Examining the association between socioeconomic status and invasive colorectal cancer incidence and mortality in California

The role of area-level socioeconomic disadvantage in racial disparities in cancer incidence in metropolitan Detroit

BACKGROUND

Neighborhood deprivation is associated with both race and cancer incidence, but there is a need to better understand the effect of structural inequities on racial cancer disparities. The goal of this analysis was to evaluate the relationship between a comprehensive measure of neighborhood-level social disadvantage and cancer incidence within the racially diverse population of metropolitan Detroit.

METHODS

We estimated breast, colorectal, lung, and prostate cancer incidence rates using Metropolitan Detroit Cancer Surveillance System and US decennial census data. Neighborhood socioeconomic disadvantage was measured by the Area Deprivation Index (ADI) using Census Bureau's American Community Survey data at the Public Use Microdata Areas (PUMA) level. Associations between ADI at time of diagnosis and cancer incidence were estimated using Poisson mixed-effects models adjusting for age and sex. Attenuation of race-incidence associations by ADI was quantified using the "mediation" package in R.

RESULTS

ADI was inversely associated with incidence of breast cancer for both non-Hispanic White (NHW) and non-Hispanic Black (NHB) women (NHW: per-quartile RR = 0.92, 95% CI 0.88-0.96; NHB: per-quartile RR = 0.94, 95% CI 0.91-0.98) and with prostate cancer incidence only for NHW men (per-quartile RR = 0.94, 95% CI 0.90-0.97). ADI was positively associated with incidence of lung cancer for NHWs and NHBs (NHW: per-quartile RR = 1.12, 95% CI 1.04-1.21; NHB: per-quartile RR = 1.37, 95% CI 1.25-1.51) and incidence of colorectal cancer (CRC) only among NHBs (per-quartile RR = 1.11, 95% CI 1.02-1.21). ADI significantly attenuated the relationship between race and hormone receptor positive, HER2-negative breast cancer (proportion attenuated = 8.5%, 95% CI 4.1-16.6%) and CRC cancer (proportion attenuated = 7.3%, 95% CI 3.7 to 12.8%), and there was a significant interaction between race and ADI for lung (interaction RR = 1.22, p < 0.0001) and prostate cancer (interaction RR = 1.09, p = 0.00092).

CONCLUSIONS

Area-level socioeconomic disadvantage is associated with risk of common cancers in a racially diverse population and plays a role in racial differences in cancer incidence.

Disparities in melanoma-specific mortality by race/ethnicity, socioeconomic status, and health care systems

BACKGROUND

Despite encouraging trends in survival, sociodemographic inequalities persist among patients with melanoma.

OBJECTIVE

We sought to quantify the effect of race/ethnicity, socioeconomic status, and health care systems on melanoma-specific mortality within an insured population of patients.

METHODS

Using a retrospective cohort study, we identified insured adults diagnosed with Stage I to IV melanoma from January 1, 2009, to December 31, 2014, followed through 2017, from the California Cancer Registry. We compared melanoma-specific mortality between insured patients diagnosed within the largest vertically integrated health care system in California, Kaiser Permanente Southern California, and insured patients with other private insurance (OPI).

RESULTS

Our cohort included 14,614 adults diagnosed with melanoma. Multivariable analyses demonstrated that race/ethnicity was not associated with survival disparities, while socioeconomic status was a strong predictor of melanoma-specific mortality, particularly for those with OPI. For example, hazard ratios demonstrate that the poorest patients with OPI have a 70% increased risk of dying from their melanoma compared to their wealthiest counterparts, while the poorest patients in Kaiser Permanente Southern California have no increased risk.

LIMITATIONS

Our main limitation includes inadequate data for certain racial/ethnic groups, such as Native Americans.

CONCLUSIONS

Our findings underscore the persistence of socioeconomic disparities within an insured population, specifically among those in non-integrated health care systems.

A systematic review of methods to estimate colorectal cancer incidence using population-based cancer registries

Background

Epidemiological studies of incidence play an essential role in quantifying disease burden, resource planning, and informing public health policies. A variety of measures for estimating cancer incidence have been used. Appropriate reporting of incidence calculations is essential to enable clear interpretation. This review uses colorectal cancer (CRC) as an exemplar to summarize and describe variation in commonly employed incidence measures and evaluate the quality of reporting incidence methods.

Methods

We searched four databases for CRC incidence studies published between January 2010 and May 2020. Two independent reviewers screened all titles and abstracts. Eligible studies were population-based cancer registry studies evaluating CRC incidence. We extracted data on study characteristics and author-defined criteria for assessing the quality of reporting incidence. We used descriptive statistics to summarize the information.

Results

This review retrieved 165 relevant articles. The age-standardized incidence rate (ASR) (80%) was the most commonly reported incidence measure, and the 2000 U.S. standard population the most commonly used reference population (39%). Slightly more than half (54%) of the studies reported CRC incidence stratified by anatomical site. The quality of reporting incidence methods was suboptimal. Of all included studies: 45 (27%) failed to report the classification system used to define CRC; 63 (38%) did not report CRC codes; and only 20 (12%) documented excluding certain CRC cases from the numerator. Concerning the denominator estimation: 61% of studies failed to state the source of population data; 24 (15%) indicated census years; 10 (6%) reported the method used to estimate yearly population counts; and only 5 (3%) explicitly explained the population size estimation procedure to calculate the overall average incidence rate. Thirty-three (20%) studies reported the confidence interval for incidence, and only 7 (4%) documented methods for dealing with missing data.

Conclusion

This review identified variations in incidence calculation and inadequate reporting of methods. We outlined recommendations to optimize incidence estimation and reporting practices. There is a need to establish clear guidelines for incidence reporting to facilitate assessment of the validity and interpretation of reported incidence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01632-7.

