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Karanth S, Mistry S, Wheeler M, Akinyemiju T, Divaker J, Yang JJ, Yoon HS, Braithwaite D. Persistent poverty disparities in incidence and outcomes among oral and pharynx cancer patients. Cancer Causes Control 2024; 35:1063-1073. [PMID: 38520565 PMCID: PMC11217118 DOI: 10.1007/s10552-024-01867-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/20/2024] [Indexed: 03/25/2024]
Abstract
PURPOSE Disparities in oral cavity and pharyngeal cancer based on race/ethnicity and socioeconomic status have been reported, but the impact of living within areas that are persistently poor at the time of diagnosis and outcome is unknown. This study aimed to investigate whether the incidence, 5-year relative survival, stage at diagnosis, and mortality among patients with oral cavity and pharyngeal cancers varied by persistent poverty. METHODS Data were drawn from the SEER database (2006-2017) and included individuals diagnosed with oral cavity and pharyngeal cancers. Persistent poverty (at census tract) is defined as areas where ≥ 20% of the population has lived below the poverty level for ~ 30 years. Age-adjusted incidence and 5-year survival rates were calculated. Multivariable logistic regression was used to estimate the association between persistent poverty and advanced stage cancer. Cumulative incidence and multivariable subdistribution hazard models were used to evaluate mortality risk. In addition, results were stratified by cancer primary site, sex, race/ethnicity, and rurality. RESULTS Of the 90,631 patients included in the analysis (61.7% < 65 years old, 71.6% males), 8.8% lived in persistent poverty. Compared to non-persistent poverty, patients in persistent poverty had higher incidence and lower 5-year survival rates. Throughout 10 years, the cumulative incidence of cancer death was greater in patients from persistent poverty and were more likely to present with advanced-stage cancer and higher mortality risk. In the stratified analysis by primary site, patients in persistent poverty with oropharyngeal, oral cavity, and nasopharyngeal cancers had an increased risk of mortality compared to the patients in non-persistent poverty. CONCLUSION This study found an association between oral cavity and pharyngeal cancer outcomes among patients in persistent poverty indicating a multidimensional strategy to improve survival.
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Affiliation(s)
- Shama Karanth
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.
- University of Florida Health Cancer Center, 2004 Mowry Road, Gainesville, FL, 32610, USA.
| | - Shilpi Mistry
- Department of Epidemiology, University of Florida College of Public Health and Health Professions, Gainesville, FL, USA
| | - Meghann Wheeler
- Department of Epidemiology, University of Florida College of Public Health and Health Professions, Gainesville, FL, USA
| | - Tomi Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Joel Divaker
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jae Jeong Yang
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Cancer Center, 2004 Mowry Road, Gainesville, FL, 32610, USA
| | - Hyung-Suk Yoon
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Cancer Center, 2004 Mowry Road, Gainesville, FL, 32610, USA
| | - Dejana Braithwaite
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Cancer Center, 2004 Mowry Road, Gainesville, FL, 32610, USA
- Department of Epidemiology, University of Florida College of Public Health and Health Professions, Gainesville, FL, USA
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Shaikh CF, Munir MM, Woldesenbet S, Endo Y, Azap L, Yang J, Katayama E, Dawood Z, Pawlik TM. Association of persistent poverty and U.S. News and World Report hospital rankings among patients undergoing major surgery. Am J Surg 2024; 228:11-19. [PMID: 37596185 DOI: 10.1016/j.amjsurg.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/27/2023] [Accepted: 08/06/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND We sought to determine the association of persistent poverty on patient outcomes relative to US News World Report (USNWR) rankings among individuals undergoing common major surgical procedures. METHODS Medicare beneficiaries who underwent AAA repair, CABG, colectomy, or lung resection were identified. Multivariable logistic regression was used to evaluate the relationship between care at USNWR hospitals, county-level duration of poverty (never-high poverty (NHP); intermittent high poverty (IHP): persistent-poverty (PP)) and 30-day mortality. RESULTS Among 916,164 beneficiaries, individuals residing in PP neighborhoods who received surgical care at ranked hospitals had lower risk-adjusted 30-day mortality (5.89% vs 8.89%; p < 0.001). On multivariable analysis, 30-day mortality was lower at ranked hospitals across all poverty categories with greatest decrease among patients from PP regions (NHP: OR-0.91, 95%CI0.87-0.95; IHP: OR-0.78, 95%CI0.69-0.88; PP: OR-0.69, 95%CI0.57-0.83; p < 0.001). CONCLUSION Receipt of surgical care at top-ranked hospitals was associated with improvement in postoperative mortality, especially among patients residing in persistent poverty..
