Secular trends in mortality from common cancers in the United States by educational attainment, 1993-2001

Educational Attainment and Cancer Incidence in a Large Nationwide Prospective Cohort

BACKGROUND

Educational attainment is a social determinant of health and frequently used as an indicator of socioeconomic status. Educational attainment is a predictor of cancer mortality, but associations with site-specific cancer incidence are variable. The aim of this study was to evaluate the association of educational attainment and site-specific cancer incidence adjusting for known risk factors in a large prospective cohort.

METHODS

Men and women enrolled in the American Cancer Society's Cancer Prevention Study-II Nutrition Cohort who were cancer free at baseline were included in this study (n = 148,965). Between 1992 and 2017, 22,810 men and 17,556 women were diagnosed with incident cancer. Cox proportional hazards regression models were used to estimate age- and multivariable-adjusted risk and 95% confidence intervals of total and site-specific cancer incidence in persons with lower versus higher educational attainment.

RESULTS

Educational attainment was inversely associated with age-adjusted cancer incidence among men but not women. For specific cancer sites, the multivariable-adjusted risk of cancer in the least versus most educated individuals remained significant for colon, rectum, and lung cancer among men and lung and breast cancer among women.

CONCLUSIONS

Educational attainment is associated with overall and site-specific cancer risk though adjusting for cancer risk factors attenuates the association for most cancer sites.

IMPACT

This study provides further evidence that educational attainment is an important social determinant of cancer but that its effects are driven by associated behavioral risk factors suggesting that targeting interventions toward those with lower educational attainment is an important policy consideration.

Critical care for multimorbid patients

Multimorbidity - the simultaneous presence of several chronic diseases - is very common in the critically ill patients. Its prevalence is roughly 40-85 % and continues to increase further. Certain chronic diseases such as diabetes, obesity, chronic heart, pulmonary, liver or kidney disease and malignancy are associated with higher risk of developing serious acute complications and therefore the possible need for intensive care. This review summarizes and discusses selected specifics of critical care for multimorbid patients.

Elevated breast cancer mortality among highly educated Asian American women

Background

Postmenopausal breast cancer (PMBC) is the most commonly diagnosed and the second leading cause of cancer death among women in the US. Research examining the association between PMBC and education level has been inconsistent; no study in the US has examined how educational level impacts PMBC mortality in Asian American women, a largely immigrant population with above-average educational attainment.

Methods

California Vital Statistics data from 2012–2017 were analyzed to derive age-adjusted mortality rate ratios (MRRs) by education level (associates degree or above referred to as “higher education”, high school, less than high school) and race [Non-Hispanic White (NHW), Asian/Pacific Islander (Asian), and its two largest subpopulations: Chinese and Filipino] from negative binomial regression models.

Results

PMBC mortality for both NHWs and Asians was greater among women with higher education compared to those who did not complete high school: NHWs had 22% higher PMBC mortality (MRR 1.22; 95% CI: 1.14–1.31) and Asians had 2.6 times greater PMBC mortality (MRR 2.64; 95% CI: 2.32–3.00) than their counterparts who did not complete high school. Asians in the lowest education level had 70% lower mortality than NHWs (MRR 0.30; 95% CI: 0.27–0.34). This mortality advantage among Asians was greatly reduced to only 27% lower among the highest educated (MRR 0.73; 95% CI: 0.68–0.78). For higher educated Filipina women, no mortality advantage was evident compared to NHWs (MRR 0.96; 95% CI: 0.88–1.05).

Conclusion

PMBC mortality for higher educated Asian women is elevated in comparison to their counterparts with less education. Given that PMBC survival is greater among those with higher education, our findings strongly suggest an excess in the incidence of PMBC (more than double) among higher educated Asian women; this warrants more research into potentially modifiable causes of PMBC in this burgeoning population.

Analysis of racial disparities in the treatment and outcomes of colorectal cancer in young adults

BACKGROUND

The incidence of colorectal cancer (CRC) in young adults is increasing. Minority populations with CRC are known to have worse survival outcomes. The aim of this study is to evaluate adults under age 50 years with CRC by race and ethnicity.

METHODS

Data were obtained from all US hospitals that contributed to the National Cancer Database (NCDB) between 2004 and 2013. Univariate and multivariable testing was done to identify factors associated with patient outcome. Kaplan-Meier analysis and Cox proportional hazards models were used for association between patient characteristics and survival.

RESULTS

A total of 83,449 patients between 18 and 50 years of age were identified. Median age was 45 years (SD ± 6), with male preponderance (53.9%). 72% were non-Hispanic Whites (NHW), Blacks (AA) were 15.1% and Hispanics (who did not identify as Blacks) were 8.3% of the study population. Distribution across stages IIV was 15.6%, 22.4%, 33.9% and 27% consecutively. 41.8% of NHW and 28.4% of AA had rectal cancers (p < 0.001). Despite equally receiving standard of care (SOC) as per national guidelines, AA had significantly lower 5-year survival rates (58.8%) compared to Hispanics (64.8%) and NHW (66.9%; HR 1.42; 1.38-1.46; p < 0.001). Furthermore, NHW (HR 0.85; 0.81-0.88; p < 0.001) and Hispanics (HR 0.75; 0.70-0.79; p < 0.001) were more likely to benefit from chemotherapy compared to AA. SOC utilization was associated with improved survival across all racial groups, especially in AA (HR 0.64; 0.60-0.69; p < 0.001).

CONCLUSION

Despite comparable rates of SOC utilization, AA young adults had worse survival outcomes compared to other races. More colon (compared to rectal) cancers in AA may have contributed to their worse outcomes.

National and State Estimates of Lost Earnings From Cancer Deaths in the United States

Importance

Information on the economic burden of cancer mortality can serve as a tool in setting policies and prioritizing resources for cancer prevention and control. However, contemporary data are lacking for the United States nationally and by state.

Objective

To estimate lost earnings due to death from cancer overall and for the major cancers in the United States nationally and by state.

Design, Setting, and Participants

Person-years of life lost (PYLL) were calculated using numbers of cancer deaths and life expectancy data in individuals aged 16 to 84 years who died from cancer in the United States in 2015. The annual median earnings in the United States were used to assign a monetary value for each PYLL by age and sex. Cancer mortality and life expectancy data were obtained from the National Center for Health Statistics and annual median earnings from the US Census Bureau's 2016 Current Population Survey's March Annual Social and Economic Supplement. Data analysis was performed from October 22, 2018, to February 25, 2019.

Main Outcomes and Measures

Lost earnings due to cancer death, represented as estimated future wages in the absence of premature death.

Results

A total of 8 739 939 person-years of life were lost to cancer death in persons aged 16 to 84 years in the United States in 2015, translating to lost earnings of $94.4 billion (95% CI, $91.7 billion-$97.3 billion). For individual cancer sites, lost earnings were highest for lung cancer ($21.3 billion), followed by colorectal ($9.4 billion), female breast ($6.2 billion), and pancreatic ($6.1 billion) cancer. Age-standardized lost earning rates per 100 000 were lowest in the West and highest in the South, ranging from $19.6 million (95% CI, $19.1 million-$20.2 million) in Utah to $35.3 million ($34.4 million-$36.3 million) in Kentucky. Approximately 2.4 million PYLL and $27.7 billion (95% CI, $26.9 billion-$28.5 billion) in lost earnings (29.3% of total that occurred in 2015) would have been avoided in 2015 if all states had the same age-specific PYLL or lost earning rates as Utah.