Examining socio-spatial mobility patterns among colon cancer patients after diagnosis

Given the growing number of cancer survivors, it is important to better understand socio-spatial mobility patterns of cancer patients after diagnosis that could have public health implications regarding post-diagnostic access to care for treatment and follow-up surveillance. In this exploratory study, residential histories from LexisNexis were linked to New Jersey colon cancer cases diagnosed from 2006 to 2011 to examine differences in socio-spatial mobility patterns after diagnosis by stage at cancer diagnosis, sex, and race/ethnicity. For the colon cancer cases, we summarized and compared the number of residences and changes in the residential census tract and neighborhood poverty after the diagnosis. We found only minor changes in neighborhood poverty among the cases during the follow-up period after diagnosis. During the follow-up period of up to 10 years after diagnosis, 67% of the patients did not move to a different residential census tract, and 10.8% moved from New Jersey to another state. Cases that moved to a different census tract changed after diagnosis were generally less wealthy than non-movers, but the destination of relocation varied by race/ethnicity and socioeconomic status. We also found a significant association between residential mobility and stage at diagnosis, whereby patients diagnosed with colon cancer at an early stage were more likely to be movers. This study contributes to understanding of the socio-spatial mobility patterns in colon cancer patients and may help to inform cancer research by summarizing the extent to which colon cancer patients move after diagnosis.

•

Post-diagnosis socio-spatial mobility is relatively low among colon cancer patients.

•

Post-diagnosis, ∼67% of all colon cancer patients in NJ did not change residence.

•

Movers spent more time living in high-poverty neighborhoods than non-movers.

•

Approximately 10% of all patients left New Jersey for other states.

•

Geographic destinations vary by race/ethnicity and socioeconomic status.

Geographic determinants of colorectal cancer in Louisiana

Purpose

Currently, rural residents in the United States (US) experience a greater cancer burden for tobacco-related cancers and cancers that can be prevented by screening. We aim to characterize geographic determinants of colorectal cancer (CRC) incidence in Louisiana due to rural residence and other known geographic risk factors, area socioeconomic status (SES), and cultural region (Acadian or French-speaking).

Methods

Primary colorectal cancer diagnosed among adults 30 years and older in 2008–2017 were obtained from the Louisiana Tumor Registry. Population and social and economic data were obtained from US Census American Community Survey. Rural areas were defined using US Department of Agriculture 2010 rural–urban commuting area codes. Estimates of relative risk (RR) were obtained from multilevel binomial regression models of incidence.

Results

The study population was 16.1% rural, 18.4% low SES, and 17.9% Acadian. Risk of CRC was greater among rural white residents (RR Women: 1.09(1.02–1.16), RR Men: 1.11(1.04–1.18)). Low SES was associated with increased CRC for all demographic groups, with excess risk ranging from 8% in Black men (RR: 1.08(1.01–1.16)) to 16% in white men (RR: 1.16(1.08–1.24)). Increased risk in the Acadian region was greatest for Black men (RR: 1.21(1.10–1.33)) and women (RR: 1.21(1.09–1.33)). Rural–urban disparities in CRC were no longer significant after controlling for SES and Acadian region.

Conclusion

SES remains a significant determinant of CRC disparities in Louisiana and may contribute to observed rural–urban disparities in the state. While the intersectionality of CRC risk factors is complex, we have confirmed a robust regional disparity for the Acadian region of Louisiana.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10552-021-01546-7.

Social inequalities in the incidence, mortality, and survival of neoplasms in women from a municipality in Southeastern Brazil

This study aims to analyze inequalities in the incidence, mortality, and survival of the main types of cancer in women according to the Social Vulnerability Index (SVI). The study was conducted in Campinas, São Paulo State, Brazil, from 2010 to 2014, and used data from the Population-based Cancer Registry and the Mortality Information System. Incidence and mortality rates standardized by age and 5-year survival estimates were calculated according to the social vulnerability strata (SVS), based on the São Paulo Social Vulnerability Index. Three SVS were delimited, with SVS1 being the lowest level of vulnerability and SVS3 being the highest. Rate ratios and the concentration index were calculated. The significance level was 5%. Women in SVS1 had a higher risk of breast cancer (0.46; 95%CI: 0.41; 0.51), colorectal cancer (0.56; 95%CI: 0.47; 0.68), and thyroid cancer (0.32; 95%CI: 0.26; 0.40), whereas women from SVS3 had a higher risk of cervical cancer (2.32; 95%CI: 1.63; 3.29). Women from SVS1 had higher mortality rates for breast (0.69; 95%CI: 0.53; 0.88) and colorectal cancer (0.69; 95%CI: 0.59; 0.80) and women from SVS3 had higher rates for cervical (2.35; 95%CI: 1.57; 3.52) and stomach cancer (1.43; 95%CI: 1.06; 1.91). Women of highest social vulnerability had lower survival rates for all types of cancer. The observed inequalities differed according to the location of the cancer and the analyzed indicator. Inequalities between incidence, mortality, and survival tend to revert and the latter is always unfavorable to the segment of highest vulnerability, indicating the existence of inequality in access to early diagnosis and timely treatment.

Impact of Socioeconomic Status on Cancer Incidence Risk, Cancer Staging, and Survival of Patients with Colorectal Cancer under Universal Health Insurance Coverage in Taiwan

This study examined the impact of socioeconomic status on colorectal cancer risk, staging, and survival under the National Health Insurance (NHI) system in Taiwan. Monthly salary and education level were used as measures of socioeconomic status to observe the risk of colorectal cancer among individuals aged 40 years or above in 2006-2015 and survival outcomes of patients with colorectal cancer until the end of 2016. Data from 286,792 individuals were used in this study. Individuals with a monthly salary ≤Q1 were at a significantly lower incidence risk of colorectal cancer than those with a monthly salary >Q3 (HR = 0.80, 95% CI = 0.74-0.85), while those with elementary or lower education were at a significantly higher risk than those with junior college, university, or higher education (HR = 1.18, 95% CI = 1.06-1.31). The results show that socioeconomic status had no significant impact on colorectal cancer stage at diagnosis. Although salary was not associated with their risk of mortality, patients with colorectal cancer who had elementary or lower education incurred a significantly higher risk of mortality than those who had junior college, university, or higher education (HR = 1.39, 95% CI = 1.07-1.77). Education level is a significant determinant of the incidence risk and survival in patients with colorectal cancer, but only income significantly impacts incidence risk.

