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Takashima A, Ishiguro M, Sasaki K, Machida R, Nagashima F, Imaizumi J, Hamaguchi T, Yamamoto Y, Masuishi T, Asayama M, Ueno H, Shinozaki K, Kudo T, Machida N, Matsuoka H, Ishida H, Yamaguchi T, Nogami H, Yamada T, Takegawa N, Kito Y, Tonoike Y, Sawada R, Tsukamoto S, Kanemitsu Y. Real-world treatment costs of first-line treatment for metastatic colorectal cancer: a survey of the JCOG colorectal cancer study group. Jpn J Clin Oncol 2024:hyae110. [PMID: 39210583 DOI: 10.1093/jjco/hyae110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 08/03/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Although treatment outcomes for metastatic colorectal cancer (mCRC) have dramatically improved over the past few decades, drug costs have also significantly increased. This study aimed to investigate which first-line treatment regimens for mCRC are actually used (frequency) in Japanese practice and at what cost. METHODS We collected data on patients with mCRC who received first-line treatment at 37 institutions of the Japan Clinical Oncology Group Colorectal Cancer Study Group from July 2021 to June 2022, and calculated the cost of regimens. The cost per month of each regimen was estimated based on standard usage, assuming a patient with a weight of 70 kg and a body surface area of 1.8 m2. We categorized the regimens into very high-cost (≥1 000 000 Japanese yen [JPY]/month), high-cost (≥500 000 JPY/month), and others (<500 000 JPY/month). RESULTS The study included 1880 participants, 24% of whom were ≥ 75 years. Molecular targeted containing regimens were received by 78% of the patients. The most frequently used regimen was the doublet regimen (fluoropyrimidine with either oxaliplatin or irinotecan) plus bevacizumab (43%), followed by doublet plus cetuximab or panitumumab (21%). The cost of molecular targeted drugs-containing regimens (ranging from 85 406 to 843 602 JPY/month) is much higher than that of only cytotoxic drug regimens (ranging from 17 672 to 51 004 JPY/month). About 16% received high-cost treatments that included panitumumab-containing regimens and pembrolizumab (17% of patients aged ≤74 years and 11% of patients aged ≥75 years). CONCLUSION About 16% of mCRC patients received first-line treatment with regimens costing >500 000JPY/month, and molecular targeted drugs being the main drivers of cost.
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Affiliation(s)
- Atsuo Takashima
- Division of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Megumi Ishiguro
- Health Science Research & Development Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keita Sasaki
- Japan Clinical Oncology Group Data Center /Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Ryunosuke Machida
- Japan Clinical Oncology Group Data Center /Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Fumio Nagashima
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Jun Imaizumi
- Department of Gastroenterological Surgery, Gunma Prefectural Cancer Center, Gunma, Japan
| | - Tetsuya Hamaguchi
- Department of Gastroenterological Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yoshiyuki Yamamoto
- Department of Gastroenterology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Toshiki Masuishi
- Department of Clinical Oncology, Aichi Cancer Center Hospital, Aichi, Japan
| | - Masako Asayama
- Department of Gastroenterology, Saitama Cancer Center, Saitama, Japan
| | - Hideki Ueno
- Department of Surgery, National Defense Medical College, Saitama, Japan
| | - Katsunori Shinozaki
- Division of Clinical Oncology, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Toshihiro Kudo
- Department of Medical Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Nozomu Machida
- Department of Gastroenterology, Kanagawa Cancer Center, Yokohama, Japan
| | - Hiroshi Matsuoka
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hideyuki Ishida
- Department of Pathology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Toshifumi Yamaguchi
- Cancer Chemotherapy Center, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Hitoshi Nogami
- Department of Surgery, Niigata Cancer Center Hospital, Niigata, Japan
| | - Takeshi Yamada
- Department of Gastroenterological Surgery, Nippon Medical School, Tokyo, Japan
| | - Naoki Takegawa
- Department of Gastroenterology, Hyogo Cancer Center, Akashi, Hyogo, Japan
| | - Yosuke Kito
- Department of Medical Oncology, Ishikawa Prefectural Central Hospital, Ishikawa, Japan
| | - Yuko Tonoike
- Department of Medical Oncology, Nagaoka Chuo General Hospital, Niigata, Japan
| | - Ryoichi Sawada
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Tsukamoto
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Center Hospital, Tokyo, Japan
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Lawler T, Parlato L, Warren Andersen S. Racial disparities in colorectal cancer clinicopathological and molecular tumor characteristics: a systematic review. Cancer Causes Control 2024; 35:223-239. [PMID: 37688643 PMCID: PMC11090693 DOI: 10.1007/s10552-023-01783-y] [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: 03/21/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023]
Abstract
PURPOSE African Americans have the highest colorectal cancer (CRC) mortality of all racial groups in the USA, which may relate to differences in healthcare access or advanced stage at diagnosis. Recent evidence indicates that differences in tumor characteristics may also underlie disparities in mortality. To highlight recent findings and areas for investigation, we completed the first systematic review of racial disparities in CRC tumor prognostic markers, including clinicopathological markers, microsatellite instability (MSI), oncogene mutations, and novel markers, including cancer stem cells and immune markers. METHODS Relevant studies were identified via PubMed, limited to original research published within the last 10 years. Ninety-six articles were identified that compared the prevalence of mortality-related CRC tumor characteristics in African Americans (or other African ancestry populations) to White cases. RESULTS Tumors from African ancestry cases are approximately 10% more likely to contain mutations in KRAS, which confer elevated mortality and resistance to epidermal growth factor receptor inhibition. Conversely, African Americans have approximately 50% lower odds for BRAF-mutant tumors, which occur less frequently but have similar effects on mortality and therapeutic resistance. There is less consistent evidence supporting disparities in mutations for other oncogenes, including PIK3CA, TP53, APC, NRAS, HER2, and PTEN, although higher rates of PIK3CA mutations and lower prevalence of MSI status for African ancestry cases are supported by recent evidence. Although emerging evidence suggests that immune markers reflecting anti-tumor immunity in the tumor microenvironment may be lower for African American cases, there is insufficient evidence to evaluate disparities in other novel markers, cancer stem cells, microRNAs, and the consensus molecular subtypes. CONCLUSION Higher rates of KRAS-mutant tumors in in African Americans may contribute to disparities in CRC mortality. Additional work is required to understand whether emerging markers, including immune cells, underlie the elevated CRC mortality observed for African Americans.
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Affiliation(s)
- Thomas Lawler
- Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Lisa Parlato
- School of Medicine and Public Health, Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Shaneda Warren Andersen
- Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA.
- School of Medicine and Public Health, Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA.
- University of Wisconsin-Madison, Suite 1007B, WARF, 610 Walnut Street, Madison, WI, 53726, USA.
