualité de vie postopératoire et, par le fait même, des répercussions psychologiques, physiques, sociales et sexuelles difficiles à assumer. La présente étude vise à décrire la qualité de vie postopératoire d’hommes tunisiens âgés ayant subi une CPT à cause d’un cancer de la vessie.

Méthodologie

Il s’agit d’une étude descriptive quantitative, menée auprès de 40 hommes cystoprostatectomisés. Les instruments de mesure utilisés sont: le questionnaire Stoma-Qualité de vie (Stoma-QOL) de Prieto, Thorsen et Juul (2005) , traduit et validé en arabe, ainsi que la version arabe du questionnaire de l’index international de la fonction érectile (IIEF5), validée par Shamloul, Ghanem et Abou-Zeid (2004) .

Résultats

77,5 % des participants obtiennent un score de qualité de vie médiocre. Toutes les dimensions de la qualité de vie sont touchées, à savoir l’image corporelle, physique et psychologique, la vie familiale et sociale, et enfin, la sexualité. En outre, tous les participants ont souffert d’impuissance sexuelle grave après l’intervention.

Conclusion

Le counseling pré et postopératoire s’avère nécessaire pour faciliter la transition après l’opération et assurer aux hommes ayant subi une CPT à cause d’un cancer de la vessie une meilleure qualité de vie liée à la santé.

Cancer treatment and survivorship statistics, 2019

The number of cancer survivors continues to increase in the United States because of the growth and aging of the population as well as advances in early detection and treatment. To assist the public health community in better serving these individuals, the American Cancer Society and the National Cancer Institute collaborate every 3 years to estimate cancer prevalence in the United States using incidence and survival data from the Surveillance, Epidemiology, and End Results cancer registries; vital statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics; and population projections from the US Census Bureau. Current treatment patterns based on information in the National Cancer Data Base are presented for the most prevalent cancer types. Cancer-related and treatment-related short-term, long-term, and late health effects are also briefly described. More than 16.9 million Americans (8.1 million males and 8.8 million females) with a history of cancer were alive on January 1, 2019; this number is projected to reach more than 22.1 million by January 1, 2030 based on the growth and aging of the population alone. The 3 most prevalent cancers in 2019 are prostate (3,650,030), colon and rectum (776,120), and melanoma of the skin (684,470) among males, and breast (3,861,520), uterine corpus (807,860), and colon and rectum (768,650) among females. More than one-half (56%) of survivors were diagnosed within the past 10 years, and almost two-thirds (64%) are aged 65 years or older. People with a history of cancer have unique medical and psychosocial needs that require proactive assessment and management by follow-up care providers. Although there are growing numbers of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based resources are needed to optimize care.

Cancer survivors' access to care and quality of life: Do sexual minorities fare worse than heterosexuals?

BACKGROUND

Adults with poor access to care are known to have worse quality of life (QOL). The purpose of the current study was to determine differences in cancer survivors' access to care by sexual orientation and to examine the association between access to care and QOL.

METHODS

The current secondary data analysis used 4 years of Behavioral Risk Factor Surveillance System data regarding adult men and women who self-reported a history of cancer. Among the 70,524 cancer survivors, a total of 1931 self-identified as sexual minorities, defined as lesbian, gay, bisexual, or other nonheterosexual orientation.

RESULTS

Sexual minority women had significantly more access deficits compared with heterosexual women (42.7% vs 28.0%; P < .0001), whereas men of different sexual orientations had similar access to care. Among sexual minority women, those with access deficits had higher odds of poor physical QOL compared with heterosexual women (odds ratio [OR], 2.0 [95% CI, 1.2-3.4] vs OR, 1.3 [95% CI, 1.2-1.5]), poor mental QOL (OR, 1.8 [95% CI, 1.1-3.1] vs OR, 1.5 [95% CI, 1.3-1.7]), and difficulties concentrating (OR, 2.0 [95% CI, 1.2-3.5] vs OR, 1.7 [95% CI, 1.4-1.9]). Sexual minority men with access deficits had greater odds of difficulty concentrating compared with heterosexual men (OR, 4.3 [95% CI, 2.0-9.3] vs OR, 1.5 [95% CI, 1.2-1.9]). Among men, sexual minority status increased the odds of poor mental QOL (OR, 1.49 [95% CI, 1.11-2.01]).

CONCLUSIONS

Access to care among sexual minority cancer survivors needs improvement. Sexual minority women should be a focus of future research because their poor access to care more strongly relates to worse QOL.