Patterns of overall mortality by race/ethnicity and socioeconomic status in insured cancer patients in Southern California

Purpose

We evaluated the influence of race/ethnicity and geocoded socioeconomic status (SES) on all-cause mortality in cancer patients with health insurance.

Methods

We identified adults diagnosed with eight common cancers from 2009 to 2014 from the California Cancer Registry and followed them through 2017 (8 years maximum). We calculated person-year mortality rates by race/ethnicity and SES. Adjusted hazard ratios for the association between overall mortality and race/ethnicity and SES were estimated using Cox proportional hazards models accounting for other demographics, stage at diagnosis, and cancer treatments.

Results

A total of 164,197 adults were diagnosed with cancer originating from breast, prostate, lung, colon, skin melanoma, uterus, kidney, and bladder. For all race/ethnic groups combined, the mortality rates from lowest to highest SES groups were 112.1/1000 PY (lowest); 100.2/1000 PY (lower-middle); 91.2/1000 PY (middle); 79.1/1000 PY (upper-middle); and 63.5/1000 PY (upper). These rates suggest that person with lowest SES have a markedly increased mortality risk after cancer diagnosis even if they have health insurance. In multivariable analyses, those in the lowest SES group had a 40–78% increased risk of all-cause mortality compared to those in the upper SES group across all race/ethnicities. For example, within African Americans, the adjusted mortality risk was up to 61% higher (HR 1.61, 95% CI 1.41–1.83) in the lowest SES group compared to the highest SES group.

Conclusion

This study suggests disparities in overall mortality risk after cancer diagnoses persist even in a cohort with health insurance, and that SES is an important driver of this disparity.

Hereditary, environmental, and dietary risk factors of colorectal cancer: a case-control study in the Algerian East

Colorectal carcinoma (CRC) is the second most common cancer diagnosed in Algeria. The incidence and the mortality rate of CRC have increased so that the nation now ranks third in Africa in both these variables. Many environmental and genetic factors are suspected to play an important role in the development of the disease. This study aimed to identify the risk factors for CRC in Algeria. We performed a case-control study in five Medical Oncology Services in this region: Tebessa, Batna, Annaba, Setif, and Constantine, from 2016 to 2019. Altogether, 200 patients diagnosed with CRC and 200 age-matched controls without any diagnosis of cancer were included. Study participants were interviewed about environmental, dietary, and hereditary risk factors, i.e., family history of cancer, using a questionnaire. Results showed a significant association between high educational level and a decreased risk of CRC. Diagnoses of any cancer or of CRC in first-degree or in second- or third-degree relatives also were significantly associated with CRC risk. Occupational exposures showed a significant link with an increased risk of CRC, as did obesity, alcohol consumption, and passive smoking. Yogurt, cereals, sugar, butter, and margarine consumption were significant protective factors, while cheese, dried fruits, red meat, juice, and fizzy drink consumption was associated with increased risk. Our findings suggest a benefit of public health campaigns to enhance awareness about CRC and to encourage healthy dietary choices and avoidance of non-dietary risk factors.

Burden of colorectal cancer attributable to diet low in milk in China, 1990-2017: findings from the global burden of disease study 2017

BACKGROUND

Colorectal cancer (CRC) has emerged as a major public health concern. However, little is known about the burden attributable to specific risk factors. The present study aimed to estimate the temporal trends and geographical variation of CRC burden attributable to a diet low in milk in China.

METHODS

Following the general analytic strategy used in the 2017 Global Burden of Disease study, we assessed the age-, sex-, and province-specific mortality and disability-adjusted life-years (DALYs) of CRC caused by a diet low in milk in China from 1990 to 2017.

RESULTS

In 2017, a diet low in milk contributed 32 032 [95% uncertainty interval (UI) = 11 350-53 806] deaths and 726 710 (95% UI = 256 651-1 218 153) DALYs for CRC with a population attributable fraction of 17.1%. The age-standardised mortality and DALY rates per 100 000 were 1.7 (95% UI = 0.6-2.9) and 36.8 (95% UI = 13.0-61.7), respectively. An upward trend with age in rates of mortality and DALYs was observed. Males had higher age-standardised rates than females. The number of deaths and DALYs increased significantly from 1990 to 2017, whereas the corresponding age-standardised rates showed relatively stable trends. In 2017, Hunan and Liaoning were ranked as the top two provinces in terms of disease burden. Socio-demographic index had a weak correlation with the age-standardised mortality (r = 0.348, P = 0.047).

CONCLUSIONS

The present study shows a substantial increase in the CRC burden attributable to a diet low in milk over the past three decades. Greater priority in CRC prevention should be given to males and the elderly population throughout China, particularly in less-developed provinces.

Effect Modification of the Association Between Race and Stage at Colorectal Cancer Diagnosis by Socioeconomic Status

OBJECTIVES

To compare risks of distant-stage colorectal cancer (CRC) diagnosis between whites and American Indian/Alaska Natives (AI/ANs) and to explore effect modification by area-based socioeconomic status (SES).

DESIGN

Retrospective cohort study using data from the Oklahoma Central Cancer Registry.

SETTING

Oklahoma.

PARTICIPANTS

White and AI/AN cases of CRC diagnosed in Oklahoma between 2001 and 2008 (N = 8 438). A subanalysis was performed on the cohort of those aged 50 years and older (N = 7 728).

MAIN OUTCOME MEASURE

Risk of distant-stage CRC diagnosis stratified by SES score.

