Socioeconomic deprivation as a determinant of cancer mortality and the Hispanic paradox in Texas, USA

Critical analyses of Latina mortality: disentangling the heterogeneity of ethnic origin, place, nativity, race, and socioeconomic status

Despite the significant body of research on social determinants of health (SDH) and mortality, limited knowledge is available on the epidemiology of aggregated Latino health overall, and by women and subgroups. In population health studies, U.S. Latinos often are considered a monolithic population and presented as an aggregate, obscuring the diversity and variations within and across Latino subgroups, contributing to missed opportunities to identify SDH of health outcomes, and limiting the understanding of health differences. Given diverse environmental, racial, class, and geographic factors, a specific focus on women facilitates a more in-depth view of health disparities. This paper provides a scoping review of current gaps in research that assesses the relationships between SDH and mortality rates for the five leading causes of chronic-disease related deaths among Latinas by ethnic origin, place, race, and SES. We analyzed 2020 national mortality statistics from the CDC WONDER Online database jointly with reviews of empirical articles on Latina health, employing the EBSCOhost MEDLINE databases. These findings challenge the phenomenon of the Hispanic paradox that identified Latinos as a relatively healthy population compared to non-Hispanic White populations despite their lower economic status. The findings confirm that prior research on Latino women had methodological limitations due to the exclusion of SDH and an overemphasis on culturalist perspectives, while overlooking the critical role of socioeconomic impacts on health. Findings indicate major knowledge gaps in Latina mortality by SDH and subgroups that may undermine surveillance efforts and treatment efficacy. We offer forward-looking recommendations to assure the inclusion of key SDH associated with Latina mortality by subgroup as essential to inform future studies, intervention programs, and health policy.

A Novel Prognostic Model for Patients with Primary Gastric Diffuse Large B-Cell Lymphoma

Objectives. Primary gastric diffuse large B-cell lymphoma (PG-DLBCL) is a common phenotype of extranodal non-Hodgkin’s lymphoma (NHL). This research aims to identify a model for predicting overall survival (OS) and cancer-specific survival (CSS) in PG-DLBCL. Methods. A total of 1716 patients diagnosed with PG-DLBCL between 1975 and 2017 were obtained from the SEER database and further randomly divided into the training and validating cohorts at a ratio of 7 : 3. Univariate and multivariate cox analyses were conducted to determine significant variables for the construction of nomogram. The performance of the model was then assessed by the concordance index (C-index), the calibration plot, and the area under the receiver operating characteristic (ROC) curve (AUC). Results. Multivariate analysis revealed that age, race, insurance status, Ann Arbor stage, marital status, chemotherapy, and radiation therapy all showed a significant association with OS and CSS. These characteristics were applied to build a nomogram. In the training cohort, the discrimination of nomogram for OS and CSS prediction was excellent (C-index = 0.764, 95% CI, 0.744–0.784 and C-index = 0.756, 95% CI, 0.732–0.780). The AUC of the nomogram for predicting 3- and 5-year OS was 0.779 and 0.784 and CSS was 0.765 and 0.772. Similar results were also observed in the internal validation set. Conclusions. We have successfully established a novel nomogram for predicting OS and CSS in PG-DLBCL patients with good accuracy, which can help physicians to quickly and accurately complete the evaluation of survival probability, risk stratification, and therapeutic strategy at diagnosis.

Spanish-Speaking Status: A Protective Factor in Colorectal Cancer Presentation at a Safety-Net Hospital

INTRODUCTION

Lower screening rates and poorer outcomes for colorectal cancer have been associated with Hispanic ethnicity and Spanish-speaking status, respectively.

METHODS

We reviewed sequential colorectal cancer patients evaluated by the surgical service at a safety-net hospital (SNH) (2016-2019). Insurance type, stage, cancer type, surgery class (elective/urgent), initial surgeon contact setting (outpatient clinic/inpatient consult), operation (resection/diversion), and follow-up were compared by patient-reported primary spoken language.

