The joint effects of census tract poverty and geographic access on late-stage breast cancer diagnosis in 10 US States

Geospatial Imprecision With Constraints for Precision Public Health: Algorithm Development and Validation

BACKGROUND

Location and environmental social determinants of health are increasingly important factors in both an individual's health and the monitoring of community-level public health issues.

OBJECTIVE

We aimed to measure the extent to which location obfuscation techniques, designed to protect an individual's privacy, can unintentionally shift geographical coordinates into neighborhoods with significantly different socioeconomic demographics, which limits the precision of findings for public health stakeholders.

METHODS

Point obfuscation techniques intentionally blur geographic coordinates to conceal the original location. The pinwheel obfuscation method is an existing technique in which a point is moved along a pinwheel-like path given a randomly chosen angle and a maximum radius; we evaluate the impact of this technique using 2 data sets by comparing the demographics of the original point and the resulting shifted point by cross-referencing data from the United States Census Bureau.

RESULTS

Using poverty measures showed that points from regions of low poverty may be shifted to regions of high poverty; similarly, points in regions with high poverty may be shifted into regions of low poverty. We varied the maximum allowable obfuscation radius; the mean difference in poverty rate before and after obfuscation ranged from 6.5% to 11.7%. Additionally, obfuscation inadvertently caused false hot spots for deaths by suicide in Cook County, Illinois.

CONCLUSIONS

Privacy concerns require patient locations to be imprecise to protect against risk of identification; precision public health requires accuracy. We propose a modified obfuscation technique that is constrained to generate a new point within a specified census-designated region to preserve both privacy and analytical accuracy by avoiding demographic shifts.

Historical Redlining, Persistent Mortgage Discrimination, and Race in Breast Cancer Outcomes

Importance

Inequities created by historical and contemporary mortgage discriminatory policies have implications for health disparities. The role of persistent mortgage discrimination (PMD) in breast cancer (BC) outcomes has not been studied.

Objective

To estimate the race-specific association of historical redlining (HRL) with the development of BC subtypes and late-stage disease and a novel measure of PMD in BC mortality.

Design, Setting, and Participants

This population-based cohort study used Georgia Cancer Registry data. A total of 1764 non-Hispanic Black and White women with a BC diagnosis and residing in an area graded by the Home Owners' Loan Corporation (HOLC) in Georgia were included. Patients were excluded if they did not have a known subtype or a derived American Joint Committee on Cancer stage or if diagnosed solely by death certificate or autopsy. Participants were diagnosed with a first primary BC between January 1, 2010, to December 31, 2017, and were followed through December 31, 2019. Data were analyzed between May 1, 2022, and August 31, 2023.

Exposures

Scores for HRL were examined dichotomously as less than 2.5 (ie, nonredlined) vs 2.5 or greater (ie, redlined). Contemporary mortgage discrimination (CMD) scores were calculated, and PMD index was created using the combination of HRL and CMD scores.

Main Outcomes and Measures

Estrogen receptor (ER) status, late stage at diagnosis, and BC-specific death.

Results

This study included 1764 women diagnosed with BC within census tracts that were HOLC graded in Georgia. Of these, 856 women (48.5%) were non-Hispanic Black and 908 (51.5%) were non-Hispanic White; 1148 (65.1%) were diagnosed at 55 years or older; 538 (30.5%) resided in tracts with HRL scores less than 2.5; and 1226 (69.5%) resided in tracts with HRL scores 2.5 or greater. Living in HRL areas with HRL scores 2.5 or greater was associated with a 62% increased odds of ER-negative BC among non-Hispanic Black women (odds ratio [OR], 1.62 [95% CI, 1.01-2.60]), a 97% increased odds of late-stage diagnosis among non-Hispanic White women (OR, 1.97 [95% CI, 1.15-3.36]), and a 60% increase in BC mortality overall (hazard ratio, 1.60 [95% CI, 1.17-2.18]). Similarly, PMD was associated with BC mortality among non-Hispanic White women but not among non-Hispanic Black women.

Conclusions and Relevance

The findings of this cohort study suggest that historical racist policies and persistent discrimination have modern-day implications for BC outcomes that differ by race. These findings emphasize the need for a more nuanced investigation of the social and structural drivers of disparate BC outcomes.

Redlining-associated methylation in breast tumors: the impact of contemporary structural racism on the tumor epigenome

Purpose

Place-based measures of structural racism have been associated with breast cancer mortality, which may be driven, in part, by epigenetic perturbations. We examined the association between contemporary redlining, a measure of structural racism at the neighborhood level, and DNA methylation in breast tumor tissue.

Methods

We identified 80 Black and White women diagnosed and treated for a first-primary breast cancer at Emory University Hospitals (2008-2017). Contemporary redlining was derived for census tracts using the Home Mortgage Disclosure Act database. Linear regression models were used to calculate the association between contemporary redlining and methylation in breast tumor tissue. We also examined epigenetic age acceleration for two different metrics, regressing β values for each cytosine-phosphate-guanine dinucleotide (CpG) site on redlining while adjusting for covariates. We employed multivariable Cox-proportional hazards models and 95% confidence intervals (CI) to estimate the association between aberrant methylation and mortality.

Results

Contemporary redlining was associated with 5 CpG sites after adjustment for multiple comparisons (FDR<0.10). All genes were implicated in breast carcinogenesis, including genes related to inflammation, immune function and stress response (ANGPT1, PRG4 and PRG4). Further exploration of the top 25 CpG sites, identified interaction of 2 sites (MRPS28 and cg11092048) by ER status and 1 site (GDP1) was associated with all-cause mortality. Contemporary redlining was associated with epigenetic age acceleration by the Hannum metric (β=5.35; CI 95%=0.30,10.4) and showed positive but non-significant correlation with the other clock.

Conclusion

We identified novel associations between neighborhood contemporary redlining and the breast tumor DNA methylome, suggesting that racist policies leading to inequitable social and environmental exposures, may impact the breast tumor epigenome. Additional research on the potential implications for prognosis is needed.

Multilevel Small Area Estimation for County-Level Prevalence of Mammography Use in the United States Using 2018 Data

Background: The U.S. Preventive Services Task Force recommends biennial screening mammography for average-risk women aged 50-74 years. We aim to generate county-level prevalence estimates for mammography use to examine disparities among counties. Materials and Methods: We used data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) (n = 111,902 women) and linked them to county-level data from the American Community Survey. We defined two outcomes: mammography within the past 2 years (current); and mammography 5 or more years ago or never (rarely or never). We poststratified the data with U.S. Census estimated county population counts, ran Monte Carlo simulations, and generated county-level estimates. We aggregated estimates to state and national levels. We validated internal consistency between our model-based and BRFSS state estimates using Spearman and Pearson correlation coefficients. Results: Nationally, more than three in four women [78.7% (95% confidence interval {CI}: 78.2%-79.2%)] were current with mammography, although with large variations among counties. Also, nationally, about one in nine women [11% (95% CI: 10.8%-11.3%)] rarely or never had a mammogram. County estimates for being current ranged from 60.4% in New Mexico to 86.9% in Hawaii. Rarely or never having a mammogram ranged from 6% in Connecticut to 23.0% in Alaska, and on average, almost one in eight women in all the counties. Internal consistency correlation coefficient tests were ≥0.94. Conclusions: Our analyses identified marked county variations in mammography use across the country among women aged 50-74 years. We generated estimates for all counties, which may be helpful for targeted outreach to increase mammography uptake.