RESULTS

Race and SES were independently associated with distant-stage diagnosis. In SES-stratified analyses, AI/ANs in the 2 lowest SES groups experienced increased risks in the overall cohort and among those aged 50 years and older. In multivariable models, risks remained significant among those aged 50 years and older in the lowest SES groups (Adjusted risk ratio SES score of 2: 1.31, 95% confidence interval: 1.06-1.63 and adjusted risk ratio SES score of 1: 1.21, 95% confidence interval: 1.01-1.44).

CONCLUSION

Socioeconomic status is an effect modifier in the association between race/ethnicity and stage at CRC diagnosis. Disparities in stage at CRC diagnosis exist between AI/ANs and whites with lower estimated SES. Efforts are needed to increase CRC screening among lower SES AI/ANs.

Social determinants of colorectal cancer risk, stage, and survival: a systematic review

BACKGROUND

Several social determinants of health have been examined in relation to colorectal cancer incidence, stage at diagnosis, and survival including income, education, neighborhood disadvantage, immigration status, social support, and social network. Colorectal cancer incidence rates are positively associated with income and other measures of socioeconomic status. In contrast, low socioeconomic status tends to be associated with poorer survival.

METHODS

The present review is based upon bibliographic searches in PubMed and CINAHL and relevant search terms. Articles published in English from 1970 through April 1, 2019 were identified using the following MeSH search terms and Boolean algebra commands: colorectal cancer AND (incidence OR stage OR mortality) AND (social determinants OR neighborhood disadvantage OR racial discrimination OR immigration OR social support).

RESULTS

This review indicates that poverty, lack of education, immigration status, lack of social support, and social isolation play important roles in colorectal cancer stage at diagnosis and survival.

CONCLUSIONS

To address social determinants of colorectal cancer, effective interventions are needed that account for the social contexts in which patients live.

Spatial access to primary care providers and colorectal cancer-specific survival in Cook County, Illinois

BACKGROUND

Spatial access to primary care has been associated with late-stage and fatal breast cancer, but less is known about its relation to outcomes of other screening-preventable cancers such as colorectal cancer. This population-based retrospective cohort study examined whether spatial access to primary care providers associates with colorectal cancer-specific survival.

METHODS

Approximately 26 600 incident colorectal cancers diagnosed between 2000 and 2008 in adults residing in Cook County, Illinois were identified through the state cancer registry and georeferenced to the census tract of residence at diagnosis. An enhanced two-step floating catchment area method measured tract-level access to primary care physicians (PCPs) in the year of diagnosis using practice locations obtained from the American Medical Association. Vital status and underlying cause of death were determined using the National Death Index. Fine-Gray proportional subdistribution hazard models analyzed the association between tract-level PCP access scores and colorectal cancer-specific survival after accounting for tract-level socioeconomic status, case demographics, tumor characteristics, and other factors.

RESULTS

Increased tract-level access to PCPs was associated with a lower risk of death from colorectal cancer (hazard ratio [HR], 95% confidence interval [CI]) = 0.87 [0.79, 0.96], P = .008, highest vs lowest quintile), especially among persons diagnosed with regional-stage tumors (HR, 95% CI = 0.80 [0.69, 0.93], P = .004, highest vs lowest quintile).

CONCLUSIONS

Spatial access to primary care providers is a predictor of colorectal cancer-specific survival in Cook County, Illinois. Future research is needed to determine which areas within the cancer care continuum are most affected by spatial accessibility to primary care such as referral for screening, accessibility of screening and diagnostic testing, referral for treatment, and access to appropriate survivorship-related care.

Trends of colorectal cancer incidence by education and socioeconomic status in Finland

Background: The aim of this study was to investigate if the incidence of colorectal cancer (CRC) is associated with education and socioeconomic status (SES) in Finland, and if there are any changes in incidence differences between the groups over the period 1976-2014.Material and methods: CRC cases (N = 77,614) were retrieved from the Finnish Cancer Registry and linked with information on the education level and SES from Statistics Finland. We used Poisson regression model to quantify differences in incidence rates between the groups, and to assess changes over calendar time.Results and conclusions: Colon cancer incidence was higher among the highly educated, than in those with basic education. Similar differences were observed by SES in men. Incidence rates increased steeply over time among men with basic education (from 16.7/100,000 in 1976-1979 to 31.8 in 2010-2014), resulting in narrowed differences between the groups (p < .001). Incidence trends of proximal and distal colon and rectal cancer in men showed similar patterns. Heterogeneity across time periods by SES was observed only in colon cancer incidence in men (p = .009). No such large differences were detected in women. Steep increase in colon cancer incidence in men with basic education, and the respective persistent high incidence in the highly educated highlights the importance of focusing the preventive measures on modifiable lifestyle factors in order to reduce CRC incidence and to narrow the educational and socioeconomic health differences.

Low colorectal cancer survival in the Mountain West state of Nevada: A population-based analysis

Colorectal cancer (CRC) is the third greatest cancer burden in the United States. The remarkably diverse Mountain West state of Nevada has uncharacteristically high CRC mortality compared to other Western states. We aimed to study the determinants of the CRC excess burden by using data from the Nevada Central Cancer Registry from 2003-2013. Five-year cause-specific age-adjusted survival from colorectal cancer was calculated and stratified by sex, race/ethnicity and region of Nevada. Cox Proportional Hazards regression modelling was used to study the impact of demographic, social, and clinical factors on CRC survival in Nevada, assessing follow-up as accurately as possible. The extent to which differences in survival can be explained by receipt of stage-appropriate treatment was also assessed. 12,413 CRC cases from 2003-2013 in Nevada were analyzed. Five-year CRC survival was low: 56.0% (95% CI: 54.6-57.5) among males and 59.5% (95% CI: 58.0-61.1) among females; significantly lower than national 5-year survival of 65.1% and 66.5%, respectively. Low survival was driven by populous Southern Nevada; after adjustment for all covariates, Southern Nevadans were at 17% higher risk of death than their counterparts in Northwestern Nevada (HR:1.17; 95% CI:1.08-1.27). Many patients did not receive stage-appropriate treatment, although this only partly explained the poor survival, uniformly low for every race/ethnicity in Nevada. The observed disparity for this one state within a single nation merits public health attention; regardless of the state or region of residence, all Americans deserve equal opportunity for optimum health outcomes in the face of a cancer diagnosis. The current study provides baseline information critical to clinicians, public health professionals, and all relevant stakeholders as they attempt to discern why Nevada's outcomes are vastly divergent from its neighboring Western states and make plans for remediation.