RESULTS

Of 157 patients, 85 (54.1%) were men, 91 (58.0%) had colon cancer, 67 (42.7%) primarily spoke Spanish, and late stage (III or IV) presentations occurred in 83 (52.9%) patients. The median age was 58 y, cancer resection was completed in 48 (30.6%) patients, and 51 (32.5%) patients were initially seen as inpatient consults. On univariate analysis, Spanish-speaking status was significantly associated with female sex, Medicaid insurance, being seen as an outpatient consult, and undergoing elective and resection surgery. On multivariable logistic regression, Spanish-speaking patients had higher odds of having Medicaid insurance (AOR 2.28, P = 0.019), receiving a resection (AOR 3.96, P = 0.006), and undergoing an elective surgery (AOR 3.24, P = 0.025). Spanish-speaking patients also had lower odds of undergoing an initial inpatient consult (AOR 0.34, P = 0.046).

CONCLUSIONS

Spanish-speaking status was associated with a lower likelihood of emergent presentation and need for palliative surgery among SNH colorectal cancer patients. Further research is needed to determine if culturally competent infrastructure in the SNH setting translates into Spanish-speaking status as a potentially protective factor.

County-Level Poverty and Barriers to Breast and Cervical Cancer Screening in a Health Education and Patient Navigation Program for Rural and Border Texas Residents

The study examined the impact of (1) county-level poverty rates and (2) patient navigation on breast and cervical cancer screening outcomes for women in rural and border counties in Texas reporting barriers to screening.Univariate analyses described the distribution and screening prevalence rates in the sample, while a series of random intercept logistic regression models analyzed mammogram (N = 2326 women aged 40+) and Papanicolaou (Pap; N = 2959 women aged 21-64) screening separately.Mammogram and Pap screening prevalence rates were highest among women who were aged 40-64, Spanish-speaking Latinas, lower educated, attending cancer education events because of the cost of the screenings, patient navigation recipients, living in the south region of Texas, and in counties with high poverty. Although models indicated significant variability in screening rates by county, county-level poverty was only significantly associated with odds of getting Pap screening in adjusted models. Not receiving patient navigation vs. receiving it was associated with lower odds for both mammogram (OR: 0.51, CI: 0.38-0.70) and Pap (OR: 0.69, CI: 0.50-0.94) screenings.County-level variation in screening rates exists for both mammogram and Pap tests and should be considered in the development and implementation of screening interventions in rural and border areas. However, other factors beyond poverty levels may explain the variation.

Social determinants of health and survival on Brazilian patients with glioblastoma: a retrospective analysis of a large populational database

Background

The majority of patients diagnosed with glioblastoma develop recurrent disease resulting in poor prognoses. The current study aimed to determine the survival rates of patients diagnosed with glioblastoma in Brazil accounting for the influence of age, treatment modalities, public and private practices, and educational level using a population-based national database.

Methods

Patients diagnosed with glioblastoma from 1999-2020 were identified from The Fundação Oncocentro de São Paulo database to create a retrospective cohort. Patients were described according to age, education level treatment modalities and medical practice. In a Cox proportional hazards model, controlled for confounding factors for overall survival, the hazard ratio and 95% CI of overall survival in adults was evaluated.

Findings

A total of 4,511 patients were included. The median lengths of survival for patients treated in the public and private settings were 8 and 17 months (p<0.001), respectively. Young patients had longer median overall survival (OS: 18 to 40 years, 41 to 60 years, 61 to 65 years, 66 to 70 years and over than 70 years was 22 months, 10 months, 6 months, 5 months, 4 months, respectively (p<0.001). In general, combined treatments were associated with higher median survival compared to monotherapy. The higher educational level, the higher median survival was observed (4 months for illiterate versus 14 months for university degree). In the multivariable analyses, the significant independent predictors for overall survival were practice setting, educational level, age and treatment modalities.

Interpretation

Public practice, older patients, less intensive treatment, and lower educational level were associated with worse survival outcomes in Brazilian glioblastoma patients.

Treatment and Survival Disparities of Colon Cancer in the Texas-Mexico Border Population: Cancer Disparities in Border Population

BACKGROUND

Previous studies have reported healthcare disparities in the Texas-Mexico border population. Our aim was to evaluate treatment utilization and oncologic outcomes of colon cancer patients in this vulnerable population.

