The burden of stomach cancer mortality by county, race, and ethnicity in the USA, 2000-2019: a systematic analysis of health disparities

Social determinants of health and upper gastrointestinal cancer outcomes in the United States: a systematic review

Introduction

Social determinants of health (SDOH) are the conditions in which individuals are born, grow, work, live, and age.

Methods

We examined the literature on the association between SDOH and survival of patients with gastrointestinal (GI) cancer [esophageal, duodenal and gastric cancer (GC)] in the United States from 2001 to 2022.

Results

From 38,654 studies across COCHRANE, EMBASE, SCOPUS, WEB OF SCIENCE, and PubMed, we identified 14 relevant studies focusing on GI cancer using the PRISMA flowchart. Eight of the 12 GC studies specifically focused on gastric adenocarcinoma (GAC), the most common histologic subtype. Uninsured patients had a significantly worse overall survival probability. For patients with GI cancer, the highest income level (i.e., in the highest quartile) was associated with improved survival. Being unmarried had a negative impact on overall survival. Overall, people with insurance, higher incomes, and who were married had better overall survival rates.

Discussion

Our findings suggest a clear association between SDOH and survival for patients with GI cancers. However, there is great variability in the factors studied and how these are measured and reported. A better understanding of SDOH is needed to design strategies with an aim to improve patient outcomes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, PROSPERO (CRD42022346854).

Disparities in Stage at Diagnosis among Hispanic Patients with Gastric Cancer in the United States

INTRODUCTION

Racial disparities in gastric cancer outcomes, including stage at diagnosis and overall survival, continue to affect Hispanic and non-Hispanic populations. This study aims to evaluate these disparities across different racial groups.

PATIENTS AND METHODS

We conducted a retrospective cohort study using SEER data from 2018 to 2021, including 18,984 patients diagnosed with gastric cancer. Patients were selected based on ICD-O-3 codes for "stomach" with malignant behavior. Using ordered logistic regression, the association between race and stage at diagnosis was analyzed, while Cox proportional hazards models were used to assess OS and CSS.

RESULTS

Hispanic patients were significantly more likely to be diagnosed at a later stage compared to non-Hispanic patients (OR: 1.19; 95% CI: 1.10-1.28). Both Hispanic and Black patients had worse OS compared to Non-Hispanic Whites (HR 1.10 CI 1.03-1.17, p = 0.003 and HR 1.13 CI 1.04-1.22, p = 0.002, respectively) as well as CSS.

CONCLUSIONS

Hispanic patients are more likely to be diagnosed with advanced-stage gastric cancer and have poorer survival outcomes compared to non-Hispanic Whites. These disparities may be linked to differences in healthcare access, insurance, language barriers, and preventive care utilization.

Assessing social vulnerabilities of salivary gland cancer care, prognosis, and treatment in the United States

BACKGROUND

Salivary gland cancers (SGC)-social determinants of health (SDoH) investigations are limited by narrow scopes of SGC-types and SDoH. This Social Vulnerability Index (SVI)-study hypothesized that socioeconomic status (SES) most contributed to SDoH-associated SGC-disparities.

METHODS

Retrospective cohort of 24 775 SGCs assessed SES, minority-language status (ML), household composition (HH), housing-transportation (HT), and composite-SDoH measured by the SVI via regressions with surveillance and survival length, late-staging presentation, and treatment (surgery, radio-, chemotherapy) receipt.

RESULTS

Increasing social vulnerability showed decreases in surveillance/survival; increased odds of advanced-presenting-stage (OR: 1.12, 95% CI: 1.07, 1.17), chemotherapy receipt (OR: 1.13, 95% CI: 1.03, 1.23); decreased odds of primary surgery (0.89, 0.84, 0.94), radiotherapy (0.91, 0.85, 0.97, p = 0.003) for SGCs. Trends were differentially correlated with SES, ML, HH, and HT-vulnerabilities.

CONCLUSIONS

Through quantifying SDoH-derived SGC-disparities, the SVI can guide targeted initiatives against SDoH that elicit the most detrimental associations for specific sociodemographics.

Using the Electronic Health Record to Develop a Gastric Cancer Risk Prediction Model

Background and Aims

Gastric cancer (GC) is a leading cause of cancer incidence and mortality globally. Population screening is limited by the low incidence and prevalence of GC in the United States. A risk prediction algorithm to identify high-risk patients allows for targeted GC screening. We aimed to determine the feasibility and performance of a logistic regression model based on electronic health records to identify individuals at high risk for noncardia gastric cancer (NCGC).