Racial-Ethnic Disparities in Late-Stage Colorectal Cancer Among Hispanics and Non-Hispanic Whites of New Mexico

INTRODUCTION

Hispanics in New Mexico are diagnosed with more later-stage colorectal cancer (CRC) than non-Hispanic Whites (NHW). Our study evaluated the interaction of race/ethnicity and risk factors for later-stage III and IV CRC among patients in New Mexico.

METHOD

CRC patients ages 30 to 75 years ( n = 163, 46% Hispanic) completed a survey on key explanatory clinical, lifestyle, preventive health, and demographic variables for CRC risk. Adjusted logistic regression models examined whether these variables differentially contributed to later-stage CRC among NHW versus Hispanics.

RESULTS

Compared with NHW, Hispanics had a higher prevalence of later-stage CRC ( p = .007), diabetes ( p = .006), high alcohol consumption ( p = .002), low education ( p = .003), and CRC diagnosis due to symptoms ( p = .06). Compared with NHW, Hispanics reporting high alcohol consumption (odds ratio [OR] = 7.59; 95% confidence interval [CI] = 1.31-43.92), lower education (OR = 3.5; 95% CI = 1.28-9.65), being nondiabetic (OR = 3.23; 95% CI = 1.46-7.15), or ever smokers (OR = 2.4; 95% CI = 1.03-5.89) were at higher risk for late-stage CRC. Adjusting for CRC screening did not change the direction or intensity of the odds ratios.

CONCLUSION

The ethnicity-risk factor interactions, identified for late-stage CRC, highlight significant factors for targeted intervention strategies aimed at reducing the burden of later-stage CRC among Hispanics in New Mexico with broad applicability to other Hispanic populations.

Evidence of a positive association between malpractice climate and thyroid cancer incidence in the United States

The incidence of thyroid cancer has risen dramatically in the past few decades. The cause of this is unclear, but several lines of evidence indicate it is largely due to overdiagnosis, the diagnosis of tumors that would have never manifest clinically if untreated. Practices leading to overdiagnosis may relate to defensive medicine. In this study, we evaluated the association between malpractice climate and incidence of thyroid, breast, prostate, colon, and lung cancer in U.S. states from 1999-2012 using publicly available government data. State-level malpractice risk was quantified as malpractice payout rate, the number of malpractice payouts per 100,000 people per state per year. Associations between state-level cancer incidence, malpractice payout rate, and several cancer risk factors were evaluated. Risk factors included several social determinants of health, including factors predicting healthcare access. States with higher malpractice payout rate had higher thyroid cancer incidence, on both univariate analysis (r = 0.51, P = 0.009, Spearman) and multivariate analysis (P<0.001, multilevel model). In contrast, state-level malpractice payout rate was not associated with incidence of any other cancer type. Malpractice climate may be a social determinant for being diagnosed with thyroid cancer. This may be a product of greater defensive medicine in states with higher malpractice risk, which leads to increased diagnostic testing of patients with thyroid nodules and potential overdiagnosis. Alternatively, malpractice risk may be a proxy for another, unmeasured risk factor.

Characteristics and comparison of colorectal cancer incidence in Beijing with other regions in the world

Background

Population-based epidemiologic studies about colorectal cancer are lacking in China. This study aims to provide a basis for colorectal cancer screening and prevention, through analysis and comparisons the characteristics of the trends in colorectal cancer incidence in Beijing and selected representative regions.

RESULTS

The annual incidence rate in Beijing region increased significantly, from 9.40/100,000 in 1998 to 18.61/100,000 in 2012. The stratified rate showed that the incidence of distal colon adenocarcinoma increased substantially in men, especially in those aged > 75 years and residing in urban areas. Although the incidence rate in Beijing is still lower than in Shanghai, Jiashan, and Hong Kong in China, it is increasing rapidly. Further, the incidence rate in Beijing is lower than in New York, Oxford and Osaka, but higher than in Mumbai and Kyadondo. The incidence trend in Beijing is increasing especially in older groups, while in other regions such as New York, it is decreasing in these age groups.

Materials and Methods

Colorectal cancer incidence data were obtained from Beijing Cancer Registry and Cancer Incidence in Five Continents Plus database. All incidence rates were age-standardized according to Segi's world population. Incidence trends were characterized by calculating the annual percent changes using the Joinpoint Regression Program.

Conclusions

Compared with other regions, Beijing has a medium level of colorectal cancer incidence, however, it is increasing significantly. There are obvious differences in the cancer subsite, sex and age distributions between Beijing and other regions. Prevention and screening of colorectal cancer in Beijing should be strengthened.

Neighborhood disadvantage and racial disparities in colorectal cancer incidence: a population-based study in Louisiana

PURPOSE

Colorectal cancer (CRC) continues to demonstrate racial disparities in incidence and survival in the United States. This study investigates the role of neighborhood concentrated disadvantage in racial disparities in CRC incidence in Louisiana.

METHODS

Louisiana Tumor Registry and U.S. Census data were used to assess the incidence of CRC diagnosed in individuals 35 years and older between 2008 and 2012. Neighborhood concentrated disadvantage index (CDI) was calculated based on the PhenX Toolkit protocol. The incidence of CRC was modeled using multilevel binomial regression with individuals nested within neighborhoods.

RESULTS

Our study included 10,198 cases of CRC. Adjusting for age and sex, CRC risk was 28% higher for blacks than whites (risk ratio [RR] = 1.28; 95% confidence interval [CI] = 1.22-1.33). One SD increase in CDI was associated with 14% increase in risk for whites (RR = 1.14; 95% CI = 1.10-1.18) and 5% increase for blacks (RR = 1.05; 95% CI = 1.02-1.09). After controlling for differential effects of CDI by race, racial disparities were not observed in disadvantaged areas.