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Affiliation(s)
- Chanza Fahim Shaikh
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lovette Azap
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jason Yang
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Erryk Katayama
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zaiba Dawood
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Papageorge MV, Woods AP, de Geus SWL, Ng SC, McAneny D, Tseng JF, Kenzik KM, Sachs TE. The Persistence of Poverty and its Impact on Cancer Diagnosis, Treatment and Survival. Ann Surg 2023; 277:995-1001. [PMID: 35796386 DOI: 10.1097/sla.0000000000005455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the effect of persistent poverty on the diagnosis, surgical resection and survival of patients with non-small cell lung (NSCLC), breast, and colorectal cancer. BACKGROUND Disparities in cancer outcomes exist in counties with high levels of poverty, defined as ≥20% of residents below the federal poverty level. Despite this well-established association, little is known about how the duration of poverty impacts cancer care and outcomes. One measure of poverty duration is that of "persistent poverty," defined as counties in high poverty since 1980. METHODS In this retrospective cohort study, patients with NSCLC, breast and colorectal cancer were identified from SEER (2012-2016). County-level poverty was obtained from the American Community Survey (1980-2015). Outcomes included advanced stage at diagnosis (stage III-IV), resection of localized disease (stage I-II) and cancer-specific survival. Hierarchical generalized linear models and accelerated failure time models with Weibull distribution were used, adjusted for patient-level covariates and region. RESULTS Overall, 522,514 patients were identified, of which 5.1% were in persistent poverty. Patients in persistent poverty were more likely to present with advanced disease [NSCLC odds ratio (OR): 1.12, 95% confidence interval (CI): 1.06-1.18; breast OR: 1.09, 95% CI: 1.02-1.17; colorectal OR: 1.00, 95% CI: 0.94-1.06], less likely to undergo surgery (NSCLC OR: 0.81, 95% CI: 0.73-0.90; breast OR: 0.82, 95% CI: 0.72-0.94; colorectal OR: 0.84, 95% CI: 0.70-1.00) and had increased cancer-specific mortality (NSCLC HR: 1.09, 95% CI: 1.06-1.13; breast HR: 1.18, 95% CI: 1.05-1.32; colorectal HR: 1.09, 95% CI: 1.03-1.17) as compared with those without poverty. These differences were observed to a lesser magnitude in counties with current, but not persistent, poverty and disappeared in counties no longer in poverty. CONCLUSIONS The duration of poverty has a direct impact on cancer-specific outcomes, with the greatest effect seen in persistent poverty and resolution of disparities when a county is no longer in poverty. Policy focused on directing resources to communities in persistent poverty may represent a possible strategy to reduce disparities in cancer care and outcomes.
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Affiliation(s)
- Marianna V Papageorge
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Alison P Woods
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Susanna W L de Geus
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Sing Chau Ng
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - David McAneny
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Jennifer F Tseng
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Kelly M Kenzik
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
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Hepatopancreaticobiliary cancer outcomes are associated with county-level duration of poverty. Surgery 2023; 173:1411-1418. [PMID: 36774319 DOI: 10.1016/j.surg.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/07/2023] [Accepted: 01/10/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Socioeconomic status can often dictate access to timely surgical care and postoperative outcomes. We sought to analyze the impact of county-level poverty duration on hepatopancreaticobiliary cancer outcomes. METHODS Patients diagnosed with hepatopancreaticobiliary cancer were identified from the Surveillance, Epidemiology, and End Results-Medicare 2010 to 2015 database linked with county-level poverty from the American Community Survey and the US Department of Agriculture between 1980 to 2010. Counties were categorized as never high-poverty, intermittent high-poverty, and persistent poverty. Hierarchical generalized linear models and accelerated failure time models with Weibull distribution were used to assess diagnosis, treatment, textbook outcomes, and survival. RESULTS Among 41,077 patients, 1,758 (4.3%) lived in persistent poverty. Counties exposed to greater durations of poverty had increased proportions of non-Hispanic Black patients (never high-poverty: 7.6%, intermittent high-poverty: 20.4%, persistent poverty: 23.2%), uninsured patients (never high-poverty: 0.5%, intermittent high-poverty: 0.5%, persistent poverty: 0.9%), and patients with a rural residence (never high-poverty: 0.6%, intermittent high-poverty: 2.4%, persistent poverty: 11.5%). Individuals residing in persistent poverty had lower odds of undergoing resection (odds ratio 0.82, 95% confidence interval 0.66-0.98), achieving textbook outcomes (odds ratio 0.54, 95% confidence interval 0.34-0.84), and increased cancer-specific mortality (hazard ratio 1.07, 95% CI 1.00-1.15) (all P < .05). Non-Hispanic Black patients were less likely to present with early-stage disease (odds ratio 0.86, 95% confidence interval 0.79-0.95) and undergo surgical treatment (odds ratio 0.58, 95% confidence interval 0.52-0.66) compared to non-Hispanic White patients (both P < .01). Notably, non-Hispanic White patients in persistent poverty were more likely to present with early-stage disease (odds ratio 1.30, 95% confidence interval 1.12-1.52) and undergo surgery for localized disease (odds ratio 1.36, 95% confidence interval 1.06-1.74) compared to non-Hispanic Black patients in never high-poverty (both P < .05). CONCLUSION Duration of poverty was associated with lower odds of receipt of surgical treatment, achievement of textbook outcomes, and worse cancer-specific survival. Non-Hispanic Black patients were at particular risk of suboptimal outcomes, highlighting the impact of structural racism independent of socioeconomic status.