Methods

We included 614 patients who had a diagnosis of NCGC between ages 40 and 80 years and who were seen at our large tertiary medical center in multiple states between 2010 and 2021. Controls without a diagnosis of NCGC were randomly selected in a 1:10 ratio of cases to controls. Multiple imputation by chained equations for missing data followed by logistic regression on imputed datasets was used to estimate the probability of NCGC. Area under the curve and the 0.632 estimator was used as the estimate for discrimination.

Results

The 0.632 estimator value was 0.731, indicating robust model performance. Probability of NCGC was higher with increasing age (odds ratio [OR] = 1.16, 95% confidence interval [CI]: 1.04-1.3), male sex (OR = 1.97; 95% CI: 1.64-2.36), Black (OR = 3.07; 95% CI: 2.46-3.83) or Asian race (OR = 4.39; 95% CI: 2.60-7.42), tobacco use (OR = 1.61; 95% CI: 1.34-1.94), anemia (OR = 1.35; 95% CI: 1.09-1.68), and pernicious anemia (OR = 6.12, 95% CI: 3.42-10.95).

Conclusion

We demonstrate the feasibility and good performance of an electronic health record-based logistic regression model for estimating the probability of NCGC. Future studies will refine and validate this model, ultimately identifying a high-risk cohort who could be eligible for NCGC screening.

Impact of the Implementation of the Affordability Care Act on Gastric Cancer Survival Rates

Introduction  Gastric cancer, a significant public health concern, remains one of the most challenging malignancies to treat effectively. In the United States, survival rates for gastric cancer have historically been low, partly due to late-stage diagnosis and disparities in access to care. The Affordable Care Act (ACA) sought to address such disparities by expanding healthcare coverage and improving access to preventive and early treatment services.  Objective This study aims to determine the causal effects of the ACA's implementation on gastric cancer survival rates, focusing on a comparative analysis between two distinct U.S. states: New Jersey, which fully embraced ACA provisions, and Georgia, which has not adopted the policy, as of 2023.  Methods In this retrospective analysis, we utilized data from the Surveillance, Epidemiology, and End Results Program (SEER) registry to assess the impact of the ACA on cancer-specific survival (CSS) among gastric cancer patients. The study spanned the period from 2000 to 2020, divided into pre-ACA (2000-2013) and post-ACA (2016-2020) periods, with a two-year washout (2013-2015). We compared Georgia (a non-expansion state) to New Jersey (an expansion state since 2014) using a Difference-in-Differences (DiD) approach. We adjusted for patient demographics, income, metropolitan status, disease stage, and treatment modalities.  Results Among 25,061 patients, 58.7% were in New Jersey (14,711), while 41.3% were in Georgia (10,350). The pre-ACA period included 18,878 patients (40.0% in Georgia and 60.0% in New Jersey), and 6,183 patients were in the post-ACA period (45.2% in Georgia and 54.8% in New Jersey). The post-ACA period was associated with a 20% reduction in mortality hazard among gastric cancer patients, irrespective of the state of residence (HR = 0.80, 95% CI: 0.73-0.88). Patients who were residents of New Jersey experienced a 12% reduction in mortality hazard compared to those who resided in Georgia in the post-ACA period (HR = 0.88, 95% CI: 0.78-0.99). Other factors linked to improved survival outcomes included surgery (OR = 0.30, 95% CI: 0.28-0.34) and female gender (OR=0.83, 95% CI: 0.76-0.91).  Conclusion The study underscores the ACA's potential positive impact on CSS among gastric cancer patients, emphasizing the importance of healthcare policy interventions in improving patient outcomes.

The associations of food environment with gastrointestinal cancer outcomes in the United States

BACKGROUND

Social conditions and dietary behaviors have been implicated in the rising burden of gastrointestinal cancers (GIC). The "food environment" reflects influences on a community level relative to food availability, nutritional assistance, and social determinants of health. Using the US Department of Agriculture-Food Environment Atlas (FEA), we sought to characterize the association of food environment on GIC presenting stage and long-term survival.