CONCLUSION

CRC incidence increased with neighborhood disadvantage and racial disparities diminished with mounting disadvantage. Our results suggest additional dimensions to racial disparities in CRC outside of neighborhood disadvantage that warrants further research.

Colorectal cancer-global burden, trends, and geographical variations

BACKGROUND

The aim of this study is to describe the trends and variations in the global burden of colorectal cancer (CRC).

METHODS

Data (2012-2030) relating to CRC was extracted from GLOBOCAN 2012 database and analyzed.

RESULTS

The results of our study demonstrate a rising global burden of colorectal cancer which persists until the year 2035 and likely beyond. The rise in the global burden is not uniform with significant variations influenced by geographic location, socio-economic status, age, and gender. Although the EURO region has the highest burden, Asia as a continent continues to bear the heaviest brunt of the disease. Although the burden of disease is higher in more developed regions, mortality is considerably higher in less developed regions and this gap widens over the next two decades. The disease predominantly affects the male gender across all regions of the world. Age has a complex relation with the burden of CRC and is affected by the cross-influences relating to socio-economic status.

CONCLUSIONS

The results of our study demonstrate a rising global burden of CRC with some unique variations. Knowledge of this data can increase awareness and help strategic targeting of efforts and resources.

Survival Differences by Race/Ethnicity and Neighborhood Socioeconomic Status in Adolescents and Young Adults Diagnosed with Non-Hodgkin Lymphoma

PURPOSE

Lymphoid malignancies are among the most common cancers diagnosed in adolescents and young adults (AYAs). However, little is known about the factors affecting survival in AYAs with non-Hodgkin lymphoma (NHL). We evaluated if survival differs by race/ethnicity and neighborhood socioeconomic status in AYAs with NHL.

METHODS

AYAs aged 15-39 diagnosed with incident NHL during 1990-2010 at Kaiser Permanente Southern California (KPSC), a large managed care organization, were identified. Demographic information and cancer characteristics were obtained from KPSC's cancer registry. Mortality data were obtained from California and national death files. Patients were followed from NHL diagnosis to 5 years postdiagnosis or 12/31/2012, whichever came first. Multivariable Cox model was used to evaluate the association between race/ethnicity, neighborhood income/education level, and mortality, adjusting for age, gender, stage, year of diagnosis, and histology subtype.

RESULTS

A total of 718 AYAs with NHL were included (mean age at diagnosis: 31 years); 45% were non-Hispanic white, 10% were African American, 36% were Hispanic, and 8% were Asian/Pacific Islander. Overall 5-year mortality was 30%. Compared to non-Hispanic whites, Asians/Pacific Islanders had increased 5-year mortality (hazard ratio=1.95, 95% confidence interval: 0.93-4.07). No significant increase in mortality was found for Hispanics or African Americans. Lower neighborhood income but not education level was associated with worse overall survival.

CONCLUSION

A survival disparity for Asians/Pacific Islanders and low-income neighborhoods was observed in AYAs with NHL despite relatively equal access to care. These results call for studies to further understand mechanisms underlying the inferior outcomes among disadvantaged subgroups.

Patients Diagnosed with Colorectal Cancer in Rural Areas in Arizona Typically Present with Higher Stage Disease

BACKGROUND

Despite the decreasing incidence of colorectal cancer (CRC) over the past three decades disparities remain in its incidence, stage at presentation, and efficiency of staging and treatment between different communities, particularly when comparing urban and rural areas. The aim of the study was to assess disparities that exist in CRC outcomes among urban, international border counties, and non-border counties in Arizona.

METHODS

A retrospective analysis of CRC data from the Arizona Cancer Registry was performed. Data obtained included age, sex, ethnicity, tumor grade, and tumor stage. The data was then categorized into three sections: international border counties, urban counties, and rural counties. The outcome measure was stage of CRC at diagnosis.

RESULTS

There were a total of 39, 958 reported incident cases of colorectal cancer from 1995-2010. Of the total incident cases, 53.1% were male and the average age at diagnosis was 69.5. 86.6% were white non-Hispanic, 8.37% Hispanic, 2.4% African American, 1.7% Native American and 1% Asian. There was a significant decrease in the incidence of CRC in all counties, 24.08% in border, 22.5% in urban, and 12.3% in rural. Rural counties showed a higher number of observed cases than expected cases of stage 4 CRC and more unknown diagnosis of grade, stage and lymph node assessment as determined by the adjusted residual.

CONCLUSION

Patients in rural counties are more likely to present with a higher stage of CRC and are less likely to have their cancer adequately staged. This is likely due to lack of better access to healthcare, lack of awareness and poor education and also inadequate specialists.

Randomized trial to increase colorectal cancer screening in an ethnically diverse sample of first-degree relatives

BACKGROUND

Ethnic minorities, especially African Americans and Latinos, bear a disproportionate burden of colorectal cancer (CRC), as reflected in incidence, cancer stage, and mortality statistics. In all ethnic groups, first-degree relatives (FDRs) of CRC cases are at an elevated disease risk. However, underuse of CRC screening persists and is particularly evident among minority groups. The current study tested a stepped intervention to increase CRC screening among an ethnically diverse sample of FDRs of CRC cases.

METHODS

A statewide cancer registry was used to recruit CRC cases and through them their FDRs. Relatives who were not current on CRC screening were randomized to intervention or usual-care control arms. The stepped intervention consisted of ethnically targeted and individually tailored print materials followed by telephone counseling for those unscreened at 6 months.

RESULTS

The study sample of 1280 individuals consisted of 403 Latino, 284 African American, 242 Asian, and 351 white FDRs. Statistically significant effects were observed for the cumulative print plus telephone intervention at 12 months (26% in the intervention vs 18% in the control group) and the print intervention alone at 6 months (15% in the intervention vs 10% in the control group). The effect of the print intervention alone versus the cumulative interventions was not statistically significantly different. Stratified analyses indicated that the intervention was effective among white, Latino, and Asian individuals, but not among African-Americans.