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Moore JX, Andrzejak SE, Jones S, Han Y. Exploring the intersectionality of race/ethnicity with rurality on breast cancer outcomes: SEER analysis, 2000-2016. Breast Cancer Res Treat 2023; 197:633-645. [PMID: 36520228 PMCID: PMC9883364 DOI: 10.1007/s10549-022-06830-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/30/2022] [Indexed: 12/16/2022]
Abstract
PURPOSE Disparities in breast cancer survival have been observed within marginalized racial/ethnic groups and within the rural-urban continuum for decades. We examined whether there were differences among the intersectionality of race/ethnicity and rural residence on breast cancer outcomes. METHODS We performed a retrospective analysis among 739,448 breast cancer patients using Surveillance Epidemiology and End Results (SEER) 18 registries years 2000 through 2016. We conducted multilevel logistic-regression and Cox proportional hazards models to estimate adjusted odds ratios (AORs) and hazard ratios (AHRs), respectively, for breast cancer outcomes including surgical treatment, radiation therapy, chemotherapy, late-stage disease, and risk of breast cancer death. Rural was defined as 2013 Rural-Urban Continuum Codes (RUCC) of 4 or greater. RESULTS Compared with non-Hispanic white-urban (NH-white-U) women, NH-black-U, NH-black-rural (R), Hispanic-U, and Hispanic-R women, respectively, were at increased odds of no receipt of surgical treatment (NH-black-U, AOR = 1.98, 95% CI 1.91-2.05; NH-black-R, AOR = 1.72, 95% CI 1.52-1.94; Hispanic-U, AOR = 1.58, 95% CI 1.52-1.65; and Hispanic-R, AOR = 1.40, 95% CI 1.18-1.67), late-stage diagnosis (NH-black-U, AOR = 1.32, 95% CI 1.29-1.34; NH-black-R, AOR = 1.29, 95% CI 1.22-1.36; Hispanic-U, AOR = 1.25, 95% CI 1.23-1.27; and Hispanic-R, AOR = 1.17, 95% CI 1.08-1.27), and increased risks for breast cancer death (NH-black-U, AHR = 1.46, 95% CI 1.43-1.50; NH-black-R, AHR = 1.42, 95% CI 1.32-1.53; and Hispanic-U, AHR = 1.10, 95% CI 1.07-1.13). CONCLUSION Regardless of rurality, NH-black and Hispanic women had significantly increased odds of late-stage diagnosis, no receipt of treatment, and risk of breast cancer death.
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Affiliation(s)
- Justin Xavier Moore
- Cancer Prevention, Control, & Population Health, Medical College of Georgia, Georgia Cancer Center, Augusta University, Augusta, GA USA ,Institute of Preventive and Public Health, Medical College of Georgia, Augusta University, Augusta, GA USA ,Cancer Prevention, Control, & Population Health Program, Department of Medicine, Institute of Public and Preventive Health, Medical College of Georgia at Augusta University, 1410 Laney Walker Blvd. CN-2135, Augusta, GA 30912 USA
| | - Sydney Elizabeth Andrzejak
- Cancer Prevention, Control, & Population Health, Medical College of Georgia, Georgia Cancer Center, Augusta University, Augusta, GA USA
| | - Samantha Jones
- Cancer Prevention, Control, & Population Health, Medical College of Georgia, Georgia Cancer Center, Augusta University, Augusta, GA USA
| | - Yunan Han
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110 USA
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Jenkins WD, Rose J, Molina Y, Lee M, Bolinski R, Luckey G, Van Ham B. Cancer Screening among Rural People Who Use Drugs: Colliding Risks and Barriers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084555. [PMID: 35457423 PMCID: PMC9026855 DOI: 10.3390/ijerph19084555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 01/27/2023]
Abstract
Rural cancer disparities are associated with lesser healthcare access and screening adherence. The opioid epidemic may increase disparities as people who use drugs (PWUD) frequently experience healthcare-associated stigmatizing experiences which discourage seeking routine care. Rural PWUD were recruited to complete surveys and interviews exploring cancer (cervical, breast, colorectal, lung) risk, screening history, and healthcare experiences. From July 2020–July 2021 we collected 37 surveys and 8 interviews. Participants were 24.3% male, 86.5% White race, and had a mean age of 44.8 years. Females were less likely to report seeing a primary care provider on a regular basis, and more likely to report stigmatizing healthcare experiences. A majority of females reporting receiving recommendations and screens for cervical and breast cancer, but only a minority were adherent. Similarly, only a minority of males and females reported receiving screening tests for colorectal and lung cancer. Screening rates for all cancers were substantially below those for the US generally and rural areas specifically. Interviews confirmed stigmatizing healthcare experiences and suggested screening barriers and possible solutions. The opioid epidemic involves millions of individuals and is disproportionately experienced in rural communities. To avoid exacerbating existing rural cancer disparities, methods to engage PWUD in cancer screening need to be developed.