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Reif de Paula T, Keller DS. A national evaluation of adjuvant chemotherapy in pT4N0M0 colon cancer from the National Cancer Database. J Natl Cancer Inst 2023; 115:1616-1625. [PMID: 37584736 DOI: 10.1093/jnci/djad164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/24/2023] [Accepted: 08/13/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND T stage is a prognostic biomarker for overall survival in colon cancer and pathologic T4 disease is a high-risk characteristic. Adjuvant chemotherapy is recommended to improve overall survival in pT4N0M0, but compliance with guidelines is unknown. We aimed to evaluate adjuvant chemotherapy use and impact on overall survival in pT4N0M0 colon cancer. METHODS The National Cancer Database was reviewed for pT4N0M0 colon adenocarcinomas undergoing curative surgical resection (2010-2017). Cases were stratified into no adjuvant chemotherapy and adjuvant chemotherapy cohorts. Moderated multiple regression assessed factors associated with no AC. Kaplan-Meier and Cox regression assessed overall survival in propensity-score matched cohorts. The main outcome measures were adjuvant chemotherapy use, factors associated with adjuvant chemotherapy, and impact on overall survival. RESULTS Of 11 847 cases, 62.4% (n = 7391) received no adjuvant chemotherapy. With private insurance, comorbidities or income do not affect adjuvant chemotherapy use. Medicare cases with a Charlson-Deyo comorbidity index of 0 (odds ratio [OR] = 0.861, 95% confidence interval [CI] = 0.760 to 0.975; P = .019) and Medicare payors with high income (OR = 0.813, 95% CI = 0.690 to 0.959; P = .014) were associated with adjuvant chemotherapy. Medicaid Charlson-Deyo comorbidity index 0 (OR = 1.374, 95% CI = 1.125 to 1.679; P = .002) and uninsured Charlson-Deyo comorbidity index 0 (OR = 1.351, 95% CI = 1.120 to 1.629; P = .002) were associated with no adjuvant chemotherapy. Adjuvant chemotherapy was associated with improved 5-year overall survival (71.7% vs 56.4%; P < .001; adjusted hazard ratio = 0.543, 95% CI = 0.499 to 0.590; P < .001). CONCLUSION Although adjuvant chemotherapy is associated with improved overall survival, compliance is low. There is a complex relationship between payor, income, comorbidity, and adjuvant chemotherapy receipt. Medicare patients with no comorbidities or higher income have better adjuvant chemotherapy use. With private insurance, adjuvant chemotherapy compliance is not affected by comorbidities or income, whereas Medicaid and uninsured patients with no comorbidities have poor compliance. Future work could target these disparities for equitable care.
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Affiliation(s)
- Thais Reif de Paula
- Lankenau Institute for Medical Research, Lankenau Medical Center, Wynnewood, PA, USA
| | - Deborah S Keller
- Lankenau Institute for Medical Research, Lankenau Medical Center, Wynnewood, PA, USA
- Department of Surgery, Lankenau Medical Center, Marks Colorectal Surgical Associates, Wynnewood, PA, 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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Hamad A, Eskander MF, Shen C, Bhattacharyya O, Fisher JL, Oppong BA, Obeng-Gyasi S, Tsung A. In search of lost time: Delays in adjuvant therapy for pancreatic adenocarcinoma among under-resourced patient populations. Surgery 2022; 172:982-988. [PMID: 35595567 DOI: 10.1016/j.surg.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The initiation of adjuvant chemotherapy for pancreatic adenocarcinoma within 12 weeks after surgery is recommended by the National Comprehensive Cancer Network. This study seeks to identify factors associated with delayed adjuvant chemotherapy and whether delays impact survival in under-resourced populations. METHODS Patients with nonmetastatic pancreatic adenocarcinoma who received a definitive resection followed by adjuvant chemotherapy between 2006 and 2017 were queried from the National Cancer Database. Multivariate logistic regression models were constructed to determine the relationship between socioeconomic/clinical variables and delayed adjuvant chemotherapy. Kaplan Meier curves compared survival between under-resourced patients receiving delayed versus timely adjuvant chemotherapy. RESULTS Among 25,008 patients, timely adjuvant chemotherapy varied by stage (stage 1: 67.9% vs stage 2: 75.8% vs stage 3: 89.2%; P < .001). Older age (odds ratio 1.02, 95% confidence interval 1.02-1.03; P < .001), Non-Hispanic Black race (odds ratio 1.25, 95% confidence interval 1.11-1.41; P < .001), increasing comorbidity score (odds ratio 1.18, 95% confidence interval 1.12-1.23; P < .001), 30-day readmission (odds ratio 1.45, 95% confidence interval 1.28-1.63; P < .001), and undergoing a Whipple (odds ratio 1.30, 95% confidence interval 1.16-1.44; P < .001) were associated with delayed adjuvant chemotherapy. Conversely, the highest neighborhood median income quartile (odds ratio 0.84, 95% confidence interval 0.73-0.97; P = .021), private insurance (odds ratio 0.59, 95% confidence interval 0.46-0.76; P < .001), Medicare (odds ratio 0.68, 95% confidence interval 0.52-0.88; P = .003), and receipt of neoadjuvant therapy (odds ratio 0.05, 95% confidence interval 0.04-0.06; P < .001) were associated with timely adjuvant chemotherapy. Non-Hispanic Black patients and patients with the lowest neighborhood education had worse overall survival when receiving delayed versus timely adjuvant chemotherapy. CONCLUSION Timely adjuvant chemotherapy for pancreatic adenocarcinoma was only achieved in 73.3% of patients. Age, race, comorbidities, median income, and insurance were identified as barriers. Delayed adjuvant chemotherapy was associated with worse survival among under-resourced populations.
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Affiliation(s)
- Ahmad Hamad
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH. https://twitter.com/ahmadhamad4
| | - Mariam F Eskander
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH; Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ. https://twitter.com/mariameskmd
| | - Chengli Shen
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | | | - James L Fisher
- The Ohio State University College of Medicine, Columbus, OH
| | - Bridget A Oppong
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH. https://twitter.com/mdBridget
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH. https://twitter.com/GyasiSamilia
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH.
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6
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Bui A, Yang L, Soroudi C, May FP. Racial and ethnic disparities in incidence and mortality for the five most common gastrointestinal cancers in the United States. J Natl Med Assoc 2022; 114:426-429. [PMID: 35525822 DOI: 10.1016/j.jnma.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/01/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Gastrointestinal cancers account for a significant burden of cancers in the United States. We sought to measure relative incidence of and mortality from the five most common gastrointestinal malignancies by race and ethnicity. METHODS We used data from the National Cancer Institute Surveillance, Epidemiology, and End Results Cancer Registry and the National Center for Health Statistics to calculate incidence and mortality rates for colorectal, pancreatic, liver, esophageal, and gastric cancer from 2013 to 2017 (incidence) and 2014 to 2018 (mortality). We then calculated incidence and mortality rate ratios, comparing each racial/ethnic group (non-Hispanic Black, non-Hispanic Asian/Pacific Islander, non-Hispanic American Indian/Alaska Native, and Hispanic) to non-Hispanic White. RESULTS Colorectal cancer had highest overall incidence and mortality. When compared to non-Hispanic White individuals, all other racial/ethnic groups had significantly higher incidence of liver and gastric cancer but lower incidence of esophageal cancer. Non-Hispanic Black individuals had higher incidence of colorectal and pancreatic cancer than non-Hispanic White individuals, while Hispanic and non-Hispanic Asian/Pacific Island individuals had lower incidence of these two cancers compared to non-Hispanic White individuals. Disparity patterns were similar for mortality. CONCLUSIONS Liver and gastric cancer have the greatest differences in incidence and mortality by race/ethnicity. Non-Hispanic Black individuals carry the highest burden of gastrointestinal malignancies overall.