Conclusions and Relevance

Our findings indicate large state variation in the economic burden of cancer and suggest the potential for substantial financial benefit through delivery of effective cancer prevention, screening, and treatment to minimize premature cancer mortality in all states.

The American Cancer Society 2035 challenge goal on cancer mortality reduction

A summary evaluation of the 2015 American Cancer Society (ACS) challenge goal showed that overall US mortality from all cancers combined declined 26% over the period from 1990 to 2015. Recent research suggests that US cancer mortality can still be lowered considerably by applying known interventions broadly and equitably. The ACS Board of Directors, therefore, commissioned ACS researchers to determine challenge goals for reductions in cancer mortality by 2035. A statistical model was used to estimate the average annual percent decline in overall cancer death rates among the US general population and among college-educated Americans during the most recent period. Then, the average annual percent decline in the overall cancer death rates of college graduates was applied to the death rates in the general population to project future rates in the United States beginning in 2020. If overall cancer death rates from 2020 through 2035 nationally decline at the pace of those of college graduates, then death rates in 2035 in the United States will drop by 38.3% from the 2015 level and by 54.4% from the 1990 level. On the basis of these results, the ACS 2035 challenge goal was set as a 40% reduction from the 2015 level. Achieving this goal could lead to approximately 1.3 million fewer cancer deaths than would have occurred from 2020 through 2035 and 122,500 fewer cancer deaths in 2035 alone. The results also show that reducing the prevalence of risk factors and achieving optimal adherence to evidence-based screening guidelines by 2025 could lead to a 33.5% reduction in the overall cancer death rate by 2035, attaining 85% of the challenge goal.

Patterns of SES Health Disparities Among Older Adults in Three Upper Middle- and Two High-Income Countries

OBJECTIVES

To examine the socioeconomic status (SES) health gradient for obesity, diabetes, and hypertension within a diverse group of health outcomes and behaviors among older adults (60+) in upper middle-income countries benchmarked with high-income countries.

METHOD

We used data from three upper middle-income settings (Colombia-SABE-Bogotá, Mexico-SAGE, and South Africa-SAGE) and two high-income countries (England-ELSA and US-HRS) to estimate logistic regression models using age, gender, and education to predict health and health behaviors.

RESULTS

The sharpest gradients appear in middle-income settings but follow expected patterns found in high-income countries for poor self-reported health, functionality, cognitive impairment, and depression. However, weaker gradients appear for obesity, hypertension, diabetes, and other chronic conditions in Colombia and Mexico and the gradient reverses in South Africa. Strong disparities exist in risky health behaviors and in early nutritional status in the middle-income settings.

DISCUSSION

Rapid demographic and nutritional transitions, urbanization, poor early life conditions, social mobility, negative health behavior, and unique country circumstances provide a useful framework for understanding the SES health gradient in middle-income settings. In contrast with high-income countries, the increasing prevalence of obesity, an important risk factor for chronic conditions and other aspects of health, may ultimately change the SES gradient for diseases in the future.

Developing a Self-Administered Decision Aid for Fecal Immunochemical Test-Based Colorectal Cancer Screening Tailored to Citizens With Lower Educational Attainment: Qualitative Study

BACKGROUND

Citizens with lower educational attainments (EA) take up colorectal cancer screening to a lesser degree, and more seldom read and understand conventional screening information than citizens with average EAs. The information needs of citizens with lower EA are diverse, however, with preferences ranging from wanting clear recommendations to seeking detailed information about screening. Decision aids have been developed to support citizens with lower EA in making informed decisions about colorectal cancer screening participation, but none embrace diverse information needs.

OBJECTIVE

The aim of this study was to develop a self-administered decision aid for participation in fecal immunochemical test-based colorectal cancer screening. The decision aid should be tailored to citizens with lower EA and should embrace diverse information needs.

METHODS

The Web-based decision aid was developed according to an international development framework, with specific steps for designing, alpha testing, peer reviewing, and beta testing the decision aid. In the design phase, a prototype of the decision aid was developed based on previous studies about the information needs of lower EA citizens and the International Patient Decision Aid Standards guidelines. Alpha testing was conducted using focus group interviews and email correspondence. Peer review was conducted using email correspondence. Both tests included both lower EA citizens and health care professionals. The beta testing was conducted using telephone interviews with citizens with lower EA. Data were analyzed using thematic analysis.

RESULTS

The developed decision aid presented information in steps, allowing citizens to read as much or as little as wanted. Values clarification questions were included after each section of information, and answers were summarized in a "choice-indicator" on the last page, guiding the citizens toward a decision about screening participation. Statistics were presented in both natural frequencies, absolute risk formats and graphically. The citizens easily and intuitively navigated around the final version of the decision aid and stated that they felt encouraged to think about the benefits and harms of colorectal cancer screening without being overloaded with information. They found the decision aid easy to understand and the text of suitable length. The health care professionals agreed with the citizens on most parts; however, concerns were raised about the length and readability of the text.

CONCLUSIONS

We have developed a self-administered decision aid presenting information in steps. We involved both citizens and health care professionals to target the decision aid for citizens with lower EA. This decision aid represents a new way of communicating detailed information and may be able to enhance informed choices about colorectal cancer screening participation among citizens with lower EA.

Changing patterns of breast cancer incidence and mortality by education level over four decades in Norway, 1971-2009

Background

In the last century, breast cancer incidence and mortality was higher among higher versus lower educated women in developed countries. Post-millennium, incidence rates have flattened off and mortality declined. We examined breast cancer trends by education level, to see whether recent improvements in incidence and mortality rates have occurred in all education groups.

Methods

We linked individual registry data on female Norwegian inhabitants aged 35 years and over during 1971–2009. Using Poisson models, we calculated absolute and relative educational differences in age-standardised breast cancer incidence and mortality over four decades. We estimated educational differences by Slope and Relative Index of Inequality, which correspond to rate difference and rate ratio, comparing the highest to lowest educated women.

Results

Pre-millennium, incidence and mortality of breast cancer were significantly higher in higher versus lower educated women. Post-millennium, educational differences in breast cancer incidence and mortality attenuated. During 2000–2009, breast cancer incidence was still 38% higher for higher versus lower educated women (Relative Index of Inequality: 1.38, 95% confidence interval: 1.31–1.44), but mortality no longer varied significantly by education level (Relative Index of Inequality: 1.09, 95% confidence interval: 0.99–1.19). Among women below 50 years, however, the education gradient for mortality reversed, and mortality was 28% lower for the highest versus lowest educated women during 2000–2009 (Relative Index of Inequality: 0.72, 95% confidence interval: 0.51–0.93).

Results

Post-millennium improvements in breast cancer incidence and mortality have primarily benefited higher educated women. Breast cancer mortality is now highest among the lowest educated women below 50 years.