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Affiliation(s)
- Wiley D. Jenkins
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL 62794, USA;
- Correspondence:
| | - Jennifer Rose
- Department of Family and Community Medicine, Southern Illinois University School of Medicine, Carbondale, IL 62901, USA; (J.R.); (G.L.)
| | - Yamile Molina
- Division of Community Health Sciences, University of Illinois at Chicago School of Public Health, Chicago, IL 60612, USA;
| | - Minjee Lee
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL 62794, USA;
- Simons Cancer Institute, Southern Illinois University School of Medicine, Springfield, IL 62702, USA
| | - Rebecca Bolinski
- Department of Sociology, Southern Illinois University, Carbondale, IL 62901, USA;
| | - Georgia Luckey
- Department of Family and Community Medicine, Southern Illinois University School of Medicine, Carbondale, IL 62901, USA; (J.R.); (G.L.)
| | - Brent Van Ham
- Center for Rural Health and Social Services Development, Southern Illinois University, Carbondale, IL 62901, USA;
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Falk D, Cubbin C, Jones B. County-Level Poverty and Barriers to Breast and Cervical Cancer Screening in a Health Education and Patient Navigation Program for Rural and Border Texas Residents. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:421-429. [PMID: 32696337 PMCID: PMC7855227 DOI: 10.1007/s13187-020-01832-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
The study examined the impact of (1) county-level poverty rates and (2) patient navigation on breast and cervical cancer screening outcomes for women in rural and border counties in Texas reporting barriers to screening.Univariate analyses described the distribution and screening prevalence rates in the sample, while a series of random intercept logistic regression models analyzed mammogram (N = 2326 women aged 40+) and Papanicolaou (Pap; N = 2959 women aged 21-64) screening separately.Mammogram and Pap screening prevalence rates were highest among women who were aged 40-64, Spanish-speaking Latinas, lower educated, attending cancer education events because of the cost of the screenings, patient navigation recipients, living in the south region of Texas, and in counties with high poverty. Although models indicated significant variability in screening rates by county, county-level poverty was only significantly associated with odds of getting Pap screening in adjusted models. Not receiving patient navigation vs. receiving it was associated with lower odds for both mammogram (OR: 0.51, CI: 0.38-0.70) and Pap (OR: 0.69, CI: 0.50-0.94) screenings.County-level variation in screening rates exists for both mammogram and Pap tests and should be considered in the development and implementation of screening interventions in rural and border areas. However, other factors beyond poverty levels may explain the variation.
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Affiliation(s)
- Derek Falk
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Catherine Cubbin
- Steve Hicks School of Social Work, The University of Texas at Austin, 1 University Station D3500, Austin, TX, 78712, USA
| | - Barbara Jones
- Steve Hicks School of Social Work, The University of Texas at Austin, 1 University Station D3500, Austin, TX, 78712, USA
- Departments of Health Social Work, Oncology, Population Health, and Psychiatry, Dell Medical School, The University of Texas at Austin, 1 University Station D3500, Austin, TX, 78712, USA
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Agovino M, Cerciello M, Musella G. Campania and cancer mortality: An inseparable pair? The role of environmental quality and socio-economic deprivation. Soc Sci Med 2021; 287:114328. [PMID: 34482276 DOI: 10.1016/j.socscimed.2021.114328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 06/20/2021] [Accepted: 08/18/2021] [Indexed: 12/29/2022]
Abstract
The region of Campania in Southern Italy features high levels of socio-economic deprivation and low levels of environmental quality. A vast strand of the scientific literature has tried to verify whether poor environmental quality and widespread socio-economic deprivation might explain the high cancer mortality rates (CMRs) observed, especially in the municipalities - infamously labelled as the 'Land of Fires' - that were hit most severely by the crisis. While some studies managed to identify links between these two confounding factors and cancer mortality, the evidence is overall mixed. Interesting information may be drawn from the observation of municipal data: in spite of previous claims, some municipalities featuring high environmental quality and low socio-economic deprivation also display high CMRs, while other Campanian municipalities facing disastrous environmental and socio-economic conditions are characterised by low CMRs. These figures, in contrast to common sentiment and previous studies, need to be investigated thoroughly in order to assess the exact role of the confounding factors. In this work, we aim to identify the municipalities where confounding factors act as driving forces in the determination of high CMRs through an original multi-step analysis based on frequentist and Bayesian analysis. Pinpointing these municipalities could allow policymakers to design targeted and effective policy measures aimed at reducing cancer mortality.
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Affiliation(s)
- Massimiliano Agovino
- Department of Economic and Legal Studies, University of Naples "Parthenope", Naples, Italy.
| | - Massimiliano Cerciello
- Department of Economic and Legal Studies, University of Naples "Parthenope", Naples, Italy.
| | - Gaetano Musella
- Department of Management and Quantitative Studies, University of Naples "Parthenope", Naples, Italy.