CONCLUSIONS

Overall, the intervention was effective in increasing screening rates. Oversampling racial/ethnic minorities allowed for the examination of effects within subgroups, revealing no effect among African American individuals. This finding illustrates the importance of including sufficient numbers of participants from diverse ethnic subgroups in intervention research to enable such stratified analyses.

How can we boost colorectal and hepatocellular cancer screening among underserved populations?

Colorectal cancer (CRC) and hepatocellular carcinoma (HCC) are common causes of cancer incidence and mortality in the USA, particularly among underserved populations such as racial/ethnic minorities, the under-/uninsured, and individuals with low socioeconomic status. Although screening can reduce cancer-related mortality, participation is suboptimal among underserved populations, likely serving as the largest contributor to observed inequities in HCC and CRC outcomes among US populations. In this narrative review, we highlight inequities across populations in the USA with respect to incidence and mortality for CRC and HCC and highlight potential causes, with a focus on screening rates. In addition, drawing from the recent literature, we highlight promising strategies for increasing screening for HCC and CRC and propose future research and policy solutions to optimize screening rates. With focused implementation of screening strategies and novel research, the burden of HCC and CRC can be reduced among underserved populations.

Cancer-specific mortality of Asian Americans diagnosed with cancer: a nationwide population-based assessment

BACKGROUND

Racial disparities in cancer survival outcomes have been primarily attributed to underlying biologic mechanisms and the quality of cancer care received. Because prior literature shows little difference exists in the socioeconomic status of non-Hispanic whites and Asian Americans, any difference in cancer survival is less likely to be attributable to inequalities of care. We sought to examine differences in cancer-specific survival between whites and Asian Americans.

METHODS

The Surveillance, Epidemiology, and End Results Program was used to identify patients with lung (n = 130 852 [16.9%]), breast (n = 313 977 [40.4%]), prostate (n = 166 529 [21.4%]), or colorectal (n = 165 140 [21.3%]) cancer (the three leading causes of cancer-related mortality within each sex) diagnosed between 1991 and 2007. Fine and Gray's competing risks regression compared the cancer-specific mortality (CSM) of eight Asian American groups (Chinese, Filipino, Hawaiian/Pacific Islander, Japanese, Korean, other Asian, South Asian [Indian/Pakistani], and Vietnamese) to non-Hispanic white patients. All P values were two-sided.

RESULTS

In competing risks regression, the receipt of definitive treatment was an independent predictor of CSM (hazard ratio [HR] = 0.37, 95% confidence interval [CI] = 0.35 to 0.40; HR = 0.55, 95% CI = 0.53 to 0.58; HR = 0.61, 95% CI = 0.60 to 0.62; and HR = 0.27, 95% CI = 0.25 to 0.29) for prostate, breast, lung, and colorectal cancers respectively, all P < .001). In adjusted analyses, most Asian subgroups (except Hawaiians and Koreans) had lower CSM relative to white patients, with hazard ratios ranging from 0.54 (95% CI = 0.38 to 0.78) to 0.88 (95% CI = 0.84 to 0.93) for Japanese patients with prostate and Chinese patients with lung cancer, respectively.

CONCLUSIONS

Despite adjustment for potential confounders, including the receipt of definitive treatment and tumor characteristics, most Asian subgroups had better CSM than non-Hispanic white patients. These findings suggest that underlying genetic/biological differences, along with potential cultural variations, may impact survival in Asian American cancer patients.

Incidence and mortality of colorectal cancer in China, 2011

OBJECTIVE

Colorectal cancer is the third most common type of cancer and the fourth leading cause of cancer-related death in the world. This article provides the most up-to-date overview of colorectal cancer burden in China.

METHODS

Totally 234 cancer registries submitted data of 2011 to the National Central Cancer Registry (NCCR). Qualified data from 177 registries was pooled and analyzed. The crude incidence and mortality rates of colorectal cancer were calculated by age, gender and geographic area. The numbers of new cases and deaths were estimated using the 5-year age-specific cancer incidence/mortality rates and the corresponding populations. China census in 2000 and Segi's world population were applied for age standardized rates.

RESULTS

The estimate of new cases diagnosed with colorectal cancer of China in 2011 was 310,244 (178,404 for males and 131,840 for females, 195,117 in urban areas and 115,128 in rural areas), accounting for 9.20% of overall new cancer cases. The crude incidence of colorectal cancer ranked fourth in all cancer sites with rate of 23.03/100,000 (25.83/100,000 for males and 20.08/100,000 for female, 28.25/100,000 in urban areas and 17.54/100,000 in rural areas). The age-standardized rates by China population and by World population were 16.79/100,000 and 16.52/100,000, respectively. The estimated number of colorectal cancer deaths of China in 2011 was 149,722 (86,427 for males and 63,295 for females, 91,682 in urban areas and 58,040 in rural areas), accounting for 7.09% of overall cancer deaths. The crude mortality rate for colorectal cancer ranked fifth leading cause of cancer-related death in all cancer sites with rate of 11.11/100,000 (12.51/100,000 for males and 9.64/100,000 for female, 13.27/100,000 in urban areas and 8.84/100,000 in rural areas). The age-standardized rates by China population and by World population for mortality were 7.77/100,000 and 7.66/100,000, respectively. For both of incidence and mortality, the rates of colorectal cancer were much higher in males than in females, and in rural areas than in urban areas. The rate of colorectal cancer increased greatly with age, especially after 40 or 45 years old.

CONCLUSIONS

Colorectal cancer is a relative common cancer in China, especially for males in urban areas. Targeted prevention and early detection programs should be carried out.

