Geographic Variation in Mortality Among Children and Adolescents Diagnosed With Cancer in Tennessee. Does Race Matter?

Geographic Information Systems Utilization in Pediatric End-of-Life Research: A Scoping Review

Currently, little is known about how geographic information systems (GIS) has been utilized to study end-of-life care in pediatric populations. The purpose of this review was to collect and examine the existing evidence on how GIS methods have been used in pediatric end-of-life research over the last 20 years. Scoping review method was used to summarize existing evidence and inform research methods and clinical practice was used. The Preferred Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA) was utilized. The search resulted in a final set of 17 articles. Most studies created maps for data visualization and used ArcGIS as the primary software for analysis. The scoping review revealed that GIS methodology has been limited to mapping, but that there is a significant opportunity to expand the use of this methodology for pediatric end-of-life care research.

Examining How Social Risk Factors Are Integrated Into Clinical Settings Using Existing Data: A Scoping Review

PURPOSE

Integrating social care into clinical care requires substantial resources. Use of existing data through a geographic information system (GIS) has the potential to support efficient and effective integration of social care into clinical settings. We conducted a scoping literature review characterizing its use in primary care settings to identify and address social risk factors.

METHODS

In December 2018, we searched 2 databases and extracted structured data for eligible articles that (1) described the use of GIS in clinical settings to identify and/or intervene on social risks, (2) were published between December 2013 and December 2018, and (3) were based in the United States. Additional studies were identified by examining references.

RESULTS

Of the 5,574 articles included for review, 18 met study eligibility criteria: 14 (78%) were descriptive studies, 3 (17%) tested an intervention, and 1 (6%) was a theoretical report. All studies used GIS to identify social risks (increase awareness); 3 studies (17%) described interventions to address social risks, primarily by identifying relevant community resources and aligning clinical services to patients' needs.

CONCLUSIONS

Most studies describe associations between GIS and population health outcomes; however, there is a paucity of literature regarding GIS use to identify and address social risk factors in clinical settings. GIS technology may assist health systems seeking to address population health outcomes through alignment and advocacy; its current application in clinical care delivery is infrequent and largely limited to referring patients to local community resources.

Measuring disparities in event-free survival among children with acute lymphoblastic leukemia in an academic institute in Oklahoma, 2005-2019

BACKGROUND

Acute lymphoblastic leukemia (ALL) is the most common type of childhood cancer. While there have been successes in the treatment of leukemia, less information is available on reasons for disparities in event-free survival (EFS) among underserved populations.

METHODS

We partnered with a children's hospital at an academic institution to abstract data from the institution's cancer registry, the state cancer registry, and electronic medical records on cancer diagnosis, treatment, and outcomes for children with ALL (n = 275) diagnosed from 2005 to 2019 prior to age 20. We evaluated the relation between 1) race/ethnicity, 2) distance to the children's hospital, and 3) area deprivation with EFS, defined as time from diagnosis to relapse, death, or the end of the study period. We evaluated differences in EFS using Kaplan-Meier analysis with the log-rank test. We used the Cox Proportional Hazards Model for multivariable survival analyses.

RESULTS

Most children were diagnosed with ALL under five years of age (45%) and with Pre-B ALL (87%). Twelve percent of children experienced a relapse and 5% died during induction or remission. EFS at 5 years was 82%. Non-Hispanic (NH) Black children had worse, though imprecise, EFS compared to NH White children (Adjusted Hazard Ratio: 2.07, 95% CI: 0.80, 5.38). Children residing in areas with higher deprivation had a higher adjusted hazard of poor outcomes compared to the least deprived areas, though estimates were imprecise (2nd quartile HR: 1.51, 3rd quartile: 1.85, 4th quartile: 1.62). We observed no association between distance to the children's hospital and EFS.

CONCLUSION

We observed poorer EFS for NH Black children and children residing in areas with high deprivation, though the estimates were not statistically significant. Our next steps include further evaluating socioeconomic factors in both rural and urban children to identify disparities in outcomes for children with ALL and other childhood cancers.