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Affiliation(s)
- Aileen Bui
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles. 100 Medical Plaza Driveway, 90095, Los Angeles, CA, USA
| | - Liu Yang
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles. 100 Medical Plaza Driveway, 90095, Los Angeles, CA, USA
| | - Camille Soroudi
- The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles. 100 Medical Plaza Driveway, 90095, Los Angeles, CA, USA
| | - Folasade P May
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles. 100 Medical Plaza Driveway, 90095, Los Angeles, CA, USA; The Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles. 100 Medical Plaza Driveway, 90095, Los Angeles, CA, USA; UCLA Kaiser Permanente Center for Health Equity, Jonsson Comprehensive Cancer Center, University of California, Los Angeles. 650 Charles E Young Dr S, 90095, Los Angeles, CA, USA; Division of Gastroenterology, Department of Medicine, VA Greater Los Angeles Healthcare System. 11301 Wilshire Blvd, 90095, Los Angeles, CA, USA.
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Hao S, Parikh AA, Snyder RA. Racial Disparities in the Management of Locoregional Colorectal Cancer. Surg Oncol Clin N Am 2021; 31:65-79. [PMID: 34776065 DOI: 10.1016/j.soc.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Racial disparities pervade nearly all aspects of management of locoregional colorectal cancer, including time to treatment, receipt of resection, adequacy of resection, postoperative complications, and receipt of neoadjuvant and adjuvant multimodality therapies. Disparate gaps in treatment translate into enduring effects on survivorship, recurrence, and mortality. Efforts to reduce these gaps in care must be undertaken on a multilevel basis and focus on modifiable factors that underlie racial disparity.
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Affiliation(s)
- Scarlett Hao
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA
| | - Alexander A Parikh
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA
| | - Rebecca A Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Surgical Oncology Suite, 4S-24, Greenville, NC 27834, USA.
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8
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Application of smart nanoparticles as a potential platform for effective colorectal cancer therapy. Coord Chem Rev 2021. [DOI: 10.1016/j.ccr.2021.213949] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Davis RE, Trickey AW, Abrahamse P, Kato I, Ward K, Morris AM. Association of Cumulative Social Risk and Social Support With Receipt of Chemotherapy Among Patients With Advanced Colorectal Cancer. JAMA Netw Open 2021; 4:e2113533. [PMID: 34106262 PMCID: PMC8190628 DOI: 10.1001/jamanetworkopen.2021.13533] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Approximately 38% of patients with advanced colorectal cancer do not receive chemotherapy. OBJECTIVE To determine whether cumulative social risk (ie, multiple co-occurring sociodemographic risk factors) is associated with lower receipt of chemotherapy among patients with advanced colorectal cancer and whether social support would moderate this association. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional, population-based, mailed survey study was conducted from 2012 to 2014. Participants were recruited between 2011 and 2014 from all adults within 1 year after diagnosis of stage III colorectal cancer in the Detroit, Michigan, and State of Georgia Surveillance, Epidemiology, End-Results cancer registries. Patients were eligible if they were aged 18 years or older, had undergone surgery 4 or more months ago, did not have stage IV cancer, and resided in the registry catchment areas. Data analyses were conducted from March 2017 to April 2021. MAIN OUTCOMES AND MEASURES The primary outcome was receipt of chemotherapy. Cumulative social risk represented a sum of 8 risk factors with the potential to drain resources from participants' cancer treatment (marital status, employment, annual income, health insurance, comorbidities, health literacy, adult caregiving, and perceived discrimination). Social support was operationalized as emotional support related to colorectal cancer diagnosis. RESULTS Surveys were mailed to 1909 eligible patients; 1301 completed the survey (response rate, 68%). A total of 1087 participants with complete data for key variables were included in the sample (503 women [46%]; mean [SD] age, 64 [13] years). Participants with 3 or more risk factors were less likely to receive chemotherapy than participants with 0 risk factors (3 factors, odds ratio [OR], 0.48 [95% CI, 0.26-0.87]; 4 factors, OR, 0.41 [95% CI, 0.21-0.78]; 5 factors, OR, 0.42 [95% CI, 0.20-0.87]; ≥6 factors, OR, 0.22 [95% CI, 0.09-0.55]). Participants with 2 or more support sources had higher odds of undergoing chemotherapy than those without social support (2 sources, OR, 3.05 [95% CI, 1.36-6.85]; 3 sources, OR, 3.24 [95% CI, 1.48-7.08]; 4 sources, OR, 3.69 [95% CI, 1.71-7.97]; 5 sources, OR, 4.40 [95% CI, 1.98-9.75]; ≥6 sources, OR 5.95 [95% CI, 2.58-13.74]). Within each social support level, participants were less likely to receive chemotherapy as cumulative social risk increased. CONCLUSIONS AND RELEVANCE Cumulative social risk was associated with reduced receipt of chemotherapy. These associations were mitigated by social support. Assessing cumulative social risk may identify patients with colorectal cancer who are at higher risk for omitting chemotherapy who can be targeted for support programs to address social disadvantage and increase social support.
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Affiliation(s)
- Rachel E. Davis
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia
| | - Amber W. Trickey
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Paul Abrahamse
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Ikuko Kato
- Department of Pathology, Karmanos Cancer Institute, Wayne State University, Michigan
| | - Kevin Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Arden M. Morris
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
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Snyder RA, Wardrop R, McLain AC, Parikh AA, Cass AL. Association of Patient Experience With Guideline-Concordant Colon Cancer Treatment in the Elderly. JCO Oncol Pract 2021; 17:e753-e763. [PMID: 33566681 DOI: 10.1200/op.20.00626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE The association between patient-reported experience of care and care quality is not well described. The purpose of this study was to assess the relationship between the patient-reported experience and receipt of guideline-concordant colon cancer (CC) treatment. METHODS Medicare beneficiaries with resected stage I-III CC (2003-2013) were identified in the linked SEER Consumer Assessment of Healthcare Providers and Systems data set. Patient-reported scores were compared by receipt of guideline concordant care (GCC) (resection of ≥ 12 lymph nodes [stage I-III] and adjuvant chemotherapy [stage III]). Linear mixed-effects regression was performed to compare adjusted mean patient experience scores by GCC. RESULTS Of the 1,010 identified patients, 58.4% of stage I (n = 192/329) and 73.4% of stage II (n = 298/406) patients underwent resection of ≥ 12 LN. Among stage III patients, 76.0% (n = 209/275) underwent resection of ≥ 12 lymph node and 52.4% (n = 144/275) received adjuvant chemotherapy. By multivariable analysis, patient-reported scores of healthcare quality, physicians, physician communication, getting needed care, and getting care quickly were similar among patients who received GCC compared with those who did not. However, mean scores of overall healthcare quality (91.3 v 82.4, P = .0004) and getting needed care (92.8 v 86.8, P = .047) were higher among stage III patients who received GCC compared with those who did not. CONCLUSION Patient-reported scores of healthcare quality and ability to get needed care are associated with GCC among elderly patients with stage III CC. Further investigation is needed to determine whether patient-reported experience correlates with other clinical measures of quality of CC care.