Geographic distribution of assisted reproductive technology clinics in the USA: a multilevel sociodemographic analysis

PURPOSE

To investigate whether sociodemographic characteristics of US Census tracts and counties and state-level infertility insurance policy are associated with the presence of assisted reproductive technology (ART) clinics.

METHODS

Multilevel logistic regression analyses using publicly available reports of ART clinic locations (2014-2018) matched with sociodemographic data from the US Census Bureau and state infertility insurance policy information.

RESULTS

At the tract-level, multivariate multilevel logistic regression found significant associations with the likelihood of an ART clinic in a tract and the size of the tract population (adjusted odds ratio (aOR): 1.063, SE = 0.018, p < .001), the tract median household income (aOR = 0.990, SE = 0.002, p < 0.001), and the percentages of the population who were Hispanic (aOR = 0.975, SE = 0.007, p < 0.001), women over 25 with a bachelor's degree or higher (aOR: 1.052, SE = 0.004, p < 0.001), and foreign-born (aOR: 1.037, SE = 0.009, p < .001). At the county-level, significant associations were found with the county median household income (aOR: 1.016, SE = 0.006, p < .01) and the percentage of the population that identified as Black (aOR = 1.013, SE = 0.006, p < .05) and Hispanic (aOR = 1.028, SE = 0.009, p < .05). Multivariate models showed no associations between tract clinic counts and state infertility policy.

CONCLUSION

There is mixed evidence that clinic concentration is associated with expected sociodemographics. In particular, physical proximity may not principally drive racial disparities in ART access. Furthermore, insurance mandates are not associated with the presence of an ART clinics in a tract, suggesting alternative policy levers may be needed to address differential access and utilization of ART services.

Influence of geographic access and socioeconomic characteristics on breast cancer outcomes: A systematic review

Socio-economic and geographical inequalities in breast cancer mortality have been widely described in European countries and the United States. To investigate the combined effects of geographic access and socio-economic characteristics on breast cancer outcomes, a systematic review was conducted exploring the relationships between: (i) geographic access to healthcare facilities (oncology services, mammography screening), defined as travel time and/or travel distance; (ii) breast cancer-related outcomes (mammography screening, stage of cancer at diagnosis, type of treatment and rate of mortality); (iii) socioeconomic status (SES) at individuals and residential context levels. In total, n = 25 studies (29 relationships tested) were included in our systematic review. The four main results are: The statistical significance of the relationship between geographic access and breast cancer-related outcomes is heterogeneous: 15 were identified as significant and 14 as non-significant. Women with better geographic access to healthcare facilities had a statistically significant fewer mastectomy (n = 4/6) than women with poorer geographic access. The relationship with the stage of the cancer is more balanced (n = 8/17) and the relationship with cancer screening rate is not observed (n = 1/4). The type of measures of geographic access (distance, time or geographical capacity) does not seem to have any influence on the results. For example, studies which compared two different measures (travel distance and travel time) of geographic access obtained similar results. The relationship between SES characteristics and breast cancer-related outcomes is significant for several variables: at individual level, age and health insurance status; at contextual level, poverty rate and deprivation index. Of the 25 papers included in the review, the large majority (n = 24) tested the independent effect of geographic access. Only one study explored the combined effect of geographic access to breast cancer facilities and SES characteristics by developing stratified models.

Area-Based Geocoding: An Approach to Exposure Assessment Incorporating Positional Uncertainty

While the spatial resolution of exposure surfaces has greatly improved, our ability to locate people in space remains a limiting factor in accurate exposure assessment. In this case-control study, two approaches to geocoding participant locations were used to study the impact of geocoding uncertainty on the estimation of ambient pesticide exposure and breast cancer risk among women living in California's Central Valley. Residential and occupational histories were collected and geocoded using a traditional point-based method along with a novel area-based method. The standard approach to geocoding uses centroid points to represent all geocoded locations, and is unable to adapt exposure areas based on geocode quality, except through the exclusion of low-certainty locations. In contrast, area-based geocoding retains the complete area to which an address matched (the same area from which the centroid is returned), and therefore maintains the appropriate level of precision when it comes to assessing exposure by geography. Incorporating the total potential exposure area for each geocoded location resulted in different exposure classifications and resulting odds ratio estimates than estimates derived from the centroids of those same areas (using a traditional point-based geocoder). The direction and magnitude of these differences varied by pesticide, but in all cases odds ratios differed by at least 6% and up to 35%. These findings demonstrate the importance of geocoding in exposure estimation and suggest it is important to consider geocode certainty and quality throughout exposure assessment, rather than simply using the best available point geocodes.

Capturing the Rest: Inpatient Mammography for Nonadherent Hospitalized Women

INTRODUCTION

More than a third of hospitalized women are overdue or nonadherent to breast cancer screening guidelines, and almost a third of them are also at high risk for developing breast cancer. The purpose of this study is to evaluate the feasibility of coordinating inpatient breast cancer screening mammography for these women before their discharge from the hospital.

METHODS

A prospective intervention study was conducted among 101 nonadherent women aged 50-74 years who were hospitalized to a general medicine service. Sociodemographic, reproductive history, family history of breast cancer, and medical comorbidities data were collected for all patients from January 2015 to October 2016. The data were analyzed in March 2018. Fisher's exact tests and unpaired t-tests were utilized to compare the characteristics of the study population.

RESULTS

Of the 101 women enrolled who were nonadherent to breast cancer screening recommendations, their mean age was 59.3 (SD=6) years, the mean 5-year Gail risk score was 1.63 (SD=0.69), and 29% of the women were African American. Almost 80% (n=79) underwent inpatient screening mammography. All women who underwent screening mammography during their inpatient stay were extremely satisfied with the experience. The convenience of having screening mammography while hospitalized was reported to be a major facilitator of completing the overdue screening. All nurses (100%) taking care of these women believed that this practice should become part of the standard of care, and most hospitalist physicians (66%) agreed that this practice is feasible.

CONCLUSIONS

This study shows that it is possible to coordinate mammography for hospitalized women who were overdue for screening and at high risk for developing breast cancer.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT04164251.

Is There a Relationship between County-Level Food Insecurity Rates and Breast Cancer Stage at Diagnosis?

The relationship between county food insecurity (FI) rate and breast cancer stage at diagnosis is not clear. Using 2010-2016 Surveillance Epidemiology and End Results (SEER) and Feeding America data we analyzed the association between county FI rate in quartiles (low, medium, high, very high) and breast cancer stage at diagnosis among adult females (≥18 years). We also analyzed the effect of insurance status and county poverty level on this relationship, and whether this relationship varies among non-elderly (<65 years) and elderly (≥ 65 years) individuals. Bivariate and multivariable multilevel logistic regression were used for analyses. Bivariate analysis showed increased likelihood of late-stage breast cancer with increasing county FI rate. This relationship persisted after adjusting for insurance status but was no longer significant after adjusting for county-level poverty rate. There was a statistically significant association between counties with very high food insecurity rates and late-stage breast cancer diagnosis (OR = 1.07; 95% CI = 1.00, 1.14) among the elderly population. Very high county food insecurity rate was associated with late-stage breast cancer among elderly women. Population-level interventions focused on counties with very high food insecurity rates could reduce disparities in stage at breast cancer diagnosis among elderly women.