Development and validation of the smart management strategy for health assessment tool-short form (SAT-SF) in cancer survivors

PURPOSE

The aim of this study was to develop and validate a short form (SF) of the Smart Management Strategy for Health Assessment Tool (SAT) for cancer patients.

METHODS

Data for item reduction were derived from cancer patient data (n = 300) previously used to develop the original SAT. We used regression methods to select and score the new SAT-SF. To assess the instrument's reliability and validity, we recruited another 354 cancer patients from the same hospitals who were older than 18 years and accustomed to using the web. All results were compared with that of the long-form SAT (original SAT).

RESULTS

The SAT-SF used is the shorter version, a 30-item (from the original 91-item) instrument, to measure cancer patient's health. The 30-item SAT-SF explained 97.7% of total variance of the full 91-item long-form SAT. All SAT-SF subscales demonstrated a high reliability with good internal consistency compared with the original SAT. The total short-form scores of the three SAT sets (SAT-Core, SAT-Preparation, SAT-Implementation) differentiated participant groups according to their stage of goal implementation and percentage of actions taken in the 10 Rules for Highly Effective Health Behavior. We found acceptable correlations between the three SAT-SF sets and the additional assessment tools compared with the original SAT.

CONCLUSIONS

The 30-item SAT-SF had a satisfactory internal consistency and validity for cancer patients with minimal loss of information compared with the original SAT.

Primary Care Issues in Inner-City America and Internationally

Inner-city patient populations are high-risk for poor outcomes, including increased risk of mortality. Barriers to delivering high-quality primary care to inner-city patients include lack of access, poor distribution of primary care providers (PCPs), competing demands, and financial restraints. Health care issues prevalent in this population include obesity, diabetes, cancer screening, asthma, infectious diseases, and obstetric and prenatal care. Population health management and quality improvement (QI) activities must target disparities in care. Partnering with patients and focusing on social determinants of health andmedical care are key areas inwhich to focus toimprove overall healthoutcomes inthispopulation.

In sickness and in health: The role of marital partners in cancer survival

Married cancer patients enjoy a survival advantage, potentially attributable to better health at diagnosis, earlier contact with health personnel, and/or access to resources to ensure more optimal treatment. These mechanisms only invoke the mere presence of a partner, but partners bring varying amounts of resources into the household. It is likely that also spousal resources contribute to differentials in survival net of own resources, as gradients in survival by the latter are well documented. Our aim is to examine the combined roles of own and spouses’ socioeconomic characteristics (SES) and age for cancer survival.

Almost 268,000 married patients diagnosed with a first cancer after age 50 during 1975–2007 were identified from the Norwegian Cancer Registry and other national registers. In a sequence of hazard models, differences in survival by patients' own education, income and age and the role of spouses' characteristics were assessed. Furthermore, we also assessed the importance of homogamy/heterogamy along the same dimensions.

Partners’ characteristics clearly matter for survival. The relative survival of patients with highly educated partners, net of their own education, is significantly higher than that of patients with lesser-educated partners. Somewhat similar effects are observed for income, net of education. A less consistent pattern is observed for age, although non-normative heterogamy patterns in age and income appear to be associated with a survival disadvantage.

The naïve perspective of only considering the presence of partners may thus conceal important differences in cancer survival. Health personnel may take advantage of such knowledge in interactions with patients and their families, and gather information on resources in immediate networks that may impact prognosis favorable and/or unfavorable and help patients utilize these resources to improve prognosis.

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For married cancer patients, survival is influenced by the resources of spouses.

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As such, who you marry play a role for your survival.

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Having a highly educated and/or a high earning spouse appears to be beneficial.

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But, non-normative spousal patterns in age and SES appear to be disadvantageous.

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Married patients’ spousal resources may help shed light on inequalities in survival.

Awareness of Cancer Symptoms and Barriers to Seeking Medical Help Among Adult People Attending Primary Care Settings in Oman

Objectives:

To explore the public’s awareness of cancer symptoms and the barriers to seeking medical help among Omani adults attending primary care settings in Muscat governorate, the capital city of Oman.

Methods:

The Cancer Awareness Measure (CAM) questionnaire (translated into Arabic) was used to collect data from a total of 12 randomly selected local health centers (LHCs) in Muscat governorate, the capital city of Oman. Omani adults aged 18 years and above attending LHCs during the study period were invited to participate in the study. Statistical Package for the Social Sciences (SPSS version 22) was used to analyze the data.

Results:

A total of 999 participants completed the CAM questionnaire from 1200 invitations (response rate = 83%). The overall recognition of common cancer symptoms was less than 50% except for an unexplained lump/swelling, which was 71%. Multinomial logistic regression showed that women recognized more cancer symptoms than men (odds ratio [OR] = 1.79; 95% confidence interval [CI]: 1.27-2.51), that more highly educated participations recognized more cancer symptoms than less educated participants (OR = 39; 95% CI: 0.23-0.69). The majority of participants (91.2%) agreed that the right time to seek medical help for possible cancer symptom was within 2 weeks. Multinomial logistic regression showed that women rather than men were more likely to perceive barriers to seeking medical help (OR = 2.10; 95% CI: 1.60-2.76). Also the less educated participants, rather than more educated, were more likely to perceive barriers to seeking medical help (OR = 2.17; 95% CI: 1.16-4.05).

Conclusion:

Levels of awareness of cancer symptoms are low in Oman. More national CAMs are needed in Oman to increase public knowledge of cancer symptoms. Also, more public awareness is needed to overcome the barriers to seeking timely medical help particularly among groups of women and the unmarried, widowed, divorced, or separated if delays in presentation are to be minimized.

Financial Quality of Life for Patients With Cancer: An Exploratory Study

OBJECTIVE

For people who are experiencing financial hardship, a cancer diagnosis can be devastating. For others, cancer may exacerbate financial stress, thereby influencing their livelihood, their ability to maintain employment benefits including health insurance, manage financial obligations, and participate meaningfully in cancer treatment. This study examined how vulnerabilities in psychosocial situations affect financial quality of life within the larger context of health-care decision making through a survey conducted with a cross-sectional availability sample of 90 cancer patients. Results from the multiple regression analysis found that health insurance adequacy, fewer perceived barriers to care, and reduced financial stress are significant predictors of better financial quality of life in this sample. Oncology social workers and other disciplines involved in psychosocial treatment with patients with cancer must assess and address financial and logistic aspects of life in order to provide comprehensive cancer care that meets all needs. Collaborative coordination with patients with cancer and their families to intervene psychosocially, medically, and financially are critical components of sound psychosocial and medical practice.

Racial disparities in operative outcomes after major cancer surgery in the United States

BACKGROUND

Numerous studies have recorded racial disparities in access to care for major cancers. We investigate contemporary national disparities in the quality of perioperative surgical oncological care using a nationally representative sample of American patients and hypothesize that disparities in the quality of surgical oncological care also exists.

METHODS

A retrospective, serial, and cross-sectional analysis of a nationally representative cohort of 3,024,927 patients, undergoing major surgical oncological procedures (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, pneumonectomy, pancreatectomy, and prostatectomy), between 1999 and 2009.