A Comparison of Young Adults With and Without Cancer in Concurrent Hospice Care: Implications for Transitioning to Adult Health Care

Purpose: Concurrent hospice care provides important end-of-life care for youth under 21 years. Those nearing 21 years must decide whether to shift to adult hospice or leave hospice for life-prolonging care. This decision may be challenging for young adults with cancer, given the intensity of oncology care. Yet, little is known about their needs. We compared young adults with and without cancer in concurrent hospice care. Methods: Retrospective comparative design used data from 2011 to 2013 U.S. Medicaid data files. Decedents were included if they were 20 years of age, enrolled in Medicaid hospice care, and used nonhospice medical services on the same day as hospice care based on their Medicaid claims activity dates. Results: Among 226 decedents, 21% had cancer; more than half were female (60.6%), Caucasian (53.5%), non-Hispanic (77.4%), urban dwelling (58%), and had mental/behavioral disorder (53%). Young adults with cancer were more often non-Caucasian (68.7% vs. 40.4%), technology dependent (47.9% vs. 24.2%), had comorbidities (83.3% vs. 30.3%), and lived in rural (58.3% vs. 37.6%), southern (41.7% vs. 20.8%) areas versus peers without cancer. Those with cancer had significantly fewer live discharges from hospice (5.7 vs. 17.3) and sought treatment for symptoms more often from nonhospice providers (35.4% vs. 14.0%). Conclusions: Young adults in concurrent hospice experience medical complexity, even at end-of-life. Understanding care accessed at 20 years helps providers guide young adults and families considering options in adult-focused care. Clinical and demographic differences among those with and without cancer in concurrent care highlight needs for research exploring racial and geographic equity.

Pediatric End-of-Life Care in Rural America: A Systematic Review

BACKGROUND

Families increasingly desire to bring their children home from the acute care setting at end of life. This transition includes home to rural or remote areas. Little is known about the end-of-life care for children who reside in rural areas.

OBJECTIVE

The purpose of this study was to comprehensively review and summarize the evidence regarding end-of-life care for children living in rural areas, identify key findings and gaps in the literature, and make recommendations for future research.

METHODS

A systematic review was conducted from 2011 to 2021 using MEDLINE and CINAHL databases.

RESULTS

Nine studies met inclusion criteria. Key themes from the literature included: barriers, facilitators, and needs. Three articles identified barriers to end-of-life care for children in rural communities, which included access to end-of-life care and clinicians trained to provide pediatric care. Three studies identified and evaluated the facilitators of end-of-life care for rural children. The articles identified technology and additional training as facilitators. Four studies reported on the needs of rural children for end-of-life care with serious illness.

CONCLUSIONS

We found major barriers and unmet needs in the delivery of rural pediatric end-of-life care. A few facilitators in delivery of this type of care were explored. Overall research in this area was sparse. Future studies should focus on understanding the complexities associated with delivery of pediatric end-of-life care in rural areas.

The Intersection of Rural Residence and Minority Race/Ethnicity in Cancer Disparities in the United States

One in every twenty-five persons in America is a racial/ethnic minority who lives in a rural area. Our objective was to summarize how racism and, subsequently, the social determinants of health disproportionately affect rural racial/ethnic minority populations, provide a review of the cancer disparities experienced by rural racial/ethnic minority groups, and recommend policy, research, and intervention approaches to reduce these disparities. We found that rural Black and American Indian/Alaska Native populations experience greater poverty and lack of access to care, which expose them to greater risk of developing cancer and experiencing poorer cancer outcomes in treatment and ultimately survival. There is a critical need for additional research to understand the disparities experienced by all rural racial/ethnic minority populations. We propose that policies aim to increase access to care and healthcare resources for these communities. Further, that observational and interventional research should more effectively address the intersections of rurality and race/ethnicity through reduced structural and interpersonal biases in cancer care, increased data access, more research on newer cancer screening and treatment modalities, and continued intervention and implementation research to understand how evidence-based practices can most effectively reduce disparities among these populations.

Rural dwellers are less likely to survive cancer - An international review and meta-analysis

BACKGROUND

Existing research from several countries has suggested that rural-dwellers may have poorer cancer survival than urban-dwellers. However, to date, the global literature has not been systematically reviewed to determine whether a rural cancer survival disadvantage is a global phenomenon.