Toward equitably high-quality cancer survivorship care

Although models of cancer survivorship care are rapidly evolving, there is increasing evidence of health disparities among cancer survivors. In the current context, Canada's survivorship care systems privilege some and not others to receive high-quality care and optimize their health outcomes. The aim of this study was to improve survivorship care systems by helping clinicians and decision makers to a better understanding of how various psychosocial/political factors, survivors' health experiences and health management strategies might shape the development of and access to high-quality survivorship care for Canadians with cancer. Using a nursing epistemological approach informed by critical and intersectional perspectives, we conducted a three-phased Interpretive Description study. We engaged in critical textual analysis of documentary sources, a secondary analysis of interview transcripts from an existing database, and qualitative interviews with 34 survivors and 12 system stakeholders. On the basis of these data, we identified individual, group, and system factors that contributed to gaps between survivors' expected and actual survivorship care experiences. By understanding what shapes survivorship care systems and resources, we help illuminate and unravel the complex nature of the issue, supporting clinicians and decision makers to find multi-layered approaches for equitably high-quality survivorship care.

Cancer survivors' access to care and quality of life: Do sexual minorities fare worse than heterosexuals?

BACKGROUND

Adults with poor access to care are known to have worse quality of life (QOL). The purpose of the current study was to determine differences in cancer survivors' access to care by sexual orientation and to examine the association between access to care and QOL.

METHODS

The current secondary data analysis used 4 years of Behavioral Risk Factor Surveillance System data regarding adult men and women who self-reported a history of cancer. Among the 70,524 cancer survivors, a total of 1931 self-identified as sexual minorities, defined as lesbian, gay, bisexual, or other nonheterosexual orientation.

RESULTS

Sexual minority women had significantly more access deficits compared with heterosexual women (42.7% vs 28.0%; P < .0001), whereas men of different sexual orientations had similar access to care. Among sexual minority women, those with access deficits had higher odds of poor physical QOL compared with heterosexual women (odds ratio [OR], 2.0 [95% CI, 1.2-3.4] vs OR, 1.3 [95% CI, 1.2-1.5]), poor mental QOL (OR, 1.8 [95% CI, 1.1-3.1] vs OR, 1.5 [95% CI, 1.3-1.7]), and difficulties concentrating (OR, 2.0 [95% CI, 1.2-3.5] vs OR, 1.7 [95% CI, 1.4-1.9]). Sexual minority men with access deficits had greater odds of difficulty concentrating compared with heterosexual men (OR, 4.3 [95% CI, 2.0-9.3] vs OR, 1.5 [95% CI, 1.2-1.9]). Among men, sexual minority status increased the odds of poor mental QOL (OR, 1.49 [95% CI, 1.11-2.01]).

CONCLUSIONS

Access to care among sexual minority cancer survivors needs improvement. Sexual minority women should be a focus of future research because their poor access to care more strongly relates to worse QOL.

Personalized Risk-Stratified Cancer Follow-Up Care: Its Potential for Healthier Survivors, Happier Clinicians, and Lower Costs

The growth in the number of cancer survivors in the face of projected health-care workforce shortages will challenge the US health-care system in delivering follow-up care. New methods of delivering follow-up care are needed that address the ongoing needs of survivors without overwhelming already overflowing oncology clinics or shuttling all follow-up patients to primary care providers. One potential solution, proposed for over a decade, lies in adopting a personalized approach to care in which survivors are triaged or risk-stratified to distinct care pathways based on the complexity of their needs and the types of providers their care requires. Although other approaches may emerge, we advocate for development, testing, and implementation of a risk-stratified approach as a means to address this problem. This commentary reviews what is needed to shift to a risk-stratified approach in delivering survivorship care in the United States.

Impact of immigration status on health behaviors and perceptions in cancer survivors

Background

Health behaviors including smoking cessation, physical activity (PA), and alcohol moderation are key aspects of cancer survivorship. Immigrants may have unique survivorship needs. We evaluated whether immigrant cancer survivors had health behaviors and perceptions that were distinct from native‐born cancer survivors.

Methods

Adult cancer patients from Princess Margaret Cancer Centre were surveyed on their smoking, PA, and alcohol habits and perceptions of the effects of these behaviors on quality of life (QoL), 5‐year survival, and fatigue. Multivariable models evaluated the association of immigration status and region‐of‐origin on behaviors and perceptions.

Results

Of the 784 patients, 39% self‐identified as immigrants. Median time of survey was 24 months after histological diagnosis. At baseline, immigrants had trends toward not meeting Canadian PA guidelines or being ever‐drinkers; patients from non‐Western countries were less likely to smoke (aOR_current = 0.46, aOR_ex‐smoker = 0.47, P = 0.02), drink alcohol (aOR_current = 0.22, aOR_ex‐drinker = 0.52, P < 0.001), or meet PA guidelines (aOR = 0.44, P = 0.006). Among immigrants, remote immigrants (migrated ≥40 years ago) were more likely to be consuming alcohol at diagnosis (aOR = 5.70, P < 0.001) compared to recent immigrants. Compared to nonimmigrants, immigrants were less likely to perceive smoking as harmful on QoL (aOR = 0.58, P = 0.008) and survival (aOR = 0.56, P = 0.002), and less likely to perceive that PA improved fatigue (aOR = 0.62, P = 0.04) and survival (aOR = 0.64, P = 0.08).