Searching beyond the Lamppost to Reduce Breast Cancer Disparities

Racial and ethnic differences in breast cancer occur by race/ethnicity in both incidence and mortality rates. Women of lower socioeconomic status likewise have poorer outcomes. When race alone is considered, incidence rates in the United States are highest among White women (130.8 per 100,000), with Black women close behind (126.7 per 100,000). Incidence is lowest among Asian/Pacific Islander women, at 93.2 per 100,000. Mortality differences are more pronounced, with Black women 40% more likely to die from breast cancer than White women (28.4 per 100,000 and 20.3 per 100,000, respectively). Mortality rates for Asian/Pacific Islander women (11.5 per 100,000) are far lower than for Black and White women. When age is considered, additional differences between Black and White women appear, in part accounted for by types of breast cancer experienced. Women of other racial/ethnic groups and socioeconomic status have received less scientific attention. In this article, we provide a brief overview of the evidence for social determinants of breast cancer and argue that the current reliance on race over racism and ethnicity contributes to our inability to eliminate breast cancer disparities in the United States and elsewhere in the world. We suggest alternatives to the current approach to research in breast cancer disparities.

Shift Work and Breast Cancer

The rates of shift work outside of daylight hours have increased in recent years, and nighttime shift work is now considered a potential carcinogenic occupational exposure. Light at night exposure, lower melatonin production, and the production of stress-related mediators disrupt normal sleep–wake cycles. Women who work lower-wage jobs and part-time workers whose shifts are determined entirely by their supervisors (rotating shifts) may be subject to stress related to efforts to align childcare and other needs with the unpredictable nature of rotating shift work. The causal link between breast cancer and the sleep cycle or circadian disruption are yet to be established; however, disruption of the circadian cycles by light at night exposure or chronic exposure to stress-related mediators have all been linked to the increased risk of breast cancer. We review the existing literature on shift work and breast cancer, identify knowledge gaps, and suggest future directions for research.

Association of time to diagnosis with socioeconomic position and geographical accessibility to healthcare among symptomatic COVID-19 patients: A retrospective study in Hong Kong

Early diagnosis is important to control COVID-19 outbreaks. This study aimed to assess how individual and area socioeconomic position and geographical accessibility to healthcare services were associated with the time to diagnosis among symptomatic COVID-19 patients in Hong Kong. Multivariable generalized linear regression was used to estimate the associations while adjusting for sociodemographic characteristics and case classification. This study found living in public rental housing and living in an area with low education were associated with longer time to diagnosis in the first wave of infections. Specifically, the risk of delayed diagnosis for public rental housing residents was mitigated by the higher density of public clinics/hospitals but was slightly increased by the higher density of private medical practitioners nearby. No such relations were found in the second wave of infections when the surveillance measures were enhanced. Given the grave impact of pandemics around the world, our findings call on taking inequalities into account when public health policies are being devised.

Environmental Quality and Invasive Breast Cancer

Background: Breast cancer is a complex and multifactorial disease, and environmental factors have been suggested to increase its risk. However, prior research has largely focused on studying exposures to one factor/contaminant at a time, which does not reflect the real-world environment.Methods: Herein, we investigate associations between breast cancer and the environmental quality index (EQI), a comprehensive assessment of five domains of environmental quality (air, water, land, sociodemographic, and built environments) at the county level. Breast cancer diagnoses for North Carolina women were obtained from the North Carolina Central Cancer Registry (2009-2014) and the county of residence at the time of diagnosis was linked with the EQI. We evaluated the odds of localized, regional, or distant metastatic breast cancer in categories of environmental quality using women with carcinoma in situ as registry-based controls.Results: Overall environmental quality was generally not associated with invasive breast cancer; however, all breast cancer types tended to be inversely associated with land quality, particularly in more rural communities [distant metastatic breast cancer was 5%-8% more likely (OR, 1.08; 95% confidence interval, 1.02-1.14; P = 0.02) compared with carcinoma in situ].Conclusions: Cumulatively, our results suggest that some broad measures of environmental quality are associated with invasive breast cancer but that associations vary by environmental domain, cancer stage, subtype, and urbanicity.Impact: Our findings suggest that components of land quality (e.g., pesticide applications and animal facilities) warrant additional investigation in relation to invasive breast cancer.See all articles in this CEBP Focus section, "Environmental Carcinogenesis: Pathways to Prevention."

Rapidly measuring spatial accessibility of COVID-19 healthcare resources: a case study of Illinois, USA

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing the coronavirus disease 2019 (COVID-19) pandemic, has infected millions of people and caused hundreds of thousands of deaths. While COVID-19 has overwhelmed healthcare resources (e.g., healthcare personnel, testing resources, hospital beds, and ventilators) in a number of countries, limited research has been conducted to understand spatial accessibility of such resources. This study fills this gap by rapidly measuring the spatial accessibility of COVID-19 healthcare resources with a particular focus on Illinois, USA.

METHOD

The rapid measurement is achieved by resolving computational intensity of an enhanced two-step floating catchment area (E2SFCA) method through a parallel computing strategy based on cyberGIS (cyber geographic information science and systems). The E2SFCA has two major steps. First, it calculates a bed-to-population ratio for each hospital location. Second, it sums these ratios for residential locations where hospital locations overlap.

RESULTS

The comparison of the spatial accessibility measures for COVID-19 patients to those of population at risk identifies which geographic areas need additional healthcare resources to improve access. The results also help delineate the areas that may face a COVID-19-induced shortage of healthcare resources. The Chicagoland, particularly the southern Chicago, shows an additional need for resources. This study also identified vulnerable population residing in the areas with low spatial accessibility in Chicago.

CONCLUSION

Rapidly measuring spatial accessibility of healthcare resources provides an improved understanding of how well the healthcare infrastructure is equipped to save people's lives during the COVID-19 pandemic. The findings are relevant for policymakers and public health practitioners to allocate existing healthcare resources or distribute new resources for maximum access to health services.

Patterns of HIV testing among women diagnosed with invasive cervical cancer in the New Jersey Medicaid Program

PURPOSE

Practice-based guidelines recommend HIV testing during initial invasive cervical cancer (ICC) workup. Determinants of HIV testing during diagnosis of AIDS-defining cancers in vulnerable populations, where risk for HIV infection is higher, are under-explored.

METHODS

We examine factors associated with patterns of HIV testing among Medicaid enrollees diagnosed with ICC. Using linked data from the New Jersey State Cancer Registry and New Jersey Medicaid claims and enrollment files, we evaluated HIV testing among 242 ICC cases diagnosed from 2012 to 2014 in ages 21-64 at (a) any point during Medicaid enrollment (2011-2014) and (b) during cancer workup 6 months pre ICC diagnosis to 6 months post ICC diagnosis. Logistic regression models identified factors associated with HIV testing.