METHODS

Patients diagnosed with GIC between 2013 and 2017 were identified using the SEER database. FEA-scores were based on 282 county-level food security variables, store-restaurant availability, SNAP/WIC enrollment, pricing/taxes, and producer vicinity adjusted-for factors of socioeconomic status, race-ethnicity, transportation access, and comorbidities. Relative FEA rankings across US counties were averaged into a composite score and assigned to patients by county-of-residence. The association of FEA, cancer stage, and survival were analyzed using multiple logistic regression and cox-proportional hazard models relative to White/non-White race/ethnicity.

RESULTS

Among 287,148 patients, the most common GIC-sites were colon (n = 97,942, 34%), pancreas (n = 49,785, 17.3%), liver (n = 31,098, 11.0%) and esophagus (n = 16,271, 5.7%). A worse food environment was independently associated with increased odds of late-stage diagnosis (esophageal odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01-1.05; hepatic OR: 1.06, 95% CI: 1.03-1.08; pancreatic OR: 1.04, 95% CI: 1.01-1.06) among all patients; in contrast, food environment was associated with colorectal cancer stage among non-White patients only (OR: 1.04, 95% CI: 1.03-1.06). Worse food environment was associated with worse 3-year survival (colon OR: 1.03, 95% CI: 1.01-1.04; hepatic OR: 1.12, 95% CI: 1.08-1.17; gastric OR: 1.07, 95% CI: 1.01-1.13). Similar associations were noted relative to overall survival among the entire cohort (biliary tract hazard ratio [HR]: 1.03, 95% CI: 1.01-1.05; esophageal HR: 1.02, 95% CI: 1.01-1.04; hepatic HR: 1.07, 95% CI: 1.06-1.09; pancreatic HR: 1.04, 95% CI: 1.02-1.05; rectum HR: 1.03, 95% CI: 1.01-1.04; gastric HR: 1.05, 95% CI: 1.03-1.07), as well as among non-White patients (biliary HR: 1.04, 95% CI: 1.01-1.07; colon HR: 1.03, 95% CI: 1.01-1.05; esophageal HR: 1.05, 95% CI: 1.02-1.08; hepatic HR: 1.08, 95% CI: 1.06-1.10) (all p < 0.003).

CONCLUSIONS

Food environment was independently associated with late-stage tumor presentation and worse 3-year and overall survival among GIC patients. Interventions to address inequities across communities relative to food environments are needed to alleviate disparities in cancer care.

ARID1A Mutations in Gastric Cancer: A Review with Focus on Clinicopathological Features, Molecular Background and Diagnostic Interpretation

AT-rich interaction domain 1 (ARID1A) is a pivotal gene with a significant role in gastrointestinal tumors which encodes a protein referred to as BAF250a or SMARCF1, an integral component of the SWI/SNF (SWItch/sucrose non-fermentable) chromatin remodeling complex. This complex is instrumental in regulating gene expression by modifying the structure of chromatin to affect the accessibility of DNA. Mutations in ARID1A have been identified in various gastrointestinal cancers, including colorectal, gastric, and pancreatic cancers. These mutations have the potential to disrupt normal SWI/SNF complex function, resulting in aberrant gene expression and potentially contributing to the initiation and progression of these malignancies. ARID1A mutations are relatively common in gastric cancer, particularly in specific adenocarcinoma subtypes. Moreover, such mutations are more frequently observed in specific molecular subtypes, such as microsatellite stable (MSS) cancers and those with a diffuse histological subtype. Understanding the presence and implications of ARID1A mutations in GC is of paramount importance for tailoring personalized treatment strategies and assessing prognosis, particularly given their potential in predicting patient response to novel treatment strategies including immunotherapy, poly(ADP) ribose polymerase (PARP) inhibitors, mammalian target of rapamycin (mTOR) inhibitors, and enhancer of zeste 2 polycomb repressive complex 2 subunit (EZH2) inhibitors.

Molecular alterations in claudin 18 suppressed and non-suppressed gastric adenocarcinomas to guide targeted therapies

BACKGROUND

Gastric adenocarcinoma represents an aggressive type of cancer and an important cause of cancer mortality. Progress in gastric cancer therapeutics has resulted from a better understanding of the molecular pathogenesis of the disease and introduction of targeted therapies, but most gastric cancer patients still rely on non-targeted chemotherapy as the mainstay of treatment for advanced disease.

METHODS

An analysis of publicly available series from The Cancer Genome Atlas (TCGA) gastric cancer cohort was undertaken to delineate the clinical and genomic landscape of gastric cancers with suppressed expression of claudin 18 compared with cancers with non-suppressed claudin 18. Claudin 18 suppressed cancers were defined as having an mRNA expression z-score relative to normal samples (log RNA Seq V2) of less than -1. Claudin 18 non-suppressed cancers were defined as having an mRNA expression z-score relative to normal samples (log RNA Seq V2) above 0.5.