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Affiliation(s)
- Rebecca A Snyder
- Department of Surgery, University of South Carolina School of Medicine - Greenville/Prisma Health, Greenville, SC.,Now with the Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC.,Now with the Department of Public Health, Brody School of Medicine, East Carolina University, Greenville, NC
| | - Rebecca Wardrop
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Alexander C McLain
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Alexander A Parikh
- Department of Surgery, University of South Carolina School of Medicine - Greenville/Prisma Health, Greenville, SC.,Now with the Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC
| | - Anna L Cass
- Department of Health Sciences, Furman University, Greenville, SC
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Merchant SJ, Kong W, Gyawali B, Hanna TP, Chung W, Nanji S, Patel SV, Booth CM. First-Line Palliative Chemotherapy for Esophageal and Gastric Cancer: Practice Patterns and Outcomes in the General Population. JCO Oncol Pract 2021; 17:e1537-e1550. [PMID: 33449833 DOI: 10.1200/op.20.00397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Clinical trials have shown that palliative chemotherapy (PC) improves survival in patients with incurable esophageal and gastric cancer; however, outcomes achieved in routine practice are unknown. We describe treatment patterns and outcomes among patients treated in the general population of Ontario, Canada. METHODS The Ontario Cancer Registry was used to identify patients with esophageal or gastric cancer from 2007 to 2016, and data were linked to other health administrative databases. Patients who received curative-intent surgery or radiotherapy were excluded. Factors associated with the receipt of PC were determined using logistic regression. First-line PC regimens were categorized, and trends over time were reported. Survival was determined using the Kaplan-Meier method. RESULTS The cohort included 9,848 patients; 22% (2,207 of 9,848) received PC. Patients receiving PC were younger (mean age, 63 v 74 years; P < .0001) and more likely male (71% v 65%; P < .0001). Thirty-seven percent of non-PC patients saw a medical oncologist in consultation. Over the study period, utilization of PC increased (from 11% in 2007 to 19% in 2016; P < .0001), whereas the proportion of patients receiving triplet regimens decreased (65% in 2007 to 56% in 2016; P = .04). In the PC group, the median overall and cancer-specific survival from treatment initiation was 7.2 months. CONCLUSION One fifth of patients with incurable esophageal and gastric cancer in the general population receive PC. Median survival of patients treated in routine practice is inferior to that in clinical trials. Only one third of patients not treated with PC had consultation with a medical oncologist. Further work is necessary to understand low utilization of PC and medical oncology consultation in this patient population.
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Affiliation(s)
- Shaila J Merchant
- Department of Surgery, Queen's University, Kingston, Ontario, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
| | - Weidong Kong
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Timothy P Hanna
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Wiley Chung
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Sulaiman Nanji
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Sunil V Patel
- Department of Surgery, Queen's University, Kingston, Ontario, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada
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12
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El-Sharkawy F, Gushchin V, Plerhoples TA, Liu C, Emery EL, Collins DT, Bijelic L. Minimally invasive surgery for T4 colon cancer is associated with better outcomes compared to open surgery in the National Cancer Database. Eur J Surg Oncol 2020; 47:818-827. [PMID: 32951935 DOI: 10.1016/j.ejso.2020.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/26/2020] [Accepted: 09/01/2020] [Indexed: 01/02/2023] Open
Abstract
Minimally invasive surgery (MIS) is favored for T1-T3 colon cancer resection due to improved short and long-term outcomes. Recommendations regarding T4 cancers remain controversial due to a paucity of clinical trials or large datasets assessing outcomes. We aim to compare outcomes for pT4 colon cancer patients treated with MIS or open surgery (OS) in the National Cancer Database (NCDB). We analyzed adults having MIS or OS for stage II or III pT4 colon cancers between 2010 and 2014 using propensity-score matching, Cox and logistic regression modeling. Of 21 998 T4 patients, 7532 (34.2%) underwent MIS, 14 466 (65.8%) OS and 22.3% were MIS converted to OS. After propensity score matching, 5624 patients in each cohort were included. MIS was associated with improved postoperative mortality (3.4 vs. 7.2%, p > .001), surgical margins, optimal lymph node harvest, adjuvant chemotherapy use and 5-year survival (46% vs. 41%, P < .001). MIS was associated with improved short and long term outcomes for T4 colon cancers compared to OS on multivariate analysis. Based on these findings, well selected pT4 colon cancers can be considered appropriate for MIS however, prospective clinical trials are needed to better define the role of MIS in T4b colon cancer.
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Affiliation(s)
- Farah El-Sharkawy
- Department of Surgical Oncology, Mercy Medical Center, Baltimore, MD, USA
| | - Vadim Gushchin
- Department of Surgical Oncology, Mercy Medical Center, Baltimore, MD, USA
| | | | - Chang Liu
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Erica L Emery
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Devon T Collins
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Lana Bijelic
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA, USA; Inova Schar Cancer Institute, Falls Church, VA, USA.
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13
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Chow Z, Gan T, Chen Q, Huang B, Schoenberg N, Dignan M, Evers BM, Bhakta AS. Nonadherence to Standard of Care for Locally Advanced Colon Cancer as a Contributory Factor for High Mortality Rates in Kentucky. J Am Coll Surg 2020; 230:428-439. [PMID: 32062006 DOI: 10.1016/j.jamcollsurg.2019.12.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Kentucky has one of the highest mortality rates for colon cancer, despite dramatic improvements in screening. The National Comprehensive Cancer Network (NCCN) guidelines recommend operation and adjuvant chemotherapy for locally advanced (stage IIb/c and stage III) colon cancer (LACC). The purpose of this study was to determine the rate of nonadherence with current standard of care (SOC) and associated factors as possible contributors to mortality. METHODS The Kentucky Cancer Registry database linked with administrative health claims was queried for individuals (20 years and older) diagnosed with LACC from 2007 to 2012. Bivariate and logistic regression of nonadherence was performed. Survival analysis was performed with Cox regression and Kaplan-Meier plots. RESULTS A total of 1,404 patients with LACC were included. Approximately 42% of patients with LACC were noted to be nonadherent to SOC, with nearly all (95.7%) failing to receive adjuvant chemotherapy. After adjusting for all significant factors, we found the factors associated with nonadherence included the following: age older than 75 years, stage III colon cancer, high Charlson Comorbidity Index (3+), low poverty level, Medicaid coverage, and disability. Adherence to SOC is associated with a significant improvement in the 5-year survival rate compared with nonadherence (63.0% and 27.4%, respectively; p < 0.0001). CONCLUSIONS Our study identified multiple factors associated with the failure of patients with LACC to receive SOC, particularly adjuvant chemotherapy, suggesting the need to focus on improving adjuvant chemotherapy compliance in specific populations. Nonadherence to LACC SOC is likely a major contributor to the persistently high mortality rates in Kentucky.
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Affiliation(s)
- Zeta Chow
- Department of Surgery, University of Kentucky Medical Center, Lexington, KY; Markey Cancer Center, University of Kentucky Medical Center, Lexington, KY
| | - Tong Gan
- Department of Surgery, University of Kentucky Medical Center, Lexington, KY; Markey Cancer Center, University of Kentucky Medical Center, Lexington, KY
| | - Quan Chen
- Markey Cancer Center, University of Kentucky Medical Center, Lexington, KY
| | - Bin Huang
- Markey Cancer Center, University of Kentucky Medical Center, Lexington, KY
| | - Nancy Schoenberg
- Department of Behavioral Science, University of Kentucky Medical Center, Lexington, KY; Markey Cancer Center, University of Kentucky Medical Center, Lexington, KY
| | - Mark Dignan
- Department of Internal Medicine, University of Kentucky Medical Center, Lexington, KY; Markey Cancer Center, University of Kentucky Medical Center, Lexington, KY
| | - B Mark Evers
- Department of Surgery, University of Kentucky Medical Center, Lexington, KY; Markey Cancer Center, University of Kentucky Medical Center, Lexington, KY
| | - Avinash S Bhakta
- Department of Surgery, University of Kentucky Medical Center, Lexington, KY; Markey Cancer Center, University of Kentucky Medical Center, Lexington, KY.