RESULTS

Overall, 13% of women had a claim for HIV testing during ICC workup. Two-thirds (68%) of women did not have a claim for HIV testing (non-receipt of HIV testing) while enrolled in Medicaid. Hispanic/NH-API/Other women had lower odds of non-receipt of HIV testing compared with NH-Whites (OR: 0.40; 95% CI: 0.17-0.94). Higher odds of non-receipt of HIV testing were observed among cases with no STI testing (OR: 4.92; 95% CI 2.27-10.67) and < 1 year of Medicaid enrollment (OR: 3.07; 95% CI 1.14- 8.26) after adjusting for other factors.

CONCLUSIONS

Few women had HIV testing claims during ICC workup. Opportunities for optimal ICC care are informed by knowledge of HIV status. Further research should explore if lack of HIV testing claims during ICC workup is an accurate indicator of ICC care, and if so, to assess testing barriers during workup.

Lung Cancer Staging at Diagnosis in the Veterans Health Administration: Is Rurality an Influencing Factor? A Cross-Sectional Study

Purpose

To evaluate the association between rurality and lung cancer stage at diagnosis.

Methods:

We conducted a cross-sectional study using Veterans Health Administration (VHA) data to identify veterans newly diagnosed with lung cancer between October 1, 2011 and September 30, 2015. We defined rurality, based on place of residence, using Rural-Urban Commuting Area (RUCA) codes with the subcategories of urban, large rural, small rural, and isolated. We used multivariable logistic regression models to determine associations between rurality and stage at diagnosis, adjusting for sociodemographic and clinical characteristics. We also analyzed data using the RUCA code for patients’ assigned primary care sites and driving distances to primary care clinics and medical centers.

Findings:

We identified 4,220 veterans with small cell lung cancer (SCLC) and 25,978 with non-small cell lung cancer (NSCLC). Large rural residence (compared to urban) was associated with early-stage diagnosis of NSCLC (OR = 1.12; 95% CI: 1.00–1.24) and SCLC (OR = 1.73; 95% CI: 1.18–1.55). However, the finding was significant only in the southern and western regions of the country. White race, female sex, chronic lung disease, higher comorbidity, receiving primary care, being a former tobacco user, and more recent year of diagnosis were also associated with diagnosing early-stage NSCLC. Driving distance to medical centers was inversely associated with late-stage NSCLC diagnoses, particularly for large rural areas.

Conclusions:

We did not find clear associations between rurality and lung cancer stage at diagnosis. These findings highlight the complex relationship between rurality and lung cancer within VHA, suggesting access to care cannot be fully captured by current rurality codes.

Epidemiology of breast cancer, a paradigm of the "common soil" hypothesis

Breast cancer is the leading cause of death in women aged 20-50 years, with some geographical difference. The yearly incidence of the disease is increasing while the related mortality is steadily decreasing. Breast cancer is associated not only with specific hormones or factors related with reproduction, but mostly to more general environmental factors, linked to socioeconomic conditions and lifestyles (smoking, stress, physical exercise and particularly dietary habits). The latter, indeed, are risk factors or conditions common to hormone-dependent tumors and other chronic degenerative disorders, such as ischemic cardio cerebro-vascular and neuro-degenerative disease. Breast cancer can indeed be considered as a paradigm of the so-called "common soil" concept, according to which the above mentioned conditions, although having different clinical manifestations, share some pathogenetic mechanisms and risk factors and intermediate predisposing phenotypes (see Type2 diabetes, metabolic syndrome or obesity). In an epidemiological perspective, evidence has been accumulated on the common response of breast cancer and cardiovascular disorders to healthy lifestyles and in particular to the beneficial effects of a close adhesion to the Mediterranean dietary model. The latter would mainly be effective thanks to its anti-inflammatory properties, thus controlling the subclinical condition of low-grade inflammation, a common risk factor of all the "common soil" disorders. Results from the prospective cohort of the Moli-sani Study (nearly 25,000 adults from the general population of the Southern Italy region of Molise) are highly suggestive in this context. In a public health perspective, the "common soil" hypothesis may thus promote the application of preventive strategies, particularly targeting lifestyles, for a broad spectrum of widely prevalent disorders, ranging from breast cancer to myocardial infarction or cognitive impairment conditions.

Breast and Cervical Cancer Screening Among Medicaid Beneficiaries: The Role of Physician Payment and Managed Care

Medicaid-insured women have low rates of cancer screening. There are multiple policy levers that may influence access to preventive services such as screening, including physician payment and managed care. We examine the relationship between each of these factors and breast and cervical cancer screening among nonelderly nondisabled adult Medicaid enrollees. We combine individual-level data on Medicaid enrollment, demographics, and use of screening services from the Medicaid Analytic eXtract files with data on states' Medicaid-to-Medicare fee ratios and estimate their impact on screening services. Higher physician fees are associated with greater screening for comprehensive managed care enrollees; for enrollees in fee-for-service Medicaid, the findings are mixed. Patient participation in primary care case management is a significant moderator of the relationship between physician fees and the rate of screening, as interactions between enrollee primary care case management status and the Medicaid fee ratio are consistently positive across models of screening.

Investigation of Relationship Between Spatial Distribution of Medical Equipment and Preventable Mortality

The aim of the study is to investigate the relationship between the spatial distribution of the selected medical equipment and the preventable mortality rate in the regions of the Slovak Republic. The main analytical approach is carried out through the cluster analysis based on a Euclidean distance technique in order to get similarity of the administrative divisions in form of a district and a pseudot2 approach aimed at the determination of a number of the districts in a cluster. A number of medical equipment had a rising tendency from the year 2008. The most extreme position according to a localisation distribution of the computed tomographs and the magnetic resonance imaging scanners is held by the Košice IV District at the level of 7.50630. From an angle of view of the preventable mortality, the Piešťany District holds the most extreme position peaking at the level of 10.97969 for the female sex and the Kežmarok District with the value of 9.44088. The study has the significant dissemination outputs for health policy interventions, especially to draw up regional health plans for computed tomography and magnetic resonance imaging deployment, mainly in locations with a high preventable mortality rate for both sexes.

GIScience and cancer: State of the art and trends for cancer surveillance and epidemiology

Maps are well recognized as an effective means of presenting and communicating health data, such as cancer incidence and mortality rates. These data can be linked to geographic features like counties or census tracts and their associated attributes for mapping and analysis. Such visualization and analysis provide insights regarding the geographic distribution of cancer and can be important for advancing effective cancer prevention and control programs. Applying a spatial approach allows users to identify location-based patterns and trends related to risk factors, health outcomes, and population health. Geographic information science (GIScience) is the discipline that applies Geographic Information Systems (GIS) and other spatial concepts and methods in research. This review explores the current state and evolution of GIScience in cancer research by addressing fundamental topics and issues regarding spatial data and analysis that need to be considered. GIScience, along with its health-specific application in the spatial epidemiology of cancer, incorporates multiple geographic perspectives pertaining to the individual, the health care infrastructure, and the environment. Challenges addressing these perspectives and the synergies among them can be explored through GIScience methods and associated technologies as integral parts of epidemiologic research, analysis efforts, and solutions. The authors suggest GIScience is a powerful tool for cancer research, bringing additional context to cancer data analysis and potentially informing decision-making and policy, ultimately aimed at reducing the burden of cancer.