RESULTS

Gastric cancers with claudin 18 mRNA suppression represented 7.7% of the gastric adenocarcinomas of TCGA cohort, while non-suppressed cancers represented 46.6% of the cases. The two groups did not differ in clinical and genomic characteristics, such as mean age, histology, grade, and stage. The mutation landscape of claudin 18 suppressed cases included high mutation rates of TP53, of genes of the WNT/β-catenin pathway and of ubiquitin ligase FBXW7. Moreover, a subset of both claudin 18 suppressed and non-suppressed cancers displayed mutations in Mismatch Repair (MMR) associated genes or a high tumor mutation burden (TMB). At the mRNA expression level, claudin 18 suppressed gastric cancers showed up-regulation of EMT core transcription factor Snail 2 and down-regulation of genes of HLA cluster. The survival of gastric cancer patients with claudin 18 mRNA suppression was not significantly different compared with patients with non-suppressed claudin 18.

CONCLUSION

Sub-sets of gastric cancers with claudin 18 mRNA suppression displayed characteristics of potential therapeutic interest, such as mutations in WNT and PI3K pathways and MMR defects. These may guide the development of alternative targeted therapies, in this sub-set of gastric cancers which are not candidates for claudin 18 targeting therapies.

Racial disparities of gastric cancer in the USA: an overview of epidemiology, global screening guidelines, and targeted screening in a heterogeneous population

Gastric cancer is the fifth most common cancer diagnosis and fourth leading cause of cancer-related death globally. The incidence of gastric cancer in the USA shows significant racial and ethnic disparities with gastric cancer incidence in Korean Americans being over five times higher than in non-Hispanic whites. Since gastric cancer is not common in the USA, there are no current screening guidelines. In countries with higher incidences of gastric cancer, screening guidelines have been implemented for early detection and intervention and this has been associated with a reduction in mortality. Immigrants from high incidence countries develop gastric cancer at lower rates once outside of their country of origin, but continue to be at higher risk for developing gastric cancer. This risk does seem to decrease with subsequent generations. With increasing availability of endoscopy, initiating gastric cancer screening guidelines for high-risk groups can have the potential to improve survival by diagnosing and treating gastric cancer at an earlier stage. This article aims to provide context to gastric cancer epidemiology globally, review risk factors for developing gastric cancer, highlight racial and ethnic disparities in gastric cancer burden in the USA, examine current guidelines that exist in high incidence countries, and suggest future studies examining the efficacy of additional screening in high-risk populations to reduce gastric cancer mortality and disparate burden on ethnic minorities in the USA.

Editorial article to: Animal experimental study on magnetic anchor technique-assisted endoscopic submucosal dissection of early gastric cancer

In this editorial we comment on the article published in the recent issue of the World Journal of Gastrointestinal Endoscopy 2023; 15 (11): 634-680. Gastric cancer (GC) remains the fifth most common malignancy and the fourth leading cause of cancer-related death worldwide. The overall prevalence of GC has declined, although that of proximal GC has increased over time. Thus, a significant proportion of GC cases and deaths can be avoided if preventive interventions are taken. Early GC (EGC) is defined as GC confined to the mucosa or submucosa. Endoscopic resection is considered the most appropriate treatment for precancerous gastrointestinal lesions improving patient quality of life, with reduced rates of complications, shorter hospitalization period, and lower costs when compared to surgical resection. Endoscopic mucosal resection (EMR) and endoscopic sub-mucosal dissection (ESD) are representative endoscopic treatments for EGC and precancerous gastric lesions. Standard EMR implies injection of a saline solution into the sub-mucosal space, followed by excision of the lesion using a snare. Complete resection rates vary depending on the size and severity of the lesion. When using conventional EMR methods for lesions less than 1 cm in size, the complete resection rate is approximately 60%, whereas for lesions larger than 2 cm, the complete resection rate is low (20%-30%). ESD can be used to remove tumors exceeding 2 cm in diameter and lesions associated with ulcers or submucosal fibrosis. Compared with EMR, ESD has higher en bloc resection rates (90.2% vs 51.7%), higher complete resection rates (82.1 vs 42.2%), and lower recurrence rates (0.65% vs 6.05%). Thus, innovative techniques have been introduced.