RESULTS

After controlling for multiple factors (including socioeconomic status), Black patients undergoing major surgical oncological procedures were more likely to experience postoperative complications (OR: 1.24; p < 0.001), in-hospital mortality (OR: 1.24; p < 0.001), homologous blood transfusions (OR: 1.52; p < 0.001), and prolonged hospital stay (OR: 1.53; p < 0.001). Specifically, Black patients have higher rates of vascular (OR: 1.24; p < 0.001), wound (OR: 1.10; p = 0.004), gastrointestinal (OR: 1.38; p < 0.001), and infectious complications (OR: 1.29; p < 0.001). Disparities in operative outcomes were particularly remarkable for Black patients undergoing colectomy, prostatectomy, and hysterectomy. Importantly, substantial attenuation of racial disparities was noted for radical cystectomy, lung resection, and pancreatectomy relative to earlier reports. Finally, Hispanic patients experienced no disparities relative to White patients in terms of in-hospital mortality or overall postoperative complications for any of the eight procedures studied.

CONCLUSIONS

Considerable racial disparities in operative outcomes exist in the United States for Black patients undergoing major surgical oncological procedures. These findings should direct future health policy efforts in the allocation of resources for the amelioration of persistent disparities in specific procedures.

Socioeconomic Disparities in Colorectal Cancer Screening in Korea: A Nationwide Cross-Sectional Study

Colorectal cancer (CRC) is a common cancer worldwide. The incidence and mortality rates of CRC are higher among lower socioeconomic status (SES) populations. We investigated the association between different indicators of SES and CRC screening rates in Korea. The eligible study population included males and females aged 50 to 74 years who participated in a nationwide cross-sectional survey (2010-2012). The "compliance with recommendation" category was applicable to participants who had undergone a fecal occult blood test (FOBT), double-contrast barium enema, or colonoscopy within 1, 5, or 10 years, respectively. In total, 6221 subjects (51.4% female, 55.6% aged 50 years) were included in the final analysis. Lower household income was significantly negatively related to compliance with screening recommendations (P for trend < 0.01) and marginally significantly related to noncompliance with recommendations (P for trend = 0.07). Older age and poor self-reported health were associated with the screening rate using the FOBT; male sex, older age, higher household income, having supplemental insurance, family history of cancer, and poor self-reported health were associated with a higher screening rate using colonoscopy. Lower household income was associated with a higher screening rate using the FOBT and with a lower screening rate using colonoscopy. To increase the rate of CRC screening using colonoscopy, efforts should be made toward improving the education and promotion of screening to the low household income target population.

Temporal trend of mortality from major cancers in Xuanwei, China

Although a number of studies have examined the etiology of lung cancer in Xuanwei County, China, other types of cancer in this county have not been reported systematically. This study aimed to investigate the temporal trend of eight major cancers in Xuanwei County using data from three mortality surveys (1973-1975, 1990-1992, and 2004-2005). The Chinese population in 1990 was used as a standard population to calculate agestandardized mortality rates. Cancers of lung, liver, breast, brain, esophagus, leukemia, rectum, and stomach were identified as the leading cancers in this county in terms of mortality rate. During the three time periods, lung cancer remained as the most common type of cancer. The mortality rates for all other types of cancer were lower than those of the national average, but an increasing trend was observed for all the cancers, particularly from 1990-1992 to 2004-2005. The temporal trend could be partly explained by changes in risk factors, but it also may be due to the improvement in cancer diagnosis and screening. Further epidemiological studies are warranted to systematically examine the underlying reasons for the temporal trend of the major cancers in Xuanwei County.

Understanding cancer screening service utilization by Somali men in Minnesota

This study examined factors that influence use of cancer screening by Somali men residing in Minnesota, USA. To better understand why recent immigrants are disproportionately less likely to use screening services, we used the health belief model to explore knowledge, beliefs, and attitudes surrounding cancer screening. We conducted a qualitative study comprised of 20 key informant interviews with Somali community leaders and 8 focus groups with Somali men (n = 44). Somali men commonly believe they are protected from cancer by religious beliefs. This belief, along with a lack of knowledge about screening, increased the likelihood to refrain from screening. Identifying the association between religion and health behaviors may lead to more targeted interventions to address existing disparities in cancer screening in the growing US immigrant population.

Patient-reported assessment of self-management strategies of health in cancer patients: development and validation of the Smart Management Strategy for Health Assessment Tool (SAT)

OBJECTIVE

The objective of this study was to evaluate the psychometric properties of the Smart Management Strategy for Health Assessment Tool (SAT), which we developed to enable cancer patients to assess their self-management (SM) strategies of health by themselves.

PATIENTS AND METHODS

The development of the questionnaire included four phases: item generation, construction, pilot testing, and field testing. To assess the instrument's sensitivity and validity, we recruited 300 cancer patients from three Korean hospitals who were 18 or more years old and accustomed to using the Internet or email. Using the appropriate and priority criteria for pilot and field testing, we tightened the content and constructed the first version of the SAT.

RESULTS

We developed the core strategies with 28 items, preparation strategies with 30 items, and implementation strategies with 33 items. Factor analysis of data from 300 patients resulted in core strategies with four factors, preparation strategies with five factors, and implementation strategies with six factors. All the SAT subscales demonstrated a high reliability with good internal consistency. The total scores of the three SAT sets differentiated participant groups well according to their stage of goal implementation and proportions of action of the 10 Rules for Highly Effective Health Behavior. Each factor of the three SAT sets correlated positively with the scores for additional assessment tool.

CONCLUSION

The SAT is a three-set, 16-factor, 91-item tool that assesses the SM strategies of health that patients use to overcome a crisis. Patients can use the SAT to assess their SM strategies of health and obtain feedback from clinicians in the practice setting.

Causal effects of time-dependent treatments in older patients with non-small cell lung cancer

Background

Treatment selection for elderly patients with lung cancer must balance the benefits of curative/life-prolonging therapy and the risks of increased mortality due to comorbidities. Lung cancer trials generally exclude patients with comorbidities and current treatment guidelines do not specifically consider comorbidities, so treatment decisions are usually made on subjective individual-case basis.

Methods

Impacts of surgery, radiation, and chemotherapy mono-treatment as well as combined chemo/radiation on one-year overall survival (compared to no-treatment) are studied for stage-specific lung cancer in 65+ y.o. patients. Methods of causal inference such as propensity score with inverse probability weighting (IPW) for time-independent and marginal structural model (MSM) for time-dependent treatments are applied to SEER-Medicare data considering the presence of comorbid diseases.

Results

122,822 patients with stage I (26.8%), II (4.5%), IIIa (11.5%), IIIb (19.9%), and IV (37.4%) lung cancer were selected. Younger age, smaller tumor size, and fewer baseline comorbidities predict better survival. Impacts of radio- and chemotherapy increased and impact of surgery decreased with more advanced cancer stages. The effects of all therapies became weaker after adjustment for selection bias, however, the changes in the effects were minor likely due to the weak selection bias or incompleteness of the list of predictors that impacted treatment choice. MSM provides more realistic estimates of treatment effects than the IPW approach for time-independent treatment.