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Kirubarajan A, Leung S, Li X, Yau M, Sobel M. Barriers and facilitators for cervical cancer screening among adolescents and young people: a systematic review. BMC Womens Health 2021; 21:122. [PMID: 33757512 PMCID: PMC7989022 DOI: 10.1186/s12905-021-01264-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 03/14/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Though cervical cancer is one of the leading causes of cancer-related death globally, its incidence is nearly entirely preventable. Young people have been an international priority for screening as this population has historically been under-screened. However, in both high-income and low-income countries, young people have not been screened appropriately according to country-specific guidelines. The aim of this systematic review was to systematically characterize the existing literature on barriers and facilitators for cervical cancer screening (CCS) among adolescents and young people globally. METHODS We conducted a systematic review following PRISMA guidelines of three key databases: Medline-OVID, EMBASE, and CINAHL. Supplementary searches were done through ClinicialTrials.Gov and Scopus. Databases were examined from 1946 until the date of our literature searches on March 12th 2020. We only examined original, peer-reviewed literature. Articles were excluded if they did not specifically discuss CCS, were not specific to individuals under the age of 35, or did not report outcomes or evaluation. All screening, extraction, and synthesis was completed in duplicate with two independent reviewers. Outcomes were summarized descriptively. Risk of bias for individual studies was graded using an adapted rating scale based on the Risk of Bias Instrument for Cross-Sectional Surveys of Attitudes and Practices. RESULTS Of the 2177 original database citations, we included 36 studies that met inclusion criteria. The 36 studies included a total of 14,362 participants, and around half (17/36, 47.2%) of studies specifically targeted students. The majority of studies (31/36, 86.1%) discussed barriers and facilitators to Pap testing specifically, while one study analyzed self-sampling (1/36, 2.8%), one study targeted HPV DNA testing (1/36, 2.8%), and the remainder (4/36, 11.1%) were not specified. Our systematic review found that there are three large categories of barriers for young people: lack of knowledge/awareness, negative perceptions of the test, and systemic barriers to testing. Facilitators included stronger relationships with healthcare providers, social norms, support from family, and self-efficacy. CONCLUSION There are unique barriers and facilitators that affect CCS rates in adolescents and young people. Health systems and healthcare providers worldwide should address the challenges for this unique population.
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Affiliation(s)
- Abirami Kirubarajan
- Faculty of Medicine, University of Toronto, 1 Kings College Circle, Medical Science Building, Toronto, ON, M5S 1A8, Canada.
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - Shannon Leung
- Faculty of Medicine, University of Toronto, 1 Kings College Circle, Medical Science Building, Toronto, ON, M5S 1A8, Canada
| | - Xinglin Li
- Faculty of Medicine, University of Toronto, 1 Kings College Circle, Medical Science Building, Toronto, ON, M5S 1A8, Canada
| | - Matthew Yau
- Faculty of Medicine, University of Toronto, 1 Kings College Circle, Medical Science Building, Toronto, ON, M5S 1A8, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Mara Sobel
- Department of Obstetrics and Gynecology, Sinai Health System, Toronto, ON, Canada
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The Intersection of Rural Residence and Minority Race/Ethnicity in Cancer Disparities in the United States. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041384. [PMID: 33546168 PMCID: PMC7913122 DOI: 10.3390/ijerph18041384] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 12/15/2022]
Abstract
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.
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11
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Moss JL, Pinto CN, Srinivasan S, Cronin KA, Croyle RT. Persistent Poverty and Cancer Mortality Rates: An Analysis of County-Level Poverty Designations. Cancer Epidemiol Biomarkers Prev 2020; 29:1949-1954. [PMID: 32998949 DOI: 10.1158/1055-9965.epi-20-0007] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/26/2020] [Accepted: 07/16/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cancer mortality is higher in counties with high levels of (current) poverty, but less is known about associations with persistent poverty. Persistent poverty counties (with ≥20% of residents in poverty since 1980) face social, structural, and behavioral challenges that may make their residents more vulnerable to cancer. METHODS We calculated 2007 to 2011 county-level, age-adjusted, and overall and type-specific cancer mortality rates (deaths/100,000 people/year) by persistent poverty classifications, which we contrasted with mortality in counties experiencing current poverty (≥20% of residents in poverty according to 2007-2011 American Community Survey). We used two-sample t tests and multivariate linear regression to assess mortality by persistent poverty, and compared mortality rates across current and persistent poverty levels. RESULTS Overall cancer mortality was 179.3 [standard error (SE) = 0.55] deaths/100,000 people/year in nonpersistent poverty counties and 201.3 (SE = 1.80) in persistent poverty counties (12.3% higher, P < 0.0001). In multivariate analysis, cancer mortality was higher in persistent poverty versus nonpersistent poverty counties for overall cancer mortality as well as for several type-specific mortality rates: lung and bronchus, colorectal, stomach, and liver and intrahepatic bile duct (all P < 0.05). Among counties experiencing current poverty, those counties that were also experiencing persistent poverty had elevated mortality rates for all cancer types as well as lung and bronchus, colorectal, breast, stomach, and liver and intrahepatic bile duct (all P < 0.05). CONCLUSIONS Cancer mortality was higher in persistent poverty counties than other counties, including those experiencing current poverty. IMPACT Etiologic research and interventions, including policies, are needed to address multilevel determinants of cancer disparities in persistent poverty counties.