METHODS

Medline, CINAHL, and EMBASE were searched for studies comparing rural and urban cancer survival. At least two authors independently screened and selected studies. We included epidemiological studies comparing cancer survival between urban and rural residents (however defined) that also took socioeconomic status into account. A meta-analysis was conducted using 11 studies with binary rural:urban classifications to determine the magnitude and direction of the association between rurality and differences in cancer survival. The mechanisms for urban-rural cancer survival differences reported were narratively synthesised in all 39 studies.

FINDINGS

39 studies were included in this review. All were retrospective observational studies conducted in developed countries. Rural-dwellers were significantly more likely to die when they developed cancer compared to urban-dwellers (HR 1.05 (95% CI 1.02 - 1.07). Potential mechanisms were aggregated into an ecological model under the following themes: Patient Level Characteristics; Institutions; Community, Culture and Environment; Policy and Service Organization.

INTERPRETATION

Rural residents were 5% less likely to survive cancer. This effect was consistently observed across studies conducted in various geographical regions and using multiple definitions of rurality. High quality mixed-methods research is required to comprehensively evaluate the underlying factors. We have proposed an ecological model to provide a coherent framework for future explanatory research.

FUNDING

None.

Temporal and geospatial trends of pediatric cancer incidence in Nebraska over a 24-year period

BACKGROUND

Data from the Surveillance, Epidemiology, and End Results (SEER) revealed that the incidence of pediatric cancer in Nebraska exceeded the national average during 2009-2013. Further investigation could help understand these patterns.

METHODS

This retrospective cohort study investigated pediatric cancer (0-19 years old) age adjusted incidence rates (AAR) in Nebraska using the Nebraska Cancer Registry. SEER AARs were also calculated as a proxy for pediatric cancer incidence in the United States (1990-2013) and compared to the Nebraska data. Geographic Information System (GIS) mapping was also used to display the spatial distribution of cancer in Nebraska at the county level. Finally, location-allocation analysis (LAA) was performed to identify a site for the placement of a medical center to best accommodate rural pediatric cancer cases.

RESULTS

The AAR of pediatric cancers was 173.3 per 1,000,000 in Nebraska compared to 167.1 per 1,000,000 in SEER. The AAR for lymphoma was significantly higher in Nebraska (28.1 vs. 24.6 per 1,000,000; p = 0.009). For the 15-19 age group, the AAR for the 3 most common pediatric cancers were higher in Nebraska (p < 0.05). Twenty-three counties located >2 h driving distance to care facilities showed at least a 10% higher incidence than the overall state AAR. GIS mapping identified a second potential treatment site that would alleviate this geographic burden.

CONCLUSIONS

Regional differences within Nebraska present a challenge for rural populations. Novel use of GIS mapping to highlight regional differences and identify solutions for access to care issues could be used by similar states.

A Scalable Field Study Protocol and Rationale for Passive Ambient Air Sampling: A Spatial Phytosampling for Leaf Data Collection

Stable, bioreactive, radicals known as environmentally persistent free radicals (EPFRs) have been found to exist on the surface of airborne PM2.5. These EPFRs have been found to form during many combustion processes, are present in vehicular exhaust, and persist in the environment for weeks and biological systems for up to 12 h. To measure EPFRs in PM samples, high volume samplers are required and measurements are less representative of community exposure; therefore, we developed a novel spatial phytosampling methodology to study the spatial patterns of EPFR concentrations using plants. Leaf samples for laboratory PM analysis were collected from 188 randomly drawn sampling sites within a 500-m buffer zone of pollution sources across a sampling grid measuring 32.9 × 28.4 km in Memphis, Tennessee. PM was isolated from the intact leaves and size fractionated, and EPFRs on PM quantified by electron paramagnetic resonance spectroscopy. The radical concentration was found to positively correlate with the EPFR g-value, thus indicating cumulative content of oxygen centered radicals in PM with higher EPFR load. Our spatial phytosampling approach reveals spatial variations and potential "hotspots" risk due to EPFR exposure across Memphis and provides valuable insights for identifying exposure and demographic differences for health studies.