Disadvantaged neighborhoods and racial disparity in breast cancer outcomes: the biological link

Neighborhoods encompass complex environments comprised of unique economic, physical, and social characteristics that have a profound impact on the residing individual's health and, collectively, on the community's wellbeing. Neighborhood disadvantage (ND) is one of several factors that prominently contributes to racial breast cancer (BC) health disparities in American women. African American (AA) women develop more aggressive breast cancer features, such as triple-negative receptor status and more advanced histologic grade and tumor stage, and suffer worse clinical outcomes than European American (EA) women. While the adverse effects of neighborhood disadvantage on health, including increased risk of cancer and decreased longevity, have recently come into focus, the specific molecular mechanisms by which neighborhood disadvantage increases BC risk and worsens BC outcomes (survivorship, recurrence, mortality) are not fully elucidated. This review illuminates the probable biological links between neighborhood disadvantage and predominantly BC risk, with an emphasis on stress reactivity and inflammation, epigenetics and telomere length in response to adverse neighborhood conditions.

Continuous Rural-Urban Coding for Cancer Disparity Studies: Is It Appropriate for Statistical Analysis?

Background: The dichotomization or categorization of rural-urban codes, as nominal variables, is a prevailing paradigm in cancer disparity studies. The paradigm represents continuous rural-urban transition as discrete groups, which results in a loss of ordering information and landscape continuum, and thus may contribute to mixed findings in the literature. Few studies have examined the validity of using rural-urban codes as continuous variables in the same analysis. Methods: We geocoded cancer cases in north central Florida between 2005 and 2010 collected by Florida Cancer Data System. Using a linear hierarchical model, we regressed the occurrence of late stage cancer (including breast, colorectal, hematological, lung, and prostate cancer) on the rural-urban codes as continuous variables. To validate, the results were compared to those from using a truly continuous rurality data of the same study region. Results: In term of associations with late-stage cancer risk, the regression analysis showed that the use of rural-urban codes as continuous variables produces consistent outcomes with those from the truly continuous rurality for all types of cancer. Particularly, the rural-urban codes at the census tract level yield the closest estimation and are recommended to use when the continuous rurality data is not available. Conclusions: Methodologically, it is valid to treat rural-urban codes directly as continuous variables in cancer studies, in addition to converting them into categories. This proposed continuous-variable method offers researchers more flexibility in their choice of analytic methods and preserves the information in the ordering. It can better inform how cancer risk varies, degree by degree, over a finer spectrum of rural-urban landscape.

Cancer statistics, 2019

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data, available through 2015, were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data, available through 2016, were collected by the National Center for Health Statistics. In 2019, 1,762,450 new cancer cases and 606,880 cancer deaths are projected to occur in the United States. Over the past decade of data, the cancer incidence rate (2006-2015) was stable in women and declined by approximately 2% per year in men, whereas the cancer death rate (2007-2016) declined annually by 1.4% and 1.8%, respectively. The overall cancer death rate dropped continuously from 1991 to 2016 by a total of 27%, translating into approximately 2,629,200 fewer cancer deaths than would have been expected if death rates had remained at their peak. Although the racial gap in cancer mortality is slowly narrowing, socioeconomic inequalities are widening, with the most notable gaps for the most preventable cancers. For example, compared with the most affluent counties, mortality rates in the poorest counties were 2-fold higher for cervical cancer and 40% higher for male lung and liver cancers during 2012-2016. Some states are home to both the wealthiest and the poorest counties, suggesting the opportunity for more equitable dissemination of effective cancer prevention, early detection, and treatment strategies. A broader application of existing cancer control knowledge with an emphasis on disadvantaged groups would undoubtedly accelerate progress against cancer.

Mobile Mammography Participation Among Medically Underserved Women: A Systematic Review

Introduction

Although breast cancer deaths have declined, the mortality rate among women from medically underserved communities is disproportionally high. Screening mammography is the most effective tool for detecting breast cancer in its early stages, yet many women from medically underserved communities do not have adequate access to screening mammograms. Mobile mammography may be able to bridge this gap by providing screening mammograms at no cost or low cost and delivering services to women in their own neighborhoods, thus eliminating cost and transportation barriers. The objective of this systematic review was to describe the scope and impact of mobile mammography programs in promoting mammographic screening participation among medically underserved women.

Methods

We searched electronic databases for English-language articles published in the United States from January 2010 through March 2018 by using the terms “mobile health unit,” “mammogram,” “mammography,” and “breast cancer screening.” Of the 93 articles initially identified, we screened 55; 16 were eligible to be assessed and 10 qualified for full text review and data extraction. Each study was coded for study purpose, research design, data collection, population targeted, location, sample size, outcomes, predictors, analytical methods, and findings.

Results

Of the 10 studies that qualified for review, 4 compared mobile mammography users with users of fixed units, and the other 6 characterized mobile mammography users only. All the mobile mammography units included reached underserved women. Most of the women screened in mobile units were African American or Latina, low income, and/or uninsured. Mobile mammography users reported low adherence to 1-year (12%–34%) and 2-year (40%–48%) screening guidelines. Some difficulties faced by mobile clinics were patient retention, patient follow-up of abnormal or inconclusive findings, and women inaccurately perceiving their breast cancer risk.

Conclusion

Mobile mammography clinics may be effective at reaching medically underserved women. Adding patient navigation to mobile mammography programs may promote attendance at mobile sites and increase follow-up adherence. Efforts to promote mammographic screening should target women from racial/ethnic minority groups, women from low-income households, and uninsured women. Future research is needed to understand how to best improve visits to mobile mammography clinics.

Geographic access to mammography facilities and frequency of mammography screening

PURPOSE

To assess the association between geographic access to mammography facilities and women's mammography utilization frequency.

METHODS

Using data from the population-based 1995-2007 Wisconsin Women's Health study, we used proportional odds and logistic regression to test whether driving times to mammography facilities and the number of mammography facilities within 10 km of women's homes were associated with mammography frequency among women aged 50-74 years and whether associations differed between Rural-Urban Commuting Areas and income and education groups.

RESULTS

We found evidence for nonlinear relationships between geographic access and mammography utilization (nonlinear effects of driving times and facility density, P-values .01 and .005, respectively). Having at least one nearby mammography facility was associated with greater mammography frequency among urban women (1 vs. 0 facilities, odds ratio 1.26, 95% confidence interval, 1.09-1.47), with similar effects among rural women. Adding more facilities had decreasing marginal effects. Long driving times tended to be associated with lower mammography frequency. We found no effect modification by income, education, or urbanicity. In rural settings, mammography nonuse was higher, facility density smaller, and driving times to facilities were longer.

CONCLUSIONS

Having at least one mammography facility near one's home may increase mammography utilization, with decreasing effects per each additional facility.

Contextual effects and cancer outcomes in the United States: a systematic review of characteristics in multilevel analyses

PURPOSE

There is increasing call for the utilization of multilevel modeling to explore the relationship between place-based contextual effects and cancer outcomes in the United States. To gain a better understanding of how contextual factors are being considered, we performed a systematic review.