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Affiliation(s)
- Jennifer L Moss
- National Cancer Institute, Bethesda, Maryland. .,Penn State College of Medicine, Hershey, Pennsylvania
| | - Casey N Pinto
- Penn State College of Medicine, Hershey, Pennsylvania
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12
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Hughes AE, Lee SC, Eberth JM, Berry E, Pruitt SL. Do mobile units contribute to spatial accessibility to mammography for uninsured women? Prev Med 2020; 138:106156. [PMID: 32473958 PMCID: PMC7388587 DOI: 10.1016/j.ypmed.2020.106156] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 03/18/2020] [Accepted: 05/24/2020] [Indexed: 10/24/2022]
Abstract
Limited spatial accessibility to mammography, and socioeconomic barriers (e.g., being uninsured), may contribute to rural disparities in breast cancer screening. Although mobile mammography may contribute to population-level access, few studies have investigated this relationship. We measured mammography access for uninsured women using the variable two-step floating catchment area (V2SFCA) method, which estimates access at the local level using estimated potential supply and demand. Specifically, we measured supply with mammography machine certifications in 2014 from FDA and brick-and-mortar and mobile facility data from the community-based Breast Screening and Patient Navigation (BSPAN) program. We measured potential demand using Census tract-level estimates of female residents aged 45-74 from 5-year 2012-2016 American Community Survey data. Using the sign test, we compared mammography access estimates based on 3 facility groupings: FDA-certified, program brick-and-mortar only, and brick-and-mortar plus mobile. Using all mammography facilities, accessibility was high in urban Dallas-Ft. Worth, low for the ring of adjacent counties, and high for rural counties outlying this ring. Brick-and-mortar-based estimates were lower for the outlying ring, and mobile-unit contribution to access was observed more in urban tracts. Weak mobile-unit contribution across the study area may indicate suboptimal dispatch of mobile units to locations. Geospatial methods could identify the optimal locations for mobile units, given existing brick-and-mortar facilities, to increase access for underserved areas.
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Affiliation(s)
- Amy E Hughes
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA; Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA.
| | - Simon C Lee
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA; Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA.
| | - Jan M Eberth
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
| | - Emily Berry
- Moncrief Cancer Center, Fort Worth, TX, USA.
| | - Sandi L Pruitt
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA; Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA.
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13
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Iacoviello L, Bonaccio M, de Gaetano G, Donati MB. Epidemiology of breast cancer, a paradigm of the "common soil" hypothesis. Semin Cancer Biol 2020; 72:4-10. [PMID: 32087245 DOI: 10.1016/j.semcancer.2020.02.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 02/07/2023]
Abstract
Breast cancer is the leading cause of death in women aged 20-50 years, with some geographical difference. The yearly incidence of the disease is increasing while the related mortality is steadily decreasing. Breast cancer is associated not only with specific hormones or factors related with reproduction, but mostly to more general environmental factors, linked to socioeconomic conditions and lifestyles (smoking, stress, physical exercise and particularly dietary habits). The latter, indeed, are risk factors or conditions common to hormone-dependent tumors and other chronic degenerative disorders, such as ischemic cardio cerebro-vascular and neuro-degenerative disease. Breast cancer can indeed be considered as a paradigm of the so-called "common soil" concept, according to which the above mentioned conditions, although having different clinical manifestations, share some pathogenetic mechanisms and risk factors and intermediate predisposing phenotypes (see Type2 diabetes, metabolic syndrome or obesity). In an epidemiological perspective, evidence has been accumulated on the common response of breast cancer and cardiovascular disorders to healthy lifestyles and in particular to the beneficial effects of a close adhesion to the Mediterranean dietary model. The latter would mainly be effective thanks to its anti-inflammatory properties, thus controlling the subclinical condition of low-grade inflammation, a common risk factor of all the "common soil" disorders. Results from the prospective cohort of the Moli-sani Study (nearly 25,000 adults from the general population of the Southern Italy region of Molise) are highly suggestive in this context. In a public health perspective, the "common soil" hypothesis may thus promote the application of preventive strategies, particularly targeting lifestyles, for a broad spectrum of widely prevalent disorders, ranging from breast cancer to myocardial infarction or cognitive impairment conditions.
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Affiliation(s)
- Licia Iacoviello
- Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli IS, Italy; Department of Medicine and Surgery, Research Center in Epidemiology and Preventive Medicine (EPIMED), University of Insubria, Varese-Como, Italy.
| | - Marialaura Bonaccio
- Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli IS, Italy
| | - Giovanni de Gaetano
- Department of Epidemiology and Prevention, IRCCS NEUROMED, Pozzilli IS, Italy
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14
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Zahnd WE, Askelson N, Vanderpool RC, Stradtman L, Edward J, Farris PE, Petermann V, Eberth JM. Challenges of using nationally representative, population-based surveys to assess rural cancer disparities. Prev Med 2019; 129S:105812. [PMID: 31422226 PMCID: PMC7289622 DOI: 10.1016/j.ypmed.2019.105812] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/08/2019] [Accepted: 08/14/2019] [Indexed: 12/16/2022]
Abstract
Population-based surveys provide important information about cancer-related health behaviors across the cancer care continuum, from prevention to survivorship, to inform cancer control efforts. These surveys can illuminate cancer disparities among specific populations, including rural communities. However, due to small rural sample sizes, varying sampling methods, and/or other study design or analytical concerns, there are challenges in using population-based surveys for rural cancer control research and practice. Our objective is three-fold. First, we examined the characterization of "rural" in four, population-based surveys commonly referenced in the literature: 1) Health Information National Trends Survey (HINTS); 2) National Health Interview Survey (NHIS); 3) Behavioral Risk Factor Surveillance System (BRFSS); and 4) Medical Expenditures Panel Survey (MEPS). Second, we identified and described the challenges of using these surveys in rural cancer studies. Third, we proposed solutions to address these challenges. We found that these surveys varied in use of rural-urban classifications, sampling methodology, and available cancer-related variables. Further, we found that accessibility of these data to non-federal researchers has changed over time. Survey data have become restricted based on small numbers (i.e., BRFSS) and have made rural-urban measures only available for analysis at Research Data Centers (i.e., NHIS and MEPS). Additionally, studies that used these surveys reported varying proportions of rural participants with noted limitations in sufficient representation of rural minorities and/or cancer survivors. In order to mitigate these challenges, we propose two solutions: 1) make rural-urban measures more accessible to non-federal researchers and 2) implement sampling approaches to oversample rural populations.