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14
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Gorey KM, Bartfay E, Kanjeekal SM, Wright FC, Hamm C, Luginaah IN, Zou G, Holowaty EJ, Richter NL, Balagurusamy MK. Palliative chemotherapy among people living in poverty with metastasised colon cancer: facilitation by primary care and health insurance. BMJ Support Palliat Care 2019; 9:e24. [PMID: 27554266 PMCID: PMC5357141 DOI: 10.1136/bmjspcare-2015-001035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 07/17/2016] [Accepted: 08/07/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Many Americans with metastasised colon cancer do not receive indicated palliative chemotherapy. We examined the effects of health insurance and physician supplies on such chemotherapy in California. METHODS We analysed registry data for 1199 people with metastasised colon cancer diagnosed between 1996 and 2000 and followed for 1 year. We obtained data on health insurance, census tract-based socioeconomic status and county-level physician supplies. Poor neighbourhoods were oversampled and the criterion was receipt of chemotherapy. Effects were described with rate ratios (RR) and tested with logistic regression models. RESULTS Palliative chemotherapy was received by less than half of the participants (45%). Facilitating effects of primary care (RR=1.23) and health insurance (RR=1.14) as well as an impeding effect of specialised care (RR=0.86) were observed. Primary care physician (PCP) supply took precedence. Adjusting for poverty, PCP supply was the only significant and strong predictor of chemotherapy (OR=1.62, 95% CI 1.02 to 2.56). The threshold for this primary care advantage was realised in communities with 8.5 or more PCPs per 10 000 inhabitants. Only 10% of participants lived in such well-supplied communities. CONCLUSIONS This study's observations of facilitating effects of primary care and health insurance on palliative chemotherapy for metastasised colon cancer clearly suggested a way to maximise Affordable Care Act (ACA) protections. Strengthening America's system of primary care will probably be the best way to ensure that the ACA's full benefits are realised. Such would go a long way towards facilitating access to palliative care.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, Windsor, Ontario, Canada
| | - Emma Bartfay
- Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada
| | - Sindu M Kanjeekal
- Department of Oncology, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Frances C Wright
- Division of General Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
- Departments of Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Caroline Hamm
- Department of Oncology, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Isaac N Luginaah
- Department of Geography, Western University, London, Ontario, Canada
| | - Guangyong Zou
- Department of Epidemiology and Biostatistics, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Eric J Holowaty
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nancy L Richter
- School of Social Work, University of Windsor, Windsor, Ontario, Canada
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15
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Zhu M, Zhao H, Peng T, Su J, Meng B, Qi Z, Jia B, Feng Y, Gao E. Structure and cytotoxicity of zinc (II) and cobalt (II) complexes based on 1,3,5-tris(1-imidazolyl) benzene. Appl Organomet Chem 2019. [DOI: 10.1002/aoc.4734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Mingchang Zhu
- The Key Laboratory of the Inorganic Molecule-Based Chemistry of Liaoning Province and Laboratory of Coordination Chemistry; Shenyang University of Chemical Technology; Shenyang 110142 China
| | - Hongwei Zhao
- The Key Laboratory of the Inorganic Molecule-Based Chemistry of Liaoning Province and Laboratory of Coordination Chemistry; Shenyang University of Chemical Technology; Shenyang 110142 China
| | - Tingting Peng
- The Key Laboratory of the Inorganic Molecule-Based Chemistry of Liaoning Province and Laboratory of Coordination Chemistry; Shenyang University of Chemical Technology; Shenyang 110142 China
| | - Junqi Su
- The Key Laboratory of the Inorganic Molecule-Based Chemistry of Liaoning Province and Laboratory of Coordination Chemistry; Shenyang University of Chemical Technology; Shenyang 110142 China
| | - Bo Meng
- The Key Laboratory of the Inorganic Molecule-Based Chemistry of Liaoning Province and Laboratory of Coordination Chemistry; Shenyang University of Chemical Technology; Shenyang 110142 China
| | - Zhenzhen Qi
- The Key Laboratory of the Inorganic Molecule-Based Chemistry of Liaoning Province and Laboratory of Coordination Chemistry; Shenyang University of Chemical Technology; Shenyang 110142 China
| | - Bing Jia
- The Key Laboratory of the Inorganic Molecule-Based Chemistry of Liaoning Province and Laboratory of Coordination Chemistry; Shenyang University of Chemical Technology; Shenyang 110142 China
| | - Yunhui Feng
- The Key Laboratory of the Inorganic Molecule-Based Chemistry of Liaoning Province and Laboratory of Coordination Chemistry; Shenyang University of Chemical Technology; Shenyang 110142 China
| | - Enjun Gao
- The Key Laboratory of the Inorganic Molecule-Based Chemistry of Liaoning Province and Laboratory of Coordination Chemistry; Shenyang University of Chemical Technology; Shenyang 110142 China
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16
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Eberth JM, Thibault A, Caldwell R, Josey MJ, Qiang B, Peña E, LaFrance D, Berger FG. A statewide program providing colorectal cancer screening to the uninsured of South Carolina. Cancer 2018; 124:1912-1920. [PMID: 29415338 DOI: 10.1002/cncr.31250] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 12/01/2017] [Accepted: 12/27/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cancer screening rates are lowest in those without insurance or a regular provider. Since 2008, the Colorectal Cancer Prevention Network (CCPN) has provided open access colonoscopy to uninsured residents of South Carolina through established, statewide partnerships and patient navigation. Herein, we describe the structure, implementation, and clinical outcomes of this program. METHODS The CCPN provides access to colonoscopy screening at no cost to uninsured, asymptomatic patients aged 50-64 years (African Americans age 45-64 years are eligible) who live at or below 150% of the poverty line and seek medical care in free medical clinics, federally qualified health centers, or hospital-based indigent practices in South Carolina. Screening is performed by board-certified gastroenterologists. Descriptive statistics and regression analysis are used to describe the population screened, and to assess compliance rates and colonoscopy quality metrics. RESULTS Out of >4000 patients referred to the program, 1854 were deemed eligible, 1144 attended an in-person navigation visit, and 1030 completed a colonoscopy; 909 were included in the final sample. Nearly 90% of participants exhibited good-to-excellent bowel preparation. An overall cecal intubation rate of 99% was measured. The polyp detection rate and adenoma detection rate were 63% and 36%, respectively, with male sex and urban residence positively associated with adenoma detection. Over 13% of participants had an advanced polyp, and 1% had a cancer diagnosis or surgical intervention. CONCLUSION The CCPN program is characterized by strong collaboration with clinicians statewide, low no-show rates, and high colonoscopy quality. Future work will assess the effectiveness of the navigation approach and will explore the mechanisms driving higher adenoma detection in urban participants. Cancer 2018;124:1912-20. © 2018 American Cancer Society.