Conclusions

Immigrants had different patterns of health behaviors than nonimmigrants. Immigrants were less likely to perceive continued smoking as harmful and were less likely to be aware of PA benefits. Culturally tailored counselling may be required for immigrants who smoke or are physically sedentary at diagnosis.

Equitably improving outcomes for cancer survivors and supporting caregivers: A blueprint for care delivery, research, education, and policy

Cancer care delivery is being shaped by growing numbers of cancer survivors coupled with provider shortages, rising costs of primary treatment and follow-up care, significant survivorship health disparities, increased reliance on informal caregivers, and the transition to value-based care. These factors create a compelling need to provide coordinated, comprehensive, personalized care for cancer survivors in ways that meet survivors' and caregivers' unique needs while minimizing the impact of provider shortages and controlling costs for health care systems, survivors, and families. The authors reviewed research identifying and addressing the needs of cancer survivors and caregivers and used this synthesis to create a set of critical priorities for care delivery, research, education, and policy to equitably improve survivor outcomes and support caregivers. Efforts are needed in 3 priority areas: 1) implementing routine assessment of survivors' needs and functioning and caregivers' needs; 2) facilitating personalized, tailored, information and referrals from diagnosis onward for both survivors and caregivers, shifting services from point of care to point of need wherever possible; and 3) disseminating and supporting the implementation of new care methods and interventions.

Affordable Care Act and Disparities in Health Services Utilization among Ethnic Minority Breast Cancer Survivors: Evidence from Longitudinal Medical Expenditure Panel Surveys 2008⁻2015

Breast cancer is the most prevalent female cancer in the US. Incidence rates are similar for white and black women but mortality rates are higher for black women. This study draws on rich, nationally representative data, the 2008⁻2015 Medical Expenditure Panel Surveys, to estimate effects of the Affordable Care Act (ACA) on reducing disparities in and access to use of diagnostic and medical services for black and Hispanic breast cancer survivors. Random effects multinomial logit, flexible hurdle and Box-Cox estimation techniques are used. The robust estimates indicate that the ACA narrowed the racial/ethnic disparity in health insurance coverage, health care utilization and out-of-pocket prescription drug expenditures among breast cancer survivors. Gaps in uninsurance significantly declined for black and Hispanic survivors. Hispanic women generally and black breast cancer survivors specifically increased use of mammography services post-ACA. The ACA did not significantly impact disparities in physician utilization or out-of-pocket prescription drug expenditures for Hispanic survivors, while there were substantive improvements for black breast cancer survivors. The paper concludes with a discussion of the strengths and limitations of the ACA for reducing disparities and improving health outcomes for a growing population of breast cancer survivors in the US.

Occupational Therapy's Role in Cancer Survivorship as a Chronic Condition

Improved medical care has resulted in a documented increase in cancer survivors in the United States. Cancer survivors face challenges in participation across all facets of life as a result of the cancer and subsequent cancer treatments. Long-term and late-term sequelae can result in impairments in neurological systems, decreased stamina, loss of range of motion, and changes in sensation and cognition. These impairments are often long lasting, which categorizes cancer survivorship as a chronic condition. This categorization presents treatment challenges, especially in creating rehabilitation and habilitation service options that support cancer survivors. Occupational therapy provides a unique focus that can benefit cancer survivors as they face limitations in participation in all aspects of daily living. Research, advocacy, and education efforts are needed to focus on the specific rehabilitation and habilitation needs of cancer survivors to increase access to occupational therapy's distinct value.

Unequal cancer survivorship care: addressing cultural and sociodemographic disparities in the clinic

The number of individuals diagnosed with cancer is growing worldwide. Cancer patients from underserved populations have widely documented disparities through the continuum of cancer care. As the number of cancer survivors (i.e., individuals who have completed cancer treatment) from underserved populations also continue to grow, these individuals may continue to experience barriers to survivorship care, resulting in persistent long-term negative impacts on health and quality of life. In addition, there is limited participation of survivors from underserved populations in clinical trials and other research studies. To address disparities and change practices in survivorship care, a better understanding of the roles of both socioeconomic status (SES) and of culture in cancer care disparities and the relevance of these to providing high-quality care is needed. SES and culture often overlap but are not identical; understanding the impact of each is especially relevant to survivorship care. To enhance health equity among cancer survivors, clinicians need to practice culturally competent care, address cultural beliefs and practices that may influence survivors' beliefs and activities, gain awareness of historical patterns of medical care in the survivor's community, and consider how barriers to cross-cultural communications may hinder communication in clinical settings. While the design and implementation of survivorship care programs emphasizing effectiveness and equity is complex and potentially time consuming, it is critical for providing optimal care for all survivors, including those from the most vulnerable populations.