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Affiliation(s)
- Whitney E Zahnd
- Rural and Minority Health Research Center, Arnold School of Public Health, University of South Carolina, 220 Stoneridge Dr. Suite 204, Columbia, SC 29210, United States of America.
| | - Natoshia Askelson
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, United States of America.
| | - Robin C Vanderpool
- Department of Health, Behavior & Society, College of Public Health, University of Kentucky, 111 Washington Avenue, Lexington, KY 40536, United States of America.
| | - Lindsay Stradtman
- Department of Health, Behavior & Society, College of Public Health, University of Kentucky, 111 Washington Avenue, Lexington, KY 40536, United States of America.
| | - Jean Edward
- College of Nursing, University of Kentucky, 751 Rose Street, Lexington, KY 40536, United States of America.
| | - Paige E Farris
- OHSU-PSU School of Public Health, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, United States of America.
| | - Victoria Petermann
- School of Nursing, University of North Carolina at Chapel Hill, Carrington Hall Campus Box #7460, Chapel Hill, NC 27599-7460, United States of America.
| | - Jan M Eberth
- Rural and Minority Health Research Center, Arnold School of Public Health, University of South Carolina, 220 Stoneridge Dr. Suite 204, Columbia, SC 29210, United States of America; Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208, United States of America; Cancer Prevention and Control Program, University of South Carolina, 915 Greene Street, Columbia, SC 29208, United States of America.
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15
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Zahnd WE, McLafferty SL, Eberth JM. Multilevel analysis in rural cancer control: A conceptual framework and methodological implications. Prev Med 2019; 129S:105835. [PMID: 31520673 PMCID: PMC7136953 DOI: 10.1016/j.ypmed.2019.105835] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/19/2019] [Accepted: 09/06/2019] [Indexed: 12/22/2022]
Abstract
Rural populations experience a myriad of cancer disparities ranging from lower screening rates to higher cancer mortality rates. These disparities are due in part to individual-level characteristics like age and insurance status, but the physical and social context of rural residence also plays a role. Our objective was two-fold: 1) to develop a multilevel conceptual framework describing how rural residence and relevant micro, macro, and supra-macro factors can be considered in evaluating disparities across the cancer control continuum and 2) to outline the unique considerations of multilevel statistical modeling in rural cancer research. We drew upon several formative frameworks that address the cancer control continuum, population-level disparities, access to health care services, and social inequities. Micro-level factors comprised individual-level characteristics that either predispose or enable individuals to utilize health care services or that may affect their cancer risk. Macro-level factors included social context (e.g. domains of social inequity) and physical context (e.g. access to care). Rural-urban status was considered a macro-level construct spanning both social and physical context, as "rural" is often characterized by sociodemographic characteristics and distance to health care services. Supra-macro-level factors included policies and systems (e.g. public health policies) that may affect cancer disparities. Our conceptual framework can guide researchers in conceptualizing multilevel statistical models to evaluate the independent contributions of rural-urban status on cancer while accounting for important micro, macro, and supra-macro factors. Statistically, potential collinearity of multilevel model predictive variables, model structure, and spatial dependence should also be considered.
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Affiliation(s)
- Whitney E Zahnd
- Rural and Minority Health Research Center, Arnold School of Public Health, University of South Carolina, 220 Stoneridge Suite 204, Columbia, SC 29210, United States of America.
| | - Sara L McLafferty
- Department of Geography and Geographic Information Science, University of Illinois Urbana-Champaign, 1301 W. Green Street Urbana, IL 61801, United States of America.
| | - Jan M Eberth
- Rural and Minority Health Research Center, Arnold School of Public Health, University of South Carolina, 220 Stoneridge Suite 204, Columbia, SC 29210, United States of America; Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Columbia, SC 29208, United States of America; Cancer Prevention and Control Program, University of South Carolina, 915 Greene Street, Columbia, SC 29208, United States of America.
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16
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Abstract
Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data, available through 2015, were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data, available through 2016, were collected by the National Center for Health Statistics. In 2019, 1,762,450 new cancer cases and 606,880 cancer deaths are projected to occur in the United States. Over the past decade of data, the cancer incidence rate (2006-2015) was stable in women and declined by approximately 2% per year in men, whereas the cancer death rate (2007-2016) declined annually by 1.4% and 1.8%, respectively. The overall cancer death rate dropped continuously from 1991 to 2016 by a total of 27%, translating into approximately 2,629,200 fewer cancer deaths than would have been expected if death rates had remained at their peak. Although the racial gap in cancer mortality is slowly narrowing, socioeconomic inequalities are widening, with the most notable gaps for the most preventable cancers. For example, compared with the most affluent counties, mortality rates in the poorest counties were 2-fold higher for cervical cancer and 40% higher for male lung and liver cancers during 2012-2016. Some states are home to both the wealthiest and the poorest counties, suggesting the opportunity for more equitable dissemination of effective cancer prevention, early detection, and treatment strategies. A broader application of existing cancer control knowledge with an emphasis on disadvantaged groups would undoubtedly accelerate progress against cancer.