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Affiliation(s)
- Jan M Eberth
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, South Carolina.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina.,South Carolina Rural Health Research Center, University of South Carolina, Columbia, South Carolina.,Center for Colon Cancer Research, University of South Carolina, Columbia, South Carolina
| | - Annie Thibault
- Center for Colon Cancer Research, University of South Carolina, Columbia, South Carolina
| | - Renay Caldwell
- Center for Colon Cancer Research, University of South Carolina, Columbia, South Carolina
| | - Michele J Josey
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, South Carolina
| | - Beidi Qiang
- Department of Statistics, University of South Carolina, Columbia, South Carolina.,Department of Mathematics and Statistics, Southern Illinois University, Edwardsville, Illinois
| | - Edsel Peña
- Department of Statistics, University of South Carolina, Columbia, South Carolina
| | | | - Franklin G Berger
- Center for Colon Cancer Research, University of South Carolina, Columbia, South Carolina.,Department of Biological Sciences, University of South Carolina, Columbia, South Carolina
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17
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Breen N, Lewis DR, Gibson JT, Yu M, Harper S. Assessing disparities in colorectal cancer mortality by socioeconomic status using new tools: health disparities calculator and socioeconomic quintiles. Cancer Causes Control 2017; 28:117-125. [PMID: 28083800 PMCID: PMC5306354 DOI: 10.1007/s10552-016-0842-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 12/20/2016] [Indexed: 01/05/2023]
Abstract
Purpose Colorectal cancer mortality rates dropped by half in the past three decades, but these gains were accompanied by striking differences in colorectal cancer mortality by socioeconomic status (SES). Our research objective is to examine disparities in colorectal cancer mortality by SES, using a scientifically rigorous and reproducible approach with publicly available online tools, HD*Calc and NCI SES Quintiles. Methods All reported colorectal cancer deaths in the United States from 1980 to 2010 were categorized into NCI SES quintiles and assessed at the county level. Joinpoint was used to test for significant changes in trends. Absolute and relative concentration indices (CI) were computed with HD*Calc to graph change in disparity over time. Results Disparities by SES significantly declined until 1993–1995, and then increased until 2010, due to a mortality drop in populations living in high SES areas that exceeded the mortality drop in lower SES areas. HD*Calc results were consistent for both absolute and relative concentration indices. Inequality aversion parameter weights of 2, 4, 6 and 8 were compared to explore how much colorectal cancer mortality was concentrated in the poorest quintile compared to the richest quintile. Weights larger than 4 did not increase the slope of the disparities trend. Conclusions There is consistent evidence for a significant crossover in colorectal cancer disparity from 1980 to 2010. Trends in disparity can be accurately and readily summarized using the HD*Calc tool. The disparity trend, combined with published information on the timing of screening and treatment uptake, is concordant with the idea that introduction of medical screening and treatment leads to lower uptake in lower compared to higher SES populations and that differential uptake yields disparity in population mortality.
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Affiliation(s)
- Nancy Breen
- Division of Cancer Control and Population Sciences, National Cancer Institute, 6707 Democracy Blvd, Suite 800 MSC 5465, Bethesda, MD, 20892-5465, USA.
- Office of Science Policy, Planning, Analysis and Reporting, National Institute on Minority Health and Health Disparities, Bethesda, MD, USA.
| | - Denise Riedel Lewis
- Division of Cancer Control and Population Sciences, National Cancer Institute, 6707 Democracy Blvd, Suite 800 MSC 5465, Bethesda, MD, 20892-5465, USA
| | | | - Mandi Yu
- Division of Cancer Control and Population Sciences, National Cancer Institute, 6707 Democracy Blvd, Suite 800 MSC 5465, Bethesda, MD, 20892-5465, USA
| | - Sam Harper
- McGill University, Montreal, Quebec, Canada
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Haji-Jama S, Gorey KM, Luginaah IN, Zou G, Hamm C, Holowaty EJ. Disparities Report: Disparities Among Minority Women With Breast Cancer Living in Impoverished Areas of California. Cancer Control 2016; 23:157-62. [PMID: 27218793 PMCID: PMC4882162 DOI: 10.1177/107327481602300210] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Interaction effects of poverty and health care insurance coverage on overall survival rates of breast cancer among women of color and non-Hispanic white women were explored. METHODS We analyzed California registry data for 2,024 women of color (black, Hispanic, Asian, Pacific Islander, American Indian, or other ethnicity) and 4,276 non-Hispanic white women (Anglo-European ancestries and no Hispanic-Latin ethnic backgrounds) diagnosed with breast cancer between the years 1996 and 2000 who were then followed until 2011. The 2000 US census categorized rates of neighborhood poverty. Health care insurance coverage was either private, Medicare, Medicaid, or none. Cox regression was used to model rates of survival. RESULTS A 3-way interaction between ethnicity, health care insurance coverage, and poverty was observed. Women of color inadequately insured and living in poor or near-poor neighborhoods in California were the most disadvantaged. Women of color adequately insured and who lived in such neighborhoods in California were also disadvantaged. The incomes of such women of color were typically lower than the incomes of non-Hispanic white women. CONCLUSIONS Women of color with or without insurance coverage are disadvantaged in poor and near-poor neighborhoods of California. Such women may be less able to bare the indirect, direct, or uncovered costs of health care for breast cancer treatment.
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Affiliation(s)
- Sundus Haji-Jama
- School of Social Work, University of Windsor, Ontario, Canada N9B 3P4.
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19
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Kangmennaang J, Mkandawire P, Luginaah I. What Prevents Men Aged 40-64 Years from Prostate Cancer Screening in Namibia? J Cancer Epidemiol 2016; 2016:7962502. [PMID: 26880917 PMCID: PMC4736914 DOI: 10.1155/2016/7962502] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 12/12/2015] [Accepted: 12/16/2015] [Indexed: 11/20/2022] Open
Abstract
Objectives. Although a growing body of evidence demonstrates the public health burden of prostate cancer in SSA, relatively little is known about the underlying factors surrounding the low levels of testing for the disease in the context of this region. Using Namibia Demographic Health Survey dataset (NDHS, 2013), we examined the factors that influence men's decision to screen for prostate cancer in Namibia. Methods. We use complementary log-log regression models to explore the determinants of screening for prostate cancer. We also corrected for the effect of unobserved heterogeneity that may affect screening behaviours at the cluster level. Results. The results show that health insurance coverage (OR = 2.95, p = 0.01) is an important predictor of screening for prostate cancer in Namibia. In addition, higher education and discussing reproductive issues with a health worker (OR = 2.02, p = 0.05) were more likely to screening for prostate cancer. Conclusions. A universal health insurance scheme may be necessary to increase uptake of prostate cancer screening. However it needs to be acknowledged that expanded screening can have negative consequences and any allocation of scarce resources towards screening must be guided by evidence obtained from the local context about the costs and benefits of screening.