METHODS

Patients with localized and regional colon cancer (CC) were identified in the Texas Cancer Registry (1995-2016). Clinicopathological data, hospital factors, receipt of optimal treatment, and overall survival (OS) were compared between Texas-Mexico Border (TMB) and the Non-Texas-Mexico Border (NTMB) cohorts. Multivariable analysis was performed to identify risk factors associated with decreased survival.

RESULTS

We identified 43,557 patients with localized/regional CC (9% TMB and 91% NTMB). TMB patients were more likely to be Hispanic (73% versus 13%), less likely to have private insurance (13% versus 21%), were more often treated at safety net hospitals (82% versus 22%) and less likely at ACS-CoC accredited hospitals (32% versus 57%). TMB patients were more likely to receive suboptimal treatment (21% versus 16%) and had a lower median OS for localized (8.58 versus 9.58 y) and regional colon cancer (5.75 versus 6.18 y, all P < 0.001). In multivariable analysis, TMB status was not associated with worse OS. Factors associated with worse survival included receipt of suboptimal treatment, Medicare/insured status, and treatment in safety net and non-accredited ACS-CoC hospitals (all P < 0.001) CONCLUSIONS: While TMB CC patients had worse OS, TMB status itself was not found to be a risk factor for decreased survival. This survival disparity is likely associated with higher rate of suboptimal treatment, Medicare/Uninsured status, and decreased access to ACS-CoC accredited hospitals.

Blood cancer health disparities in the United States Hispanic population

Cancer is a challenging, multifaceted disease that involves a combination of biological and nonbiological factors. Aside from COVID-19, cancer is the second leading cause of death in the United States and the first among Hispanic Americans. The Hispanic population is the largest minority group in the United States, which is rapidly growing in size. Unfortunately, U.S. Hispanics and other minority groups experience many different health disparities, resulting in poor survival outcomes and a reduced quality of life. Factors such as genomic mutations, lower socioeconomic status, lack of education, reduced access to health care, comorbidities, and environmental factors all contribute to these health-care inequalities. In the context of blood cancer health disparities, Hispanic patients are often diagnosed at a younger age and have worse outcomes compared with non-Hispanic individuals. In this commentary, we highlight the existing knowledge about cancer health disparities in the Hispanic population, with a focus on chronic and acute leukemia. In our experience at the U.S./Mexican border, analysis of several different blood cancers demonstrated that younger Hispanic patients with acute lymphoid or myeloid leukemia have higher incidence rates and worse prognoses. A combined approach, involving improved health-care access and better knowledge of the underlying factors, will allow for more timely diagnoses and the development of intervention strategies aimed at reducing or eliminating the disparities.

A Disparity beneath a Paradox: Cancer Mortality among Young Hispanic Americans in the US-Mexico Border Region

The age-adjusted mortality rate for cancer in the US Hispanic population is two thirds that of the non-Hispanic white population, probably because of differences in smoking rates. We aimed to determine whether Hispanic white (HW) cancer mortality in the US-Mexico Border Region was also lower than that of the non-Hispanic white (NHW) border population, particularly in the younger population less likely to develop smoking-related cancer. We obtained age-adjusted cancer mortality rates from 1999 to 2017 for the 44 border counties, the four US-Mexico border states, and the rest of the US. We obtained cancer incidence rates for 1999-2016 from state registries. We stratified rates by age group, ethnicity, border state, urbanization, and cancer site. Age-adjusted border cancer mortality rates were 139.1/100,000 in the HW and 171.4 in the NHW populations, a ratio of 0.8. HW mortality rates were higher than NHW rates only for the 0-34 age group. State-specific HW cancer incidence rates for people 0-34 years old were 77%-80% of NHW rates. We also calculated mortality-incidence ratios (MIR) for the 0-34 population. Border mortality-incidence ratios were higher in the HW population. HW rates exceeded NHW rates for all cancer sites except skin cancer. The HW cancer disparity is due to poorer survival in the HW population, which might be due to limited access to prevention and treatment in a medically underserved area. Mortality among young border Hispanic residents might be reduced through efforts to improve insurance coverage and increase access to medical providers .