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Affiliation(s)
- Rebecca L Siegel
- Scientific Director, Surveillance Research, American Cancer Society, Atlanta, GA
| | - Kimberly D Miller
- Senior Associate Scientist, Surveillance Research, American Cancer Society, Atlanta, GA
| | - Ahmedin Jemal
- Scientific Vice President, Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
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17
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Wheeler DC, Czarnota J, Jones RM. Estimating an area-level socioeconomic status index and its association with colonoscopy screening adherence. PLoS One 2017; 12:e0179272. [PMID: 28594927 PMCID: PMC5464664 DOI: 10.1371/journal.pone.0179272] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 05/27/2017] [Indexed: 01/28/2023] Open
Abstract
Socioeconomic status (SES) is often considered a risk factor for health outcomes. SES is typically measured using individual variables of educational attainment, income, housing, and employment variables or a composite of these variables. Approaches to building the composite variable include using equal weights for each variable or estimating the weights with principal components analysis or factor analysis. However, these methods do not consider the relationship between the outcome and the SES variables when constructing the index. In this project, we used weighted quantile sum (WQS) regression to estimate an area-level SES index and its effect in a model of colonoscopy screening adherence in the Minnesota–Wisconsin Metropolitan Statistical Area. We considered several specifications of the SES index including using different spatial scales (e.g., census block group-level, tract-level) for the SES variables. We found a significant positive association (odds ratio = 1.17, 95% CI: 1.15–1.19) between the SES index and colonoscopy adherence in the best fitting model. The model with the best goodness-of-fit included a multi-scale SES index with 10 variables at the block group-level and one at the tract-level, with home ownership, race, and income among the most important variables. Contrary to previous index construction, our results were not consistent with an assumption of equal importance of variables in the SES index when explaining colonoscopy screening adherence. Our approach is applicable in any study where an SES index is considered as a variable in a regression model and the weights for the SES variables are not known in advance.
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Affiliation(s)
- David C. Wheeler
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, United States of America
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia, United States of America
- * E-mail:
| | - Jenna Czarnota
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - Resa M. Jones
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia, United States of America
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, United States of America
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18
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Abstract
PURPOSE Health services research often utilizes secondary data sources such as the Behavioral Risk Factor Surveillance System (BRFSS). Since 2006, the released BRFSS data do not include respondents who live in counties with 10,000 or fewer residents, and the CDC no longer offers the opportunity to access the unrestricted data set. As a result, rural residents can be underrepresented in BRFSS data after 2005. The purpose of this analysis is to examine the potential for bias introduced by rural underestimation. METHODS We utilized 6 BRFSS data sets; the 2005 full data and the 2005-2009 restricted data. We estimated population sizes for each survey year, and we compared these estimates to comparable data from the US Census intercensal estimates. We also compared estimates of preventive service utilization (mammography, Pap tests, colorectal cancer screening, and influenza vaccinations) between the two 2005 data versions. RESULTS Rural populations were underrepresented, particularly with the smaller counties excluded. Remote rural residents were the most consistently underrepresented. Preventive service delivery estimates differed between the full and restricted 2005 data versions. Mammography and Pap test estimates tended to be higher in the restricted data, while colorectal cancer screening and influenza vaccinations were similar or inconsistent. These results indicate that restricting by county size introduced bias in these estimates. CONCLUSIONS Having quality, nationally representative data is important to study disparities in service delivery. The potential bias introduced by the BRFSS county restriction may result in rural research being less effective for policy recommendations and interventions.
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Affiliation(s)
- Kevin J Bennett
- Department of Family and Preventive Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA.
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19
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Cole AM, Jackson JE, Doescher M. Colorectal Cancer Screening Disparities for Rural Minorities in the United States. J Prim Care Community Health 2012; 4:106-11. [DOI: 10.1177/2150131912463244] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Despite the existence of effective screening, colorectal cancer remains the second leading cause of cancer death in the United States. Adults living in rural areas and members of minority populations both experience disparities in colorectal cancer screening. Methods: Cross-sectional prevalence study of Behavioral Risk Factor Surveillance System from the Centers for Disease Control from 1998 to 2005. Primary outcome: Predicted probability of reporting timely colorectal cancer screening. Independent variables: rural residence, race/ethnicity. We adjusted for demographic and socioeconomic characteristics of respondents. Results: After adjustment rural non-Hispanic whites (44.3%), rural African American/blacks (44.8%), urban and rural Hispanic/Latinos (43.7% and 40.8%, respectively), urban and rural American Indian/Alaska Natives (45.8% and 46.8%), and urban and rural Asians (35.4% and 39.6%) had lower compared with urban non-Hispanic whites (49.5%; P < .05% for all comparisons). Urban Asians were least likely to report use of fecal occult blood testing (8.6%, 95% confidence interval = 6.3% to 10.9%) and rural Asians were least likely to report use of endoscopy screening (21.2%, 95% confidence interval = 16.2% to 26.2%). Discussion: Rural minorities may face different barriers to colorectal cancer screening than urban minorities or rural non-Hispanic whites. Further research to develop interventions to improve screening in these populations is warranted.
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