Conclusions

Causal inference methods provide substantive results on treatment choice and survival of older lung cancer patients with realistic expectations of potential benefits of specific treatments. Applications of these models to specific subsets of patients can aid in the development of practical guidelines that help optimize lung cancer treatment based on individual patient characteristics.

Potentially preventable premature lung cancer deaths in the USA if overall population rates were reduced to those of educated whites in lower-risk states

PURPOSE

Death rates for lung cancer, the leading cause of cancer death in the USA, vary substantially by the level of education at the national level, but this has not previously been analyzed by state.

METHODS

We examined age-standardized lung cancer death rates by educational attainment, race/ethnicity, and state in men and women (aged 25-64 years) in the USA in 2008-2010 and estimated the proportion of potentially avoidable premature lung cancer deaths for each state if rates were reduced to those achieved among more educated non-Hispanic whites in five states with low lung cancer rates, using data on 134,869 lung cancer deaths.

RESULTS

Age-standardized lung cancer mortality rates differed substantially by state and education level. Among non-Hispanic white men, for example, rates per 100,000 ranged from below 6 in more educated men (≥16 years of education) in Utah, Colorado, and Montana to >75 in less educated men (≤12 years of education) in Mississippi, Oklahoma, and Kentucky. An estimated 73 % of lung cancer deaths in the USA (32,700 deaths annually in 25- to 64-year-old individuals alone) would be prevented. This proportion was ≥85 % among men in Arkansas, Alabama, Kentucky, and Mississippi, and ≥80 % among women in West Virginia and Kentucky.

CONCLUSION

Most premature lung cancer deaths in the USA are potentially avoidable. As most of these deaths can be attributed to smoking, our findings underscore the importance of increasing tobacco control measures in high-risk states and targeting tobacco control interventions to less educated populations in all states.

Inequalities in premature death from colorectal cancer by state

PURPOSE

Although disparities in colorectal cancer (CRC) with regard to race, socioeconomic status, and geography are well documented, the extent to which these factors contribute to premature death resulting from CRC nationwide and by state is unknown.

PATIENTS AND METHODS

We calculated age-standardized CRC death rates for three broad educational categories as a marker of socioeconomic status by race/ethnicity and state among individuals age 25 to 64 years from 2008 through 2010. We also calculated the proportion of premature death resulting from CRC that could potentially be averted in each state by applying the average death rate for the five states with the lowest rates among the most educated whites (Connecticut, North Dakota, Utah, Vermont, and Wisconsin) to all populations.

RESULTS

Compared with those with the most education, those with the least education had significantly higher CRC death rates in virtually all states for each racial/ethnic group. For example, rate ratios ranged from 1.15 (95% CI, 0.66 to 2.01) in Delaware to 3.18 (95% CI, 2.01 to 5.05) in New Mexico among whites. Overall, half the premature deaths resulting from CRC that occurred nationwide from 2008 through 2010, or 7,690 deaths annually, would have been avoided if everyone had experienced the lowest death rates of the most educated whites. More premature deaths could be averted in southern states (60% to 70%) than in northern and western states (30% to 40%). Restricting the analyses to persons age 50 to 64 years, for whom CRC screening is recommended, resulted in similar findings.

CONCLUSION

The majority of premature deaths from CRC in southern states and half these deaths nationwide are due to racial/ethnic, socioeconomic, and geographic inequalities.

Factors associated with attendance to scheduled outpatient endoscopy

BACKGROUND

Non-attendance of 42% has been reported for outpatient colonoscopy among persons with low socioeconomic status (SES) in an open access system in the USA.

OBJECTIVES

To evaluate attendance to outpatient endoscopy among populations with low SES after inperson consultations with endoscopists prior to scheduling.

METHODS

Retrospectively, we reviewed the endoscopy schedule from September 2009 to August 2010 in an inner city teaching hospital in Washington, DC. We identified patients who came for their procedures. We defined non-attendance as when patients did not notify the facility up to 24 h prior to their scheduled procedures and did not show up.

RESULTS

A total of 3304 patients were scheduled for outpatient endoscopy (mean age 55.2 years; 59.5% women). Only 36 (1.1%) patients were uninsured. 716 (21.7%) patients did not show up for their procedures. There were no differences in attendance by age, sex and race. Patients seen in a private endoscopist's office (OR=1.47; 95% CI 1.07 to 2.04) were more likely to attend when compared with patients seen in trainees' continuity clinic. Married patients (OR=1.40; 95% CI 1.11 to 1.78) were also more likely to attend. Conversely, Medicaid and uninsured patients were less likely to attend. Restricting our analysis to patients scheduled for only colonoscopy yielded similar results except that patients aged 50 years and older were more likely to attend.

CONCLUSIONS

Our study suggests improved attendance to endoscopy when populations with lower SES undergo prior consultation with an endoscopist. There is a potential to further improve attendance to outpatient endoscopy by directly involving the social support of the patients.

Access to treatment and educational inequalities in cancer survival

The public health care systems in the Nordic countries provide high quality care almost free of charge to all citizens. However, social inequalities in health persist. Previous research has, for example, documented substantial educational inequalities in cancer survival. We investigate to what extent this may be driven by differential access to and utilization of high quality treatment options. Quasi-experimental evidence based on the establishment of regional cancer wards indicates that (i) highly educated individuals utilized centralized specialized treatment to a greater extent than less educated patients and (ii) the use of such treatment improved these patients' survival.

Outcomes in non-metastatic colorectal cancer

The measurement of outcomes in non-metastatic colon and rectal cancer patients is a multi-dimensional endeavor involving prediction tools, standard of care, and best treatment guidelines. Socioeconomic, demographic, and racial impacts on outcome must be carefully considered. Consideration must also be given to measures of cost, quality, and healthcare delivery in response to initiatives meant to optimize patient health while maintaining quality of life.

Disparities in selective referral for cancer surgeries: implications for the current healthcare delivery system

OBJECTIVES

Among considerable efforts to improve quality of surgical care, expedited measures such as a selective referral to high-volume institutions have been advocated. Our objective was to examine whether racial, insurance and/or socioeconomic disparities exist in the use of high-volume hospitals for complex surgical oncological procedures within the USA.

DESIGN, SETTING AND PARTICIPANTS

Patients undergoing colectomy, cystectomy, oesophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy or prostatectomy were identified retrospectively, using the Nationwide Inpatient Sample, between years 1999 and 2009. This resulted in a weighted estimate of 2 508 916 patients.

PRIMARY OUTCOME MEASURES

Distribution of patients according to race, insurance and income characteristics was examined according to low-volume and high-volume hospitals (highest 20% of patients according to the procedure-specific mean annual volume). Generalised linear regression models for prediction of access to high-volume hospitals were performed.