METHODS

We reviewed studies published between January 1, 2002 and December 31, 2016 and assessed the following attributes: (1) contextual considerations such as geographic scale and contextual factors used; (2) methods used to quantify contextual factors; and (3) cancer type and outcomes. We searched PubMed, Scopus, and Web of Science and initially identified 1060 studies. One hundred twenty-two studies remained after exclusions.

RESULTS

Most studies utilized a two-level structure; census tracts were the most commonly used geographic scale. Socioeconomic factors, health care access, racial/ethnic factors, and rural-urban status were the most common contextual factors addressed in multilevel models. Breast and colorectal cancers were the most common cancer types, and screening and staging were the most common outcomes assessed in these studies.

CONCLUSIONS

Opportunities for future research include deriving contextual factors using more rigorous approaches, considering cross-classified structures and cross-level interactions, and using multilevel modeling to explore understudied cancers and outcomes.

County-level cumulative environmental quality associated with cancer incidence

BACKGROUND

Individual environmental exposures are associated with cancer development; however, environmental exposures occur simultaneously. The Environmental Quality Index (EQI) is a county-level measure of cumulative environmental exposures that occur in 5 domains.

METHODS

The EQI was linked to county-level annual age-adjusted cancer incidence rates from the Surveillance, Epidemiology, and End Results (SEER) Program state cancer profiles. All-site cancer and the top 3 site-specific cancers for male and female subjects were considered. Incident rate differences (IRDs; annual rate difference per 100,000 persons) and 95% confidence intervals (CIs) were estimated using fixed-slope, random intercept multilevel linear regression models. Associations were assessed with domain-specific indices and analyses were stratified by rural/urban status.

RESULTS

Comparing the highest quintile/poorest environmental quality with the lowest quintile/best environmental quality for overall EQI, all-site county-level cancer incidence rate was positively associated with poor environmental quality overall (IRD, 38.55; 95% CI, 29.57-47.53) and for male (IRD, 32.60; 95% CI, 16.28-48.91) and female (IRD, 30.34; 95% CI, 20.47-40.21) subjects, indicating a potential increase in cancer incidence with decreasing environmental quality. Rural/urban stratified models demonstrated positive associations comparing the highest with the lowest quintiles for all strata, except the thinly populated/rural stratum and in the metropolitan/urbanized stratum. Prostate and breast cancer demonstrated the strongest positive associations with poor environmental quality.

CONCLUSION

We observed strong positive associations between the EQI and all-site cancer incidence rates, and associations differed by rural/urban status and environmental domain. Research focusing on single environmental exposures in cancer development may not address the broader environmental context in which cancers develop, and future research should address cumulative environmental exposures. Cancer 2017;123:2901-8. © 2017 American Cancer Society.

County-level cumulative environmental quality associated with cancer incidence

BACKGROUND

Individual environmental exposures are associated with cancer development; however, environmental exposures occur simultaneously. The Environmental Quality Index (EQI) is a county-level measure of cumulative environmental exposures that occur in 5 domains.

METHODS

The EQI was linked to county-level annual age-adjusted cancer incidence rates from the Surveillance, Epidemiology, and End Results (SEER) Program state cancer profiles. All-site cancer and the top 3 site-specific cancers for male and female subjects were considered. Incident rate differences (IRDs; annual rate difference per 100,000 persons) and 95% confidence intervals (CIs) were estimated using fixed-slope, random intercept multilevel linear regression models. Associations were assessed with domain-specific indices and analyses were stratified by rural/urban status.

RESULTS

Comparing the highest quintile/poorest environmental quality with the lowest quintile/best environmental quality for overall EQI, all-site county-level cancer incidence rate was positively associated with poor environmental quality overall (IRD, 38.55; 95% CI, 29.57-47.53) and for male (IRD, 32.60; 95% CI, 16.28-48.91) and female (IRD, 30.34; 95% CI, 20.47-40.21) subjects, indicating a potential increase in cancer incidence with decreasing environmental quality. Rural/urban stratified models demonstrated positive associations comparing the highest with the lowest quintiles for all strata, except the thinly populated/rural stratum and in the metropolitan/urbanized stratum. Prostate and breast cancer demonstrated the strongest positive associations with poor environmental quality.

CONCLUSION

We observed strong positive associations between the EQI and all-site cancer incidence rates, and associations differed by rural/urban status and environmental domain. Research focusing on single environmental exposures in cancer development may not address the broader environmental context in which cancers develop, and future research should address cumulative environmental exposures. Cancer 2017;123:2901-8. © 2017 American Cancer Society.

Information Poverty and Reproductive Healthcare: Assessing the Reasons for Inequity between Income Groups

It is commonly known that in the United States women who are low income do not access reproductive healthcare services and information with the same reliability and regularity of women who are higher income. A qualitative research approach was undertaken to assess the root cause of this disparity. In-depth semistructured interviews were conducted with 15 women divided among socioeconomic lines. The primary barriers to care for women who are low income are clinical staff attitudes, knowledge of care available and needed, and cost or lack of insurance. This study adds to the current understanding of the barriers to reproductive healthcare for women of different socioeconomic statuses.

Demographic Disparities in Late-Stage Diagnosis of Breast and Colorectal Cancers Across the USA

BACKGROUND

We determined whether there were disparities in the likelihood of being diagnosed at a late stage for breast cancer (BC) or colorectal cancer (CRC) in each of 40 states, using the recently available US Cancer Statistics (USCS) database.

METHODS

We extracted 981,457 BC cases and 558,568 CRC cases diagnosed in 2004-2009. Separate multilevel regressions were run for each state and each cancer type. Models included person and area-level covariates and were identically specified across states. The disparities foci were race or ethnicity (white, African-American, Hispanic, Asian, all other), gender, and age (<40, 40-49, 50-64, 65-74, and 75+). Using whites, males, and the oldest age group as reference groups, we noted the statistically significant disparities coefficients (p value ≤0.05) and translated the findings via a set of maps of states in the USA.

RESULTS

National disparity estimates were not consistent with disparities identified in the states. Some states had estimates consistent with the national average, while others did not. Patterns of disparities across states were different for each covariate and mapped separately.

CONCLUSION

National disparity estimates may mask what is true at the more local, state level because national estimates can confound the effects of race with place. Cancer control efforts are local and require locally relevant information to assess needs. Findings from the period 2004-2009 establish valuable benchmarks against which to assess changes following national health reform implemented in 2010. The USCS database is a valuable new resource that will facilitate future disparities research.

Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review

OBJECTIVES

To investigate whether there is an association between differences in travel time/travel distance to healthcare services and patients' health outcomes and assimilate the methodologies used to measure this.

DESIGN

Systematic Review. We searched MEDLINE, Embase, Web of Science, Transport database, HMIC and EBM Reviews for studies up to 7 September 2016. Studies were excluded that included children (including maternity), emergency medical travel or countries classed as being in the global south.

SETTINGS

A wide range of settings within primary and secondary care (these were not restricted in the search).