Colorectal cancer mortality among Hispanics in California: differences by neighborhood socioeconomic status and nativity

BACKGROUND

Socioeconomic status (SES) plays an important role in colorectal cancer (CRC) mortality, although the independent and joint effects with nativity and neighborhood factors have yet to be evaluated.

METHODS

With nearly one-third of all US Hispanics residing in California, the authors obtained information from the California Cancer Registry to examine the associations between neighborhood SES and mortality in all 33,146 Hispanic individuals diagnosed with CRC from 1988 through 2010, with a particular focus on associations among US-born and foreign-born Hispanics. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CI) for overall and CRC-specific mortality.

RESULTS

Hispanics residing in lower SES neighborhoods demonstrated a higher rate of overall and CRC-specific mortality than those residing in high SES neighborhoods (SES quintile 1[low] vs quintile 5 [high]: HR, 1.15 [95% CI, 1.05-1.26] and HR, 1.16 [95% CI, 1.03-1.30], respectively). Nativity modified the associations between SES and mortality (P for interaction, .02 for overall and P for interaction, .01 for CRC-specific mortality) such that the SES associations were observed only among US-born (P for trend < .01 for overall and CRC-specific mortality) but not among foreign-born Hispanics.

CONCLUSIONS

Neighborhood SES demonstrates significant differential effects on overall and CRC-specific mortality between US-born and foreign-born Hispanics. Future efforts should investigate the underlying contextual and individual-level factors that could account for these differential associations by nativity.

Associations of census-tract poverty with subsite-specific colorectal cancer incidence rates and stage of disease at diagnosis in the United States

Background. It remains unclear whether neighborhood poverty contributes to differences in subsite-specific colorectal cancer (CRC) incidence. We examined associations between census-tract poverty and CRC incidence and stage by anatomic subsite and race/ethnicity. Methods. CRC cases diagnosed between 2005 and 2009 from 15 states and Los Angeles County (N = 278,097) were assigned to 1 of 4 groups based on census-tract poverty. Age-adjusted and stage-specific CRC incidence rates (IRs) and incidence rate ratios (IRRs) were calculated. Analyses were stratified by subsite (proximal, distal, and rectum), sex, race/ethnicity, and poverty. Results. Compared to the lowest poverty areas, CRC IRs were significantly higher in the most impoverished areas for men (IRR = 1.14 95% CI 1.12-1.17) and women (IRR = 1.06 95% CI 1.05-1.08). Rate differences between high and low poverty were strongest for distal colon (male IRR = 1.24 95% CI 1.20-1.28; female IRR = 1.14 95% CI 1.10-1.18) and weakest for proximal colon. These rate differences were significant for non-Hispanic whites and blacks and for Asian/Pacific Islander men. Inverse associations between poverty and IRs of all CRC and proximal colon were found for Hispanics. Late-to-early stage CRC IRRs increased monotonically with increasing poverty for all race/ethnicity groups. Conclusion. There are differences in subsite-specific CRC incidence by poverty, but associations were moderated by race/ethnicity.

The relationship between area poverty rate and site-specific cancer incidence in the United States

BACKGROUND

The relationship between socioeconomic status and cancer incidence in the United States has not traditionally been a focus of population-based cancer surveillance systems.

METHODS

Nearly 3 million tumors diagnosed between 2005 and 2009 from 16 states plus Los Angeles were assigned into 1 of 4 groupings based on the poverty rate of the residential census tract at time of diagnosis. The sex-specific risk ratio of the highest-to-lowest poverty category was measured using Poisson regression, adjusting for age and race, for 39 cancer sites.

RESULTS

For all sites combined, there was a negligible association between cancer incidence and poverty; however, 32 of 39 cancer sites showed a significant association with poverty (14 positively associated and 18 negatively associated). Nineteen of these sites had monotonic increases or decreases in risk across all 4 poverty categories. The sites most strongly associated with higher poverty were Kaposi sarcoma, larynx, cervix, penis, and liver; those most strongly associated with lower poverty were melanoma, thyroid, other nonepithelial skin, and testis. Sites associated with higher poverty had lower incidence and higher mortality than those associated with lower poverty.

CONCLUSIONS

These findings demonstrate the importance and relevance of including a measure of socioeconomic status in national cancer surveillance. Cancer 2014;120:2191–2198. © 2014 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.

A majority of cancer sites exhibit significant associations with area poverty rates. Those associated with higher poverty had lower incidence but higher mortality than those associated with lower poverty.

Geographical variation and factors associated with colorectal cancer mortality in a universal health care system

OBJECTIVE

To investigate the geographical variation and small geographical area level factors associated with colorectal cancer (CRC) mortality.

METHODS

Information regarding CRC mortality was obtained from the population-based Manitoba Cancer Registry, population counts were obtained from Manitoba's universal health care plan Registry and characteristics of the area of residence were obtained from the 2001 Canadian census. Bayesian spatial Poisson mixed models were used to evaluate the geographical variation of CRC mortality and Poisson regression models for determining associations with CRC mortality. Time trends of CRC mortality according to income group were plotted using joinpoint regression.

RESULTS

The southeast (mortality rate ratio [MRR] 1.31 [95% CI 1.12 to 1.54) and southcentral (MRR 1.62 [95% CI 1.35 to 1.92]) regions of Manitoba had higher CRC mortality rates than suburban Winnipeg (Manitoba's capital city). Between 1985 and 1996, CRC mortality did not vary according to household income; however, between 1997 and 2009, individuals residing in the highest-income areas were less likely to die from CRC (MRR 0.77 [95% CI 0.65 to 0.89]). Divergence in CRC mortality among individuals residing in different income areas increased over time, with rising CRC mortality observed in the lowest income areas and declining CRC mortality observed in the higher income areas.

CONCLUSIONS

Individuals residing in lower income neighbourhoods experienced rising CRC mortality despite residing in a jurisdiction with universal health care and should receive increased efforts to reduce CRC mortality. These findings should be of particular interest to the provincial CRC screening programs, which may be able to reduce the disparities in CRC mortality by reducing the disparities in CRC screening participation.