RESULTS

Insurance providers and county income levels varied differently according to patients' race. Most Caucasians resided in wealthier counties, regardless of insurance types (private/Medicare), while most African Americans resided in less wealthy counties (≤$24 999), despite being privately insured. In general, Caucasians, privately insured, and those residing in wealthier counties (≥$45 000) were more likely to receive surgery at high-volume hospitals, even after adjustment for all other patient-specific characteristics. Depending on the procedure, some disparities were more prominent, but the overall trend suggests a collinear effect for race, insurance type and county income levels.

CONCLUSIONS

Prevailing disparities exist according to several patient and sociodemographic characteristics for utilisation of high-volume hospitals. Efforts should be made to directly reduce such disparities and ensure equal healthcare delivery.

Racial disparity in colorectal cancer: the role of equal treatment

BACKGROUND

Racial disparity exists in colorectal cancer outcomes. The reasons for this are multifactorial.

OBJECTIVE

The aim of this study was to evaluate the role of equal treatment of blacks and whites in the elimination of racial disparity in colorectal cancer outcomes.

DESIGN

A retrospective cohort study of 878 patients with colorectal cancer diagnosed between 1998 and 2008 was done at a University tertiary referral center. Demographic variables including age, sex, and race were abstracted. Tumor-specific variables including American Joint Committee on Cancer stage, anatomic tumor location, vital status, and survival were obtained. Treatment-specific variables including surgery, chemotherapy, radiotherapy, and follow-up were also obtained. Racial differences in these variables were studied and their effect on overall survival was determined by using univariate and multivariate analyses. The findings were then compared with previous data from our institution.

SETTING

University tertiary referral center.

MAIN OUTCOME MEASURES

The primary outcomes measured were overall survival and cancer-specific mortality.

RESULTS

A total of 878 patients met the inclusion criteria, 186 (21.2%) of whom were black. Blacks were significantly younger at diagnosis in comparison with whites, with a median (quartiles) age of 55 years (28-87) compared with 59 years (23-94) (p = 0.0012). Equal proportions of blacks (78.5%) and whites (79.2%) underwent surgery (p = 0.84), similar proportions of blacks (55.4%) and whites (60.8%) received chemotherapy (p = 0.18), and similar proportions of blacks (17.2%) and whites (20.5%) received radiation therapy (p = 0.31). There was no difference in overall survival or cancer-specific mortality between the 2 racial groups. Univariate analysis showed American Joint Committee on Cancer stage and surgery as the only statistically significant factors for overall survival. On multivariate analysis, stage, surgery, and chemotherapy were the only statistically significant factors. Race was not an independent determinant of survival.

CONCLUSIONS

There were no differences in overall survival and cancer-related mortality between blacks and whites, and this may have resulted from identical treatment. The previously noted disparities in treatment and overall survival at our institution have disappeared.

Stage-adjusted lung cancer survival does not differ between low-income Blacks and Whites

INTRODUCTION

Few lung cancer studies have focused on lung cancer survival in underserved populations. We conducted a prospective cohort study among 81,697 racially diverse and medically underserved adults enrolled in the Southern Community Cohort Study throughout an 11-state area of the Southeast from March 2002 to September 2009.

METHODS

Using linkages with state cancer registries, we identified 501 incident non-small-cell lung cancer cases. We applied Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for subsequent mortality among black and white participants.

RESULTS

The mean observed follow-up time (the time from diagnosis to death or end of follow-up) was 1.25 years (range, 0-8.3 years) and 75% (n = 376) of cases died during follow-up. More blacks were diagnosed at distant stage than whites (57 versus 45%; p = 0.03). In multivariable analyses adjusted for pack-years of smoking, age, body mass index, health insurance, socioeconomic status and disease stage, the lung cancer mortality HR was higher for men versus women (HR = 1.41; 95% CI, 1.09-1.81) but similar for blacks versus whites (HR = 0.99; 95% CI, 0.74-1.32).

CONCLUSION

These findings suggest that although proportionally more blacks present with distant-stage disease there is no difference in stage-adjusted lung cancer mortality between blacks and whites of similar low socioeconomic status.

Diverging trends in educational inequalities in cancer mortality between men and women in the 2000s in France

BACKGROUND

Socioeconomic inequalities in cancer mortality have been observed in different European countries and the US until the end of the 1990s, with changes over time in the magnitude of these inequalities and contrasted situations between countries. The aim of this study is to estimate relative and absolute educational differences in cancer mortality in France between 1999 and 2007, and to compare these inequalities with those reported during the 1990s.

METHODS

Data from a representative sample including 1% of the French population were analysed. Educational differences among people aged 30-74 were quantified with hazard ratios and relative indices of inequality (RII) computed using Cox regression models as well as mortality rate difference and population attributable fraction.

RESULTS

In the period 1999-2007, large relative inequalities were found among men for total cancer and smoking and/or alcohol related cancers mortality (lung, head and neck, oesophagus). Among women, educational differences were reported for total cancer, head and neck and uterus cancer mortality. No association was found between education and breast cancer mortality. Slight educational differences in colorectal cancer mortality were observed in men and women. For most frequent cancers, no change was observed in the magnitude of relative inequalities in mortality between the 1990s and the 2000s, although the RII for lung cancer increased both in men and women. Among women, a large increase in absolute inequalities in mortality was observed for all cancers combined, lung, head and neck and colorectal cancer. In contrast, among men, absolute inequalities in mortality decreased for all smoking and/or alcohol related cancers.

CONCLUSION

Although social inequalities in cancer mortality are still high among men, an encouraging trend is observed. Among women though, the situation regarding social inequalities is less favourable, mainly due to a health improvement limited to higher educated women. These inequalities may be expected to further increase in future years.

Incidence, life expectancy and prognostic factors in cancer patients under prolonged mechanical ventilation: a nationwide analysis of 5,138 cases during 1998-2007

INTRODUCTION

This study is aimed at determining the incidence, survival rate, life expectancy, quality-adjusted life expectancy (QALE) and prognostic factors in patients with cancer in different organ systems undergoing prolonged mechanical ventilation (PMV).

METHODS

We used data from the National Health Insurance Research Database of Taiwan from 1998 to 2007 and linked it with the National Mortality Registry to ascertain mortality. Subjects who received PMV, defined as having undergone mechanical ventilation continuously for longer than 21 days, were enrolled. The incidence of cancer patients requiring PMV was calculated, with the exception of patients with multiple cancers. The life expectancies and QALE of patients with different types of cancer were estimated. Quality-of-life data were taken from a sample of 142 patients who received PMV. A multivariable proportional hazards model was constructed to assess the effect of different prognostic factors, including age, gender, type of cancer, metastasis, comorbidities and hospital levels.

RESULTS

Among 9,011 cancer patients receiving mechanical ventilation for more than 7 days, 5,138 undergoing PMV had a median survival of 1.37 months (interquartile range [IQR], 0.50 to 4.57) and a 1-yr survival rate of 14.3% (95% confidence interval [CI], 13.3% to 15.3%). The incidence of PMV was 10.4 per 100 ICU admissions. Head and neck cancer patients seemed to survive the longest. The overall life expectancy was 1.21 years, with estimated QALE ranging from 0.17 to 0.37 quality-adjusted life years for patients with poor and partial cognition, respectively. Cancer of liver (hazard ratio [HR], 1.55; 95% CI, 1.34 to 1.78), lung (HR, 1.45; 95% CI, 1.30 to 1.41) and metastasis (HR, 1.53; 95% CI, 1.42 to 1.65) were found to predict shorter survival independently.