Racial and ethnic differences in diffuse large B-cell lymphoma survival among an underserved, urban population

Racial/ethnic differences in diffuse large B-cell lymphoma (DLBCL) survival have focused on non-Hispanic Whites (NHW) and non-Hispanic Blacks (NHB), often excluding Hispanics/Latinos. To further assess these racial/ethnic survival differences, we identified incident DLBCL cases diagnosed between 2005 and 2016 (n = 404; NHW = 136, NHB = 106, Hispanic/Latino = 162) at Montefiore Medical Center (Bronx, NY). All-cause mortality survival curves were assessed by the Kaplan-Meier method and log-rank test. Cox proportional hazards regression assessed the association between demographic/clinical factors and all-cause mortality. Hispanic/Latino patients experienced 52% lower risk of mortality compared to NHWs (HR = 0.48, 95%CI = 0.28-0.83), after adjusting for clinical prognostic factors. This reduced risk experienced by Hispanics/Latinos was similarly observed by age at diagnosis (≤60 years, >60 years), stage (I/II, III/IV), and receipt of chemotherapy. NHBs and NHWs experienced similar risk of mortality (HR = 0.85, 95%CI = 0.52-1.40). Overall, among DLBCL patients, Hispanics/Latinos had improved survival compared to NHWs. Additional research should seek to identify the drivers of this survival benefit.

Patterns of racial/ethnic disparities in baseline health-related quality of life and relationship with overall survival in patients with colorectal cancer

PURPOSE

Racial disparities are evident in colorectal cancer (CRC) prognosis with black patients experiencing worse outcomes than Hispanics and whites, yet mediators of these disparities are not fully known. The aim of this study is to identify variables that contribute to racial/ethnic disparities in health-related quality of life (HR-QoL) and overall survival in CRC.

METHODS

Using SF-12 questionnaires, we assessed HR-QoL in 1132 CRC patients by calculating their physical (PCS) and mental composite summary (MCS) scores. Associations between poor PCS/MCS and sociodemographic factors were estimated and survival differences were identified by race/ethnicity.

RESULTS

Hispanic patients who never married were at greater risk of poor PCS (OR 2.69; 95% CI 1.11-6.49; P = 0.028) than were currently married patients. College education was associated with a decreased risk of poor PCS in Hispanic and white, but not black, patients. Gender was significantly associated with poor MCS among white patients only. CRC patients who reported a poor PCS or MCS had poor survival, with differences in median survival times (MSTs) by race. The effect of PCS was strongest in white CRC patients with a difference in overall MST of > 116 months between those with favorable versus poor physical HR-QoL. Black patients who reported poor Physical and Mental HR-QoL showed significant risk of a poor outcome.

CONCLUSION

These findings suggest that racial/ethnic disparities in CRC survival may be related to differences in HR-QoL. Identified mediators of HR-QoL could supplement current CRC management strategies to improve patients' survival.

The impact of socioeconomic deprivation on the uptake of colorectal cancer screening in London

OBJECTIVE

Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality from colorectal cancer (CRC). However, a significant variation exists in uptake of the test within the UK. Disproportionate uptake risks increasing inequity during staging at diagnosis and survival from CRC. This study aims to evaluate the impact of socioeconomic deprivation on the uptake of CRC screening (FOBT) in London.

METHODS

A retrospective review of the "Vanguard RM Informatics" database was performed to identify eligible individuals for CRC screening across all general practices across London over 30 months (2014-2017). The postcodes of the general practices were used to obtain the deprivation data via the "Indices of Deprivation" database. A Spearman's rho correlation was performed to quantify the impact of the deprivation variables on FOBT uptake.

RESULTS

Overall, 697,402 individuals were eligible for screening across 1359 London general practices, within 5 Clinical Commissioning Groups (CCGs); 48.4% (range: 13%-74%) participated in CRC screening with the lowest participation rates in North West (46%) and North East (47%) London CCGs. All indices of deprivation had a significant correlation with the uptake of FOBT (p < 0.01).

CONCLUSION

This is the largest study across London to date demonstrating a significant positive correlation between deprivation indices and FOBT uptake, highlighting areas of particular risk. Further studies are imperative to quantify the impact of deprivation on CRC morbidity and mortality, together with focused strategies to reduce socioeconomic inequalities in screening in these high risk areas.