RESULTS

108 studies met the inclusion criteria. The results were mixed. 77% of the included studies identified evidence of a distance decay association, whereby patients living further away from healthcare facilities they needed to attend had worse health outcomes (eg, survival rates, length of stay in hospital and non-attendance at follow-up) than those who lived closer. 6 of the studies identified the reverse (a distance bias effect) whereby patients living at a greater distance had better health outcomes. The remaining 19 studies found no relationship. There was a large variation in the data available to the studies on the patients' geographical locations and the healthcare facilities attended, and the methods used to calculate travel times and distances were not consistent across studies.

CONCLUSIONS

The review observed that a relationship between travelling further and having worse health outcomes cannot be ruled out and should be considered within the healthcare services location debate.

The impact of car ownership and public transport usage on cancer screening coverage: Empirical evidence using a spatial analysis in England

A spatial analysis has been conducted in England, with the aim to examine the impact of car ownership and public transport usage on breast and cervical cancer screening coverage. District-level cancer screening coverage data (in proportions) and UK census data have been collected and linked. Their effects on cancer screening coverage were modelled by using both non-spatial and spatial models to control for spatial correlation. Significant spatial correlation has been observed and thus spatial model is preferred. It is found that increased car ownership is significantly associated with improved breast and cervical cancer screening coverage. Public transport usage is inversely associated with breast cancer screening coverage; but positively associated with cervical cancer screening. An area with higher median age is associated with higher screening coverage. The effects of other socio-economic factors such as deprivation and economic activity have also been explored with expected results. Some regional differences have been observed, possibly due to unobserved factors. Relevant transport and public health policies are thus required for improved coverage. While restricting access to cars may lead to various benefits in public health, it may also result in worse cancer screening uptake. It is thus recommended that careful consideration should be taken before implementing policy interventions.

Baby Boomers and Birth Certificates: Early-Life Socioeconomic Status and Cancer Risk in Adulthood

BACKGROUND

Early-life socioeconomic status (SES) may play a role in cancer risk in adulthood. However, measuring SES retrospectively presents challenges. Parental occupation on the birth certificate is a novel method of ascertaining early-life SES that has not been applied in cancer epidemiology.

METHODS

For a Baby-Boom cohort born from 1945-1959 in two Utah counties, individual-level Nam-Powers SES (Np-SES) was derived from parental industry/occupation reported on birth certificates. Neighborhood SES was estimated from average household income of census tract at birth. Cancer incidence was determined by linkage to Utah Cancer Registry records through the Utah Population Database. Hazard ratios (HR) for cancer risk by SES quartile were estimated using Cox proportional hazards regression.

RESULTS

Females with low Np-SES at birth had lower risk of breast cancer compared with those in the highest Np-SES group [HR_Q1/Q4 = 0.83; 95% confidence interval (CI), 0.72-0.97; HR_Q2/Q4 = 0.81; 95% CI, 0.69-0.96]. Np-SES was inversely associated with melanoma (HR_Q1/Q4 = 0.81; 95% CI, 0.67-0.98) and prostate cancer (HR_Q1/Q4 = 0.70; 95% CI, 0.56-0.88). Women born into lower SES neighborhoods had significantly increased risk for invasive cervical cancer (HR_Q1/Q4 = 1.44; 95% CI, 1.12-1.85; HR_Q2/Q4 = 1.33; 95% CI, 1.04-1.72). Neighborhood SES had similar effects for melanoma and prostate cancers, but was not associated with female breast cancer. We found no association with SES for pancreas, lung, and colon and rectal cancers.

CONCLUSIONS

Individual SES derived from parental occupation at birth was associated with altered risk for several cancer sites.

IMPACT

This novel methodology can contribute to improved understanding of the role of early-life SES on cancer risk. Cancer Epidemiol Biomarkers Prev; 26(1); 75-84. ©2016 AACR.

Racial disparities in all-cause mortality among younger commercially insured women with incident metastatic breast cancer

Racial disparities in breast cancer mortality persist and are likely related to multiple factors. Over the past decade, progress has been made in treating metastatic breast cancer, particularly in younger women. Whether disparities exist in this population is unknown. Using administrative claims data between 2000 and 2011 (OptumInsight, Eden Prairie, MN) of members insured through a large national US health insurer, we identified women aged 25-64 years diagnosed with incident metastatic breast cancer diagnosed between November 1, 2000, and December 31, 2008. We examined time from diagnosis to death, with up to 3 years of follow-up. We stratified analyses by geocoded race and socio-economic status, age-at-diagnosis, morbidity score, US region of residence, urban/non-urban, and years of diagnosis. We constructed Kaplan-Meier survival plots and analyzed all-cause mortality using multivariate Cox proportional hazard models. Among 6694 women with incident metastatic breast cancer (78 % Caucasian, 4 % African American, and 18 % other), we found higher mortality rates among women residing in predominantly African American versus Caucasian neighborhoods (hazard ratio (HR) 1.84; 95 % confidence interval, CI 1.39-2.45), women with high versus lower morbidity (HR 1.30 [1.12-1.51]), and women whose incident metastatic diagnosis was during 2000-2004 versus 2005-2008 (HR 1.60 [1.39-1.83]). Caucasian (HR 0.61 [0.52-0.71]) but not African American women (HR not significant) experienced improved mortality in 2005-2008 versus 2000-2004. Despite insured status, African American women and women with multi-morbidity had poorer survival. Only Caucasian women had improved mortality over time. Modifiable risk factors for increased mortality need to be addressed in order to reduce disparities.

United States Health Policies and Late-stage Breast and colorectal cancer diagnosis: Why such disparities by age?

BACKGROUND

Colorectal and breast cancers are the second most common causes of cancer deaths in the US. Population cancer screening rates are suboptimal and many cancers are diagnosed at an advanced stage, which results in increased morbidity and mortality. Younger populations are more likely to be diagnosed at a later stage, and this age disparity is not well understood. We examine the associations between late-stage breast cancer (BC) and colorectal cancer (CRC) diagnoses and multilevel factors, focusing on individual state regulations of insurance and health practitioners, and interactions between such policies and age. We expect state-level regulations are significant predictors of the rates of late-stage diagnosis among younger adults.

METHODS

We included adults of all ages, with BC or CRC diagnosed between 2004 -2009, obtained from a newly available cancer population database covering 98 % of all known new cancer cases. We included personal characteristics, linked with a set of county and state-level predictors based on residence. We applied multilevel models to robustly examine differences in risk of late-stage cancer diagnosis across age groups (defined as age 65+ or < 65), focusing specifically on the effects of state regulatory factors and their interactions with age.

RESULTS

Late stage BC diagnoses range from 24 %-36 %, while CRC diagnoses range from 54 %-60 % of newly diagnosed BC or CRC cases across states. After controlling statistically for many confounding factors at three levels, age < 65 is the largest person-level predictor for CRC, while black race is the largest predictor for BC. State regulations of health markets exhibit significant interactions with age groups.

CONCLUSIONS

The state regulatory climate is an important predictor of late-stage BC and CRC diagnoses, especially among people younger than Medicare eligible age (65). State regulations can enhance the climate of access for younger, less well-insured or uninsured persons who fall outside normative screening guidelines.