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Affiliation(s)
- Joseph Kangmennaang
- Department of Geography and Environment, University of Waterloo, 200 University Avenue West, Waterloo, ON, Canada N2L 3G1
| | - Paul Mkandawire
- The Institute of Interdisciplinary Studies, 2201 Dunton Tower, 1125 Colonel By Drive, Ottawa, ON, Canada K1S 5B6
| | - Isaac Luginaah
- Department of Geography, Western University, 1151 Richmond Street, London, ON, Canada N6A 5C2
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20
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Gorey KM, Kanjeekal SM, Wright FC, Hamm C, Luginaah IN, Bartfay E, Zou G, Holowaty EJ, Richter NL. Colon cancer care and survival: income and insurance are more predictive in the USA, community primary care physician supply more so in Canada. Int J Equity Health 2015; 14:109. [PMID: 26511360 PMCID: PMC4625439 DOI: 10.1186/s12939-015-0246-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/15/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Our research group advanced a health insurance theory to explain Canada's cancer care advantages over America. The late Barbara Starfield theorized that Canada's greater primary care-orientation also plays a critically protective role. We tested the resultant Starfield-Gorey theory by examining the effects of poverty, health insurance and physician supplies, primary care and specialists, on colon cancer care in Ontario and California. METHODS We analyzed registry data for people with non-metastasized colon cancer from Ontario (n = 2,060) and California (n = 4,574) diagnosed between 1996 and 2000 and followed to 2010. We obtained census tract-based socioeconomic data from population censuses and data on county-level physician supplies from national repositories: primary care physicians, gastroenterologists and other specialists. High poverty neighborhoods were oversampled and the criterion was 10 year survival. Hypotheses were explored with standardized rate ratios (RR) and tested with logistic regression models. RESULTS Significant inverse associations of poverty (RR = 0.79) and inadequate health insurance (RR = 0.80) with survival were observed in the California, while they were non-significant or non-existent in Ontario. The direct associations of primary care physician (RRs of 1.32 versus 1.11) and gastroenterologist (RRs of 1.56 versus 1.15) supplies with survival were both stronger in Ontario than California. The supply of primary care physicians took precedence. Probably mediated through the initial course of treatment, it largely explained the Canadian advantage. CONCLUSIONS Poverty and health insurance were more predictive in the USA, community physician supplies more so in Canada. Canada's primary care protections were greatest among the most socioeconomically vulnerable. The protective effects of Canadian health care prior to enactment of the Affordable Care Act (ACA) clearly suggested the following. Notwithstanding the importance of insuring all, strengthening America's system of primary care will probably be the best way to ensure that the ACA's full benefits are realized. Finally, Canada's strong primary care system ought to be maintained.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, Ontario, N9B 3P4, Canada.
| | - Sindu M Kanjeekal
- Department of Oncology, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Frances C Wright
- Division of General Surgery, Sunnybrook Health Sciences Center and cross appointed Departments of Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Caroline Hamm
- Department of Oncology, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Isaac N Luginaah
- Department of Geography, Western University, London, Ontario, Canada.
| | - Emma Bartfay
- Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada.
| | - Guangyong Zou
- Department of Epidemiology and Biostatistics and Robarts Research Institute, Western University, London, Ontario, Canada.
| | - Eric J Holowaty
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Nancy L Richter
- School of Social Work, University of Windsor, Ontario, Canada.
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21
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Wang A, Shaukat A, Acosta RD, Bruining DH, Chandrasekhara V, Chathadi KV, Eloubeidi MA, Fanelli RD, Faulx AL, Fonkalsrud L, Gurudu SR, Kelsey LR, Khashab MA, Kothari S, Lightdale JR, Muthusamy VR, Pasha S, Saltzman JR, Yang J, Cash BD, DeWitt JM. Race and ethnicity considerations in GI endoscopy. Gastrointest Endosc 2015; 82:593-9. [PMID: 26260384 DOI: 10.1016/j.gie.2015.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/05/2015] [Indexed: 02/08/2023]
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22
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Becerra AZ, Probst CP, Tejani MA, Aquina CT, González MG, Hensley BJ, Noyes K, Monson JR, Fleming FJ. Opportunity lost: Adjuvant chemotherapy in patients with stage III colon cancer remains underused. Surgery 2015; 158:692-9. [DOI: 10.1016/j.surg.2015.03.057] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 03/16/2015] [Accepted: 03/17/2015] [Indexed: 12/24/2022]
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Lin CC, Bruinooge SS, Kirkwood MK, Olsen C, Jemal A, Bajorin D, Giordano SH, Goldstein M, Guadagnolo BA, Kosty M, Hopkins S, Yu JB, Arnone A, Hanley A, Stevens S, Hershman DL. Association Between Geographic Access to Cancer Care, Insurance, and Receipt of Chemotherapy: Geographic Distribution of Oncologists and Travel Distance. J Clin Oncol 2015; 33:3177-85. [PMID: 26304878 DOI: 10.1200/jco.2015.61.1558] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Geographic access to care may be associated with receipt of chemotherapy but has not been fully examined. This study sought to evaluate the association between density of oncologists and travel distance and receipt of adjuvant chemotherapy for colon cancer within 90 days of colectomy. PATIENTS AND METHODS Patients in the National Cancer Data Base with stage III colon cancer, diagnosed between 2007 and 2010, and age 18 to 80 years were selected. Generalized estimating equation clustering by hospital service area was conducted to examine the association between geographic access and receipt of oncology services, controlling for patient sociodemographic and clinical characteristics. RESULTS Of 34,694 patients in the study cohort, 75.7% received adjuvant chemotherapy within 90 days of colectomy. Compared with travel distance less than 12.5 miles, patients who traveled 50 to 249 miles (odds ratio [OR], 0.87; P=.009) or ≥250 miles (OR, 0.36; P<.001) had decreased likelihood of receiving adjuvant chemotherapy. Density level of oncologists was not statistically associated with receipt of adjuvant chemotherapy (low v high density: OR, 0.98; P=.77). When stratifying analyses by insurance status, non-privately insured patients who resided in areas with low density of oncologists were less likely to receive adjuvant chemotherapy (OR, 0.85; P=.03). CONCLUSION Increased travel burden was associated with a decreased likelihood of receiving adjuvant chemotherapy, regardless of insurance status. Patients with nonprivate insurance who resided in low-density oncologist areas were less likely to receive adjuvant chemotherapy. If these findings are validated prospectively, interventions to decrease geographic barriers may improve the timeliness and quality of colon cancer treatment.
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Affiliation(s)
- Chun Chieh Lin
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT.