CONCLUSIONS

Cancer patients requiring PMV had poor long-term outcomes. Palliative care should be considered early in these patients, especially when metastasis has occurred.

Needs regarding care and factors associated with unmet needs in disease-free survivors of surgically treated lung cancer

BACKGROUND

To evaluate the long-term needs of lung cancer survivors and to explore factors associated with unmet need.

PATIENTS AND METHODS

We recruited lung patients treated with curative surgery from 2001 through 2006 at two centers in Korea. Needs in the domains of information, supportive care, education and counseling, and socioeconomic support were measured. We selected the four most frequently reported items of unmet need among 19 items in four domains.

RESULTS

The most frequently reported unmet needs were Complementary and alternative medicine (CAM) and folk remedies (59.8%) in the Information domain, Counseling and treatment of depression and anxiety (63.5%) in the Supportive care domain, diet, exercise and weight control (55.1%) in the Education and counseling domain and Financial support (90.4%) in the socioeconomic support domain. Unmet needs for psychological treatment was significantly greater in participants who were employed (adjusted odds ratio [aOR], 2.25; 95% confidential interval [CI], 1.12 to 4.53). Unmet needs for diet, exercise and weight control were significantly greater in participants who had not received chemotherapy (aOR, 1.76; 95% CI, 1.09 to 2.85). Unmet need for financial support was greater in participants who were married (aOR, 4.14, 95%CI, 1.12 to 15.22) and those who had not received chemotherapy (aOR, 5.91, 95%CI, 1.91 to 18.31).

CONCLUSION

There were substantial unmet needs for information regarding psychological support, education for diet and exercise, and financial support among lung cancer survivors.

Short- and long-term risk of colorectal adenoma recurrence among whites and blacks

BACKGROUND

It is unclear whether the higher burden from colorectal cancer among blacks is due to an increased biological susceptibility.

OBJECTIVE

To determine whether non-Hispanic blacks (blacks) have a higher risk of adenoma recurrence than non-Hispanic whites (whites) after removal of colorectal adenoma.

DESIGN

Secondary analysis of the Polyp Prevention Trial (PPT) data.

SETTING

United States.

PATIENTS

Patients were 1668 self-identified whites and 153 blacks who completed the 4-year trial. Of these, 688 whites and 55 blacks enrolled in a posttrial, passive Polyp Prevention Trial Continued Follow-up Study (PPT-CFS) and underwent another colonoscopy.

MAIN OUTCOME MEASUREMENTS

Recurrence and location of the adenoma and advanced adenoma by race-ethnicity during PPT and cumulative recurrence over a mean follow-up of 8.3 years (range, 4.9-12.4 years) among PPT-CFS enrollees.

RESULTS

Blacks had similar risk of recurrence of adenoma (39.2% vs 39.4%; incidence risk ratio [RR] = .98; 95% CI, .80-1.20) and advanced adenoma (8.5% vs 6.4%; RR = 1.18; 95% CI, .68-2.05) as whites at the end of PPT. Recurrence risk did not differ by colon subsite. Among PPT-CFS enrollees, the cumulative recurrence rate over a maximal follow-up period of 12 years was similar for blacks and whites for adenoma (67.3% vs 67.0%; RR = 1.01; 95% CI, .84-1.21) and advanced adenoma (14.5% vs 16.9%; RR = 1.03; 95% CI, .60-1.79).

LIMITATION

There were few blacks in the long-term follow-up study.

CONCLUSIONS

Adenoma and advanced adenoma recurrence did not differ by race. Our study does not support more frequent surveillance colonoscopies for blacks with a personal history of adenoma as an intervention to reduce colorectal cancer disparity.

Racial disparity in colorectal cancer: the role of ABO blood group

BACKGROUND

We tested the hypothesis that racial differences that exist in the distribution of ABO blood type would partially explain the racial disparity in overall survival seen in colorectal cancer.

METHODS

retrospective analysis of the cancer registry of a university hospital for patients treated for colorectal cancer between 1996 and 2008. Demographic, tumor-specific, and treatment-specific variables were abstracted. We also obtained ABO blood group data. The primary end point was overall survival. We divided patients into two groups based on where they underwent surgery: the University of Arkansas for Medical Sciences (UAMS) or outside facilities.

RESULTS

Of 833 patients, 182 (21.8%) were black. There was no difference in overall survival between blacks and whites for the entire group (P = 0.61). There was a statistically significant difference in overall survival between patients at the UAMS and outside facilities (P < 0.0001). For the outside facilities group, there was a statistically significant difference in overall survival between blacks and whites (hazard ratio, CI: 1.48 [1.06-2.00]; P = 0.012); no race difference existed for the UAMS group. The ABO blood group had no effect on overall survival. On stage-stratified univariate and multivariate analyses, chemotherapy and surgery were the only statistically significant determinants of survival.

CONCLUSIONS

In this study, racial differences in ABO blood group distribution had no effect on overall survival.

Cancer control needs of 2-1-1 callers in Missouri, North Carolina, Texas, and Washington

Innovative interventions are needed to connect underserved populations to cancer control services. With data from Missouri, North Carolina, Texas, and Washington this study a) estimated the cancer control needs of callers to 2-1-1, an information and referral system used by underserved populations, b) compared rates of need with state and national data, and c) examined receptiveness to needed referrals. From October 2009 to March 2010 callers' (N=1,408) cancer control needs were assessed in six areas: breast, cervical, and colorectal cancer screening, HPV vaccination, smoking, and smoke-free homes using Behavioral Risk Factor Surveillance System (BRFSS) survey items. Standardized estimates were compared with state and national rates. Nearly 70% of the sample had at least one cancer control need. Needs were greater for 2-1-1 callers than for state and national rates, and callers were receptive to referrals. 2-1-1 could be a key partner in efforts to reduce cancer disparities.

Cancer incidence in South Asian migrants to England, 1986-2004: unraveling ethnic from socioeconomic differentials

Studies on cancer in migrants are informative about the relative influence of environmental and genetic factors on cancer risk. This study investigates trends in incidence from colorectal, lung, breast and prostate cancer in England among South Asians and examines the influence of deprivation, a key environmental exposure. South Asian ethnicity was assigned to patients recorded in the population-based National Cancer Registry of England during 1986-2004, using the computerized algorithm SANGRA: South Asian Names and Groups Recognition Algorithm. Population denominators were derived from population censuses. Multivariable flexible (splines) Poisson models were used to estimate trends and socioeconomic differentials in incidence in South Asians compared to non-South Asians. Overall, age-adjusted cancer incidence in South Asians was half that in non-South Asians but rose over time. Cancer-specific incidence trends and patterns by age and deprivation differed widely between the two ethnic groups. In contrast to non-South Asians, lung cancer incidence in South Asians did not fall. Colorectal and breast cancer incidence rose in both groups, more steeply in South Asians though remaining less common than in non-South Asians. The deprivation gaps in cancer-specific incidence were much less marked among South Asians, explaining some of the ethnic differences in overall incidence. Although still lower than in non-South Asians, cancer incidence is rising in South Asians, supporting the concept of transition in cancer incidence among South Asians living in England. Although these trends vary by cancer, they have important implications for both prevention and anticipating health-care demand.