Travel by public transit to mammography facilities in 6 US urban areas

We examined lack of private vehicle access and 30 minutes or longer public transportation travel time to mammography facilities for women 40 years of age or older in the urban areas of Boston, Philadelphia, San Antonio, San Diego, Denver, and Seattle to identify transit marginalized populations - women for whom these travel characteristics may jointly present a barrier to clinic access. This ecological study used sex and race/ethnicity data from the 2010 US Census and household vehicle availability data from the American Community Survey 2008-2012, all at Census tract level. Using the public transportation option on Google Trip Planner we obtained the travel time from the centroid of each census tract to all local mammography facilities to determine the nearest mammography facility in each urban area. Median travel times by public transportation to the nearest facility for women with no household access to a private vehicle were obtained by ranking travel time by population group across all U.S. census tracts in each urban area and across the entire study area. The overall median travel times for each urban area for women without household access to a private vehicle ranged from a low of 15 minutes in Boston and Philadelphia to 27 minutes in San Diego. The numbers and percentages of transit marginalized women were then calculated for all urban areas by population group. While black women were less likely to have private vehicle access, and both Hispanic and black women were more likely to be transit marginalized, this outcome varied by urban area. White women constituted the largest number of transit marginalized. Our results indicate that mammography facilities are favorably located for the large majority of women, although there are still substantial numbers for whom travel may likely present a barrier to mammography facility access.

Geographic disparities in late stage breast cancer incidence: results from eight states in the United States

Background

Late stage of cancer at diagnosis is an important predictor of cancer mortality. In many areas worldwide, cancer registry systems, available data and mapping technologies can provide information about late stage cancer by geographical regions, offering valuable opportunities to identify areas where further investigation and interventions are needed. The current study examined geographical variation in late stage breast cancer incidence across eight states in the United States with the objective to identify areas that might benefit from targeted interventions.

Methods

Data from the Surveillance Epidemiology and End Results Program on late stage breast cancer incidence was used as dependent variable in regression analysis and certain factors known to contribute to high rates of late stage cancer (socioeconomic characteristics, health insurance characteristics, and the availability and utilization of cancer screening) as covariates. Geographic information systems were used to map and highlight areas that have any combination of high late stage breast cancer incidence and significantly associated risk factors.

Results

The differences in mean rates of late stage breast cancer between eight states considered in this analysis are statistically significant. Factors that have statistically negative association with late stage breast cancer incidence across the eight states include: density of mammography facilities, percent population with Bachelor’s degree and English literacy while percent black population has statistically significant positive association with late stage breast cancer incidence.

Conclusions

This study describes geographic disparities in late stage breast cancer incidence and identifies areas that might benefit from targeted interventions. The results suggest that in the eight US states examined, higher rates of late stage breast cancer are more common in areas with predominantly black population, where English literacy, percentage of population with college degree and screening availability are low. The approach described in this work may be utilized both within and outside US, wherever cancer registry systems and technologies offer the same opportunity to identify places where further investigation and interventions for reducing cancer burden are needed.

Geographic Access to Mammography and Its Relationship to Breast Cancer Screening and Stage at Diagnosis: A Systematic Review

INTRODUCTION

A review was conducted to summarize the current evidence and gaps in the literature on geographic access to mammography and its relationship to breast cancer-related outcomes.

METHODS

Ovid, Medline, and PubMed were searched for articles published between January 1, 2000, and April 1, 2013, using Medical Subject Headings and key terms representing geographic accessibility and breast cancer-related outcomes. Owing to a paucity of breast cancer treatment and mortality outcomes meeting the criteria (N = 6), outcomes were restricted to breast cancer screening and stage at diagnosis. Studies included one or more of the following types of geographic accessibility measures: capacity, density, distance, and travel time. Study findings were grouped by outcome and type of geographic measure.

RESULTS

Twenty-one articles met the inclusion criteria. Fourteen articles included stage at diagnosis as an outcome, five included mammography use, and two included both. Geographic measures of mammography accessibility varied widely across studies. Findings also varied, but most articles found either increased geographic access to mammography associated with increased use and decreased late-stage at diagnosis or no association.

CONCLUSION

The gaps and methodologic heterogeneity in the literature to date limit definitive conclusions about an underlying association between geographic mammography access and breast cancer-related outcomes. Future studies should focus on the development and application of more precise and consistent measures of geographic access to mammography.

A commuter-based two-step floating catchment area method for measuring spatial accessibility of daycare centers

This paper puts forward a commuter-based version of the two-step floating catchment area (2SFCA) method, which has gained acceptance in studies on spatial health care accessibility. Current implementations of the 2SFCA method are static in that they consider centroid-based night-time representations of the population. The proposed enhancement to the 2SFCA approach addresses this limitation by accounting for trip-chaining behavior. The presented method is illustrated in a case study of accessibility of daycare centers in the province East Flanders in Belgium. The results show significant spatial differences in accessibility between the original and commuter-based version of the 2SFCA (CB2SFCA). They highlight the importance of giving heed to more complex travel behavior in cases where the need for detailed accessibility calculations is apparent.

The influence of geographical access to health care and material deprivation on colorectal cancer survival: evidence from France and England

This article investigates the influence of distance to health care and material deprivation on cancer survival for patients diagnosed with a colorectal cancer between 1997 and 2004 in France and England. This population-based study included all cases of colorectal cancer diagnosed between 1997 and 2004 in 3 cancer registries in France and 1 cancer registry in England (N=40,613). After adjustment for material deprivation, travel times in England were no longer significantly associated with survival. In France patients living between 20 and 90min from the nearest cancer unit tended to have a poorer survival, although this was not statistically significant. In England, the better prognosis observed for remote patients can be explained by associations with material deprivation; distance to health services alone did not affect survival whilst material deprivation level had a major influence, with lower survival for patients living in deprived areas. Increases in travel times to health services in France were associated with poorer survival rates. The pattern of this influence seems to follow an inverse U distribution, i.e. maximal for average travel times.

Association between individual and geographic factors and nonadherence to mammography screening guidelines

BACKGROUND

This study investigates factors that are associated with nonadherence to mammography screening guidelines in Utah, a state where mammography screening rates have remained consistently lower than national averages.

METHODS

We examined data on reported mammography use among women aged 40-74 years from the 2008 and 2010 Utah Behavioral Risk Factor Surveillance System (n=5,197, weighted n=417,064). Logistic regression models were used to estimate the effects of individual-level and geographic (travel time to nearest mammography facility, geographic accessibility, and rural/urban residence) factors on the odds of a woman not reporting receiving a mammogram in the last 2 years.

RESULTS

In 2008 and 2010, a disproportionate number of women aged 40-49 (43.1%, 95% confidence interval [CI] 39.9%-46.3%) reported not receiving a mammogram within the last 2 years compared to women 50-74 (26.8%, 95% CI 24.9%-28.7%). None of the geographic factors were significant predictors of screening adherence. Based on covariate adjusted models, statistically significant (p<0.05) factors associated with increased odds of not receiving mammogram within the last 2 years included not having a regular physician, no health insurance, being aged 40-49, income less than $25,000, and the presence of three or more children in the home.

CONCLUSION

Mammography screening efforts in Utah should focus on improving access to insurance or a regular source of health care. Future research should also consider how best to address extreme time demands and competing priorities that present potential barriers for women with large families, resulting in lower screening levels among these women.