| | - Suanna S Bruinooge
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - M Kelsey Kirkwood
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - Christine Olsen
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - Ahmedin Jemal
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - Dean Bajorin
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - Sharon H Giordano
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - Michael Goldstein
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - B Ashleigh Guadagnolo
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - Michael Kosty
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - Shane Hopkins
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - James B Yu
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - Anna Arnone
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - Amy Hanley
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - Stephanie Stevens
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
| | - Dawn L Hershman
- Chun Chieh Lin and Ahmedin Jemal, American Cancer Society, Atlanta, GA; Suanna S. Bruinooge, M. Kelsey Kirkwood, and Amy Hanley, American Society of Clinical Oncology, Alexandria; Anna Arnone and Stephanie Stevens, American Society for Radiation Oncology, Fairfax, VA; Christine Olsen, Massachusetts General Hospital; Michael Goldstein, Beth Israel Deaconess Medical Center, Boston, MA; Dean Bajorin, Memorial Sloan Kettering Cancer Center; Dawn L. Hershman, Columbia University Medical Center, New York, NY; Sharon H. Giordano and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; Michael Kosty, Scripps Clinic, La Jolla, CA; Shane Hopkins, William R. Bliss Cancer Center, Ames, IA; and James B. Yu, Yale University School of Medicine, New Haven, CT
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Gorey KM, Richter NL, Luginaah IN, Hamm C, Holowaty EJ, Zou G, Balagurusamy MK. Breast Cancer among Women Living in Poverty: Better Care in Canada than in the United States. SOCIAL WORK RESEARCH 2015; 39:107-118. [PMID: 26180488 PMCID: PMC4500640 DOI: 10.1093/swr/svv006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 05/29/2014] [Accepted: 06/02/2014] [Indexed: 06/04/2023]
Abstract
This historical study estimated the protective effects of a universally accessible, single-payer health care system versus a multi-payer system that leaves many uninsured or underinsured by comparing breast cancer care of women living in high poverty neighborhoods in Ontario or California between 1996 and 2011. Women in Canada experienced better care particularly as compared to women who were inadequately insured in the United States. Women in Canada were diagnosed earlier (rate ratio [RR] = 1.12) and enjoyed better access to breast conserving surgery (RR = 1.48), radiation (RR = 1.60) and hormone therapies (RR = 1.78). Women living in high poverty Canadian neighborhoods even experienced shorter waits for surgery (RR = 0.58) and radiation therapy (RR = 0.44) than did such women in the US. Consequently, women in Canada were much more likely to survive longer. Regression analyses indicated that health insurance could explain most of the better care and better outcomes in Canada. Over this study's 15-year timeframe 31,500 late diagnoses, 94,500 sub-optimum treatment plans and 103,500 early deaths were estimated in high poverty US neighborhoods due to relatively inadequate health insurance coverage. Implications for social work practice, including advocacy for future reforms of US health care are discussed.
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Affiliation(s)
- Kevin M. Gorey
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
| | - Nancy L. Richter
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
| | - Isaac N. Luginaah
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
| | - Caroline Hamm
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
| | - Eric J. Holowaty
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
| | - Guangyong Zou
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
| | - Madham K. Balagurusamy
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
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25
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Levitz NR, Haji-Jama S, Munro T, Gorey KM, Luginaah IN, Bartfay E, Zou G, Wright FC, Kanjeekal SM, Hamm C, Balagurusamy MK, Holowaty EJ. Multiplicative disadvantage of being an unmarried and inadequately insured woman living in poverty with colon cancer: historical cohort exploration in California. BMC Womens Health 2015; 15:8. [PMID: 25783640 PMCID: PMC4333264 DOI: 10.1186/s12905-015-0166-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 01/20/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Many Americans diagnosed with colon cancer do not receive indicated chemotherapy. Certain unmarried women may be particularly disadvantaged. A 3-way interaction of the multiplicative disadvantages of being an unmarried and inadequately insured woman living in poverty was explored. METHODS California registry data were analyzed for 2,319 women diagnosed with stage II to IV colon cancer between 1996 and 2000 and followed until 2014. Socioeconomic data from the 2000 census classified neighborhoods as high poverty (≥30% of households poor), middle (5-29%) or low poverty (<5% poor). Primary health insurance was private, Medicare, Medicaid or none. Comparisons of chemotherapy rates used standardized rate ratios (RR). We respectively used logistic and Cox regression models to assess chemotherapy and survival. RESULTS A statistically significant 3-way marital status by health insurance by poverty interaction effect on chemotherapy receipt was observed. Chemotherapy rates did not differ between unmarried (39.0%) and married (39.7%) women who lived in lower poverty neighborhoods and were privately insured. But unmarried women (27.3%) were 26% less likely to receive chemotherapy than were married women (37.1%, RR = 0.74, 95% CI 0.58, 0.95) who lived in high poverty neighborhoods and were publicly insured or uninsured. When this interaction and the main effects of health insurance, poverty and chemotherapy were accounted for, survival did not differ by marital status. CONCLUSIONS The multiplicative barrier to colon cancer care that results from being inadequately insured and living in poverty is worse for unmarried than married women. Poverty is more prevalent among unmarried women and they have fewer assets so they are probably less able to absorb the indirect and direct, but uncovered, costs of colon cancer care. There seem to be structural inequities related to the institutions of marriage, work and health care that particularly disadvantage unmarried women that policy makers ought to be cognizant of as future reforms of the American health care system are considered.
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Affiliation(s)
- Naomi R Levitz
- />School of Social Work, University of Windsor, Windsor, Ontario Canada
| | - Sundus Haji-Jama
- />Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
| | - Tonya Munro
- />School of Social Work, University of Windsor, Windsor, Canada
| | - Kevin M Gorey
- />School of Social Work, University of Windsor, Windsor, Canada
| | - Isaac N Luginaah
- />Department of Geography, Western University, London, Ontario Canada
| | - Emma Bartfay
- />Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario Canada
| | - Guangyong Zou
- />Department of Epidemiology and Biostatistics, and Robarts Research Institute, Western University, London, Ontario Canada
| | - Frances C Wright
- />Division of General Surgery, Sunnybrook Health Sciences Center and Departments of Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada
| | - Sindu M Kanjeekal
- />Medical Oncology Department, Windsor Regional Cancer Center, Windsor, Ontario Canada
| | - Caroline Hamm
- />Medical Oncology Department, Windsor Regional Cancer Center and School of Medicine and Dentistry, Department of Oncology, Western University, London, Canada
| | | | - Eric J Holowaty
- />Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
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Ramachandran A, Freund KM, Bak SM, Heeren TC, Chen CA, Battaglia TA. Multiple barriers delay care among women with abnormal cancer screening despite patient navigation. J Womens Health (Larchmt) 2014; 24:30-6. [PMID: 25513858 DOI: 10.1089/jwh.2014.4869] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND While there is widespread dissemination of patient navigation programs in an effort to reduce delays in cancer care, little is known about the impact of barriers to care on timely outcomes. METHODS We conducted a secondary analysis of the Boston Patient Navigation Research Program (PNRP) to examine the effect that the presence of barriers had on time to diagnostic resolution of abnormal breast or cervical cancer screening tests. We used multivariable Cox proportional hazards regression with time to diagnostic resolution as the outcome to examine the effect of the number of barriers, controlling for demographic covariates and clustered by patients' primary navigator. RESULTS There were 1481 women who received navigation; mean age was 39 years; 32% were White, 27% Black, and 31% Hispanic; 28% had private health insurance; and 38% did not speak English. Overall, half (n=745, 50%) had documentation of one or more barriers to care. Women with barriers were more likely to be older, non-White, non-English language speakers, and on public or no health insurance compared with women without barriers. In multivariable analyses, we found less timely diagnostic resolution as the number of barriers increased (one barrier, adjusted hazard ratio [aHR] 0.81 [95% CI 0.56-1.17], p=0.26; two barriers, aHR 0.55 [95% CI 0.37-0.81], p=0.0025; three or more barriers, aHR 0.31 [95% CI 0.21-0.46], p<0.0001)]. CONCLUSION Within a patient navigation program proven to reduce delays in care, we found that navigated patients with documented barriers to care experience less timely resolution of abnormal cancer screening tests.
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Affiliation(s)
- Ambili Ramachandran
- 1 Women's Health Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine , Boston, Massachusetts
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