The Ohio Patient Navigation Research Program: does the American Cancer Society patient navigation model improve time to resolution in patients with abnormal screening tests?

BACKGROUND

Patient navigation (PN) has been suggested as a way to reduce cancer health disparities; however, many models of PN exist and most have not been carefully evaluated. The goal of this study was to test the Ohio American Cancer Society model of PN as it relates to reducing time to diagnostic resolution among persons with abnormal breast, cervical, or colorectal cancer screening tests or symptoms.

METHODS

A total of 862 patients from 18 clinics participated in this group-randomized trial. Chart review documented the date of the abnormality and the date of resolution. The primary analysis used shared frailty models to test for the effect of PN on time to resolution. Crude HR were reported as there was no evidence of confounding.

RESULTS

HRs became significant at 6 months; conditional on the random clinic effect, the resolution rate at 15 months was 65% higher in the PN arm (P = 0.012 for difference in resolution rate across arms; P = 0.009 for an increase in the HR over time).

CONCLUSIONS

Participants with abnormal cancer screening tests or symptoms resolved faster if assigned to PN compared with those not assigned to PN. The effect of PN became apparent beginning six months after detection of the abnormality.

IMPACT

PN may help address health disparities by reducing time to resolution after an abnormal cancer screening test.

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

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

An ecological approach to examine lung cancer disparities due to sexual orientation

OBJECTIVES

To determine whether there is an association between geographical areas with greater sexual minority density, defined as gay and lesbian individuals, and incidence and mortality rates for lung cancer.

STUDY DESIGN

As individual surveillance data on sexual orientation are not available, this study used an ecological approach to examine the link between sexual minorities and lung cancer.

METHODS

Population-based surveillance data on the incidence of and mortality due to lung cancer from 1996 to 2004 were used from 12 Surveillance, Epidemiology and End Results (SEER) registries and 2000 Census data on same-sex-partnered households for the geographical area covered by SEER 12. Using multiple regression models, the county-level association of sexual minority density with incidence or mortality rates for lung cancer was examined.

RESULTS

A significant positive association was found between both incidence and mortality rates for lung cancer and areas with a higher density of sexual minority men, and a significant negative association was found between both incidence and mortality rates for lung cancer and areas with a higher density of sexual minority women.

CONCLUSIONS

In the absence of surveillance data, this novel methodological strategy approximates population-level lung cancer disparities for sexual minority populations at the aggregate level.

Time trends in educational differences in lung and upper aero digestive tract cancer mortality in France between 1990 and 2007

BACKGROUND

We investigated the magnitude of educational differences in lung and upper aero digestive tract (UADT) cancer mortality in France from 1990 to 2007.

METHODS

The analyses were based on census data from a representative sample of the French population. Educational level was used as the indicator for socioeconomic status. Educational differences in mortality from lung and UADT cancer were calculated among people aged 30-74 and by birth cohort. Two periods were compared: 1990-1998 and 1999-2007. Mortality rates, hazard ratios and relative indices of inequality (RII) were computed.

RESULTS

We found higher lung and UADT cancer mortality among those with less education. Inequalities in male UADT cancer mortality remained stable over time (RII(1990-1998)=0.21 (95% confidence interval 0.15-0.29); RII(1999-2007)=0.17 (0.11-0.26)) whereas inequalities in lung cancer mortality increased among the younger men (RII(1990-1998)=0.48 (0.28-0.83); RII(1999-2007)=0.16 (0.09-0.31)). Among women, inequalities in lung cancer mortality became apparent during the second period with higher mortality among those with less education. This trend was exclusively driven by the younger women, among whom inequalities reached about the same magnitude as among younger men (RII(1999-2007)=0.21 (0.08-0.56)).

CONCLUSION

UADT cancer mortality rates strongly decreased over time for every educational level. This implies that the burden of health associated with socioeconomic inequalities in UADT cancer mortality decreased substantially. Inequalities in lung cancer mortality are increasing among the younger generation and are expected to increase even more. Differences in magnitude of inequalities among men and women may disappear in the coming decades.

Shrinking, widening, reversing, and stagnating trends in US socioeconomic inequities in cancer mortality for the total, black, and white populations: 1960-2006

OBJECTIVES OF STUDY

To test recent claims that cancer inequities are bound to increase as population health improves.

METHODS

We analyzed 1960-2006 age-standardized US county cancer mortality data, total and site-specific (lung, prostate, colorectal, breast, cervix, stomach), stratified by county income quintile for the US total, black, and white populations.

RESULTS

Between 1960 and 2006, US socioeconomic inequities in cancer mortality variously shrunk, widened, reversed, and stagnated, depending on time period and cancer site. For all cancers combined and most, but not all, sites, absolute, but not relative, socioeconomic gaps were greater for the black compared to white population. Compared to the yearly age-specific mortality rates among whites in the most affluent counties, the percent of excess cancer deaths among whites in the lower four county income quintiles first rose above 0 in 1990 and in 2006 equaled 5.4% (95% CI 4.8, 6.0); among blacks, it rose from 6.0% (95% CI 4.5, 7.4) in 1960 to 24.7% (95% CI 23.9, 25.5) in 1990 and remained at this level through 2006.

CONCLUSIONS

The hypothesis that cancer mortality inequities are bound to increase is refuted by long-term data on total and site-specific cancer mortality stratified by socioeconomic position and race/ethnicity.

Explaining racial differences in prostate cancer mortality

BACKGROUND

In the United States, black males have an annual death rate from prostate cancer that is 2.4 times that of white males. The reasons for this are poorly understood.

METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare database, 77,038 black and white males aged >65 years were identified with a first primary diagnosis of prostate cancer between 1995 and 2005, as well as 49,769 controls. The racial gap in mortality was decomposed to differential incidence and stage-specific prostate cancer mortality. The importance of various clinical and socioeconomic factors to each of these components was then examined.

RESULTS

The estimated mortality gap for prostate cancer-specific mortality was 1320 more cases per 100,000 males among black than white men. This gap was due to higher prostate cancer incidence among black males (76%) and higher stage-specific mortality once diagnosed (24%). Differences in prostate-specific antigen testing, comorbidities, and income explained 29% of the difference in metastatic cancer incidence but none of the racial gap for local/regional incidence. Conditional on diagnosis, tumor characteristics explained 50% of the racial gap, comorbidities an additional 4%, choice of treatment and physician 17%, and socioeconomic factors 15%. Overall, approximately 25% of the racial gap in mortality and 86% of the gap in mortality conditional on diagnosis could be explained.

CONCLUSIONS

More frequent prostate-specific antigen testing for black and low-income males could potentially reduce the prostate cancer mortality gap through earlier diagnosis of tumors that otherwise may become metastatic. More aggressive treatment of prostate cancer, especially in poor communities, might also reduce the gap.