Factors associated with HPV testing in oropharyngeal cancer in the National Cancer Data Base from 2013 to 2015

OBJECTIVES

Given the recent treatment deintensification clinical trials for Human Papillomavirus (HPV)-associated oropharyngeal cancer, College of American Pathologists recommendation for HPV-testing of all oropharyngeal cancers and treatment disparities in head and neck cancer, determining factors related to HPV testing are exceedingly pertinent.

MATERIALS AND METHODS

We used the National Cancer Data Base, accounting for 70% of new cancer diagnoses. To reduce the heterogeneity due to the recent recommendation of HPV-testing, we used squamous cell oropharyngeal cancer patients from 2013 to 2015. We only used patients that have either reported HPV testing and non-testing (30.5% of the sample). We used a chi-square test to compare the factors among tested and untested patients and calculated the prevalence ratio for not tested to those tested with Poisson regression. As a sensitivity analysis, we used a fully Conditional Specification implemented by the MICE algorithm to impute missing variables.

RESULTS

Of the 24,241 oropharyngeal cancer patients with HPV testing data, 12% were not been tested for HPV. Across the study period, integrated network and low-volume hospitals had the lowest proportion of HPV testing from 2013 to 2015. In a multivariable analysis, compared to patients with private insurance, Medicaid (PR: 1.82; 95% Confidence Interval (CI): 1.63-2.02) and uninsured (PR: 1.75; 95% CI: 1.52-2.01) patients were more likely not to be tested for HPV. We saw similar results in the imputed dataset, in which 12.5% of patients were not tested.

CONCLUSIONS

This heterogeneity in testing is significant, given potential de-intensification of treatment for HPV-positive cancer. Future research should examine interventions in non-academic low-volume to ensure equitable treatment for all.

Socioeconomic inequalities in metastasis, recurrence, stage and grade of breast cancer: a hospital-based retrospective cohort study

Introduction

This study aims to estimate the Socio-Economic Status (SES) inequality on the metastasis, recurrence, stage and grade in Breast Cancer (BC).

Methods

This retrospective cohort study conducted on 411 BC patients in Arak, Iran. Asset-based questionnaire used to estimate the household SES. For calculate of SES inequality was used from Concentration Index (C). Moreover for investigate the association between recurrence and metastasis with other variables were used from multilevel logistic regression and analysis of variance were used to investigate the relationship between SES and other variables. The data were analyzed with Stata (v.13) software.

Results

Results of analysis of variance showed statistical significant relationship between SES with, insurance, surgery, grade, stage, recurrence and metastasis (p-value < 0.05). Moreover the Odds Ratio (OR) were significant of recurrence with age, academic level of education, supplementary insurance history of BC in first-degree relatives, stage and grade, also, metastasis with age of > 80 years, insurance, supplementary insurance, history of BC in first-degree relatives, chemotherapy, radiotherapy, stage and grade four. The total C index obtained 0.015 (0.002, 0.026), 0.011 (0.003, 0.031), – 0.014 (– 0.034, – 0.001) and – 0.042 (– 0.061, – 0.002) for metastasis, recurrence, stage and grade of BC respectively.

Conclusions

Our results showed evidence of inequality in the metastasis, recurrence, stage and grade in BC patients.

Racial differences in long-term adjuvant endocrine therapy adherence and mortality among Medicaid-insured breast cancer patients in Texas: Findings from TCR-Medicaid linked data

BACKGROUND

There are racial/ethnic disparities in breast cancer mortality may be attributed to differences in receipt of adjuvant cancer treatment. Our purpose was to determine whether the mortality disparities could be explained by racial/ethnic differences in long-term adherence to adjuvant endocrine therapy (AET).

METHODS

We conducted a retrospective cohort study with the Texas Cancer Registry and Medicaid claims-linked dataset of women (20-64 years) diagnosed with local and regional breast cancer who filled a prescription for AET from 2000-2008. Adherence to AET was measured at three time points (1-, 3-, and 5-year adherence) using a value for the percentage of medication filled for each period divided by the total number of possible prescriptions prescribed (Medication Possession Ratio, MPR). We created a binary variable of adherence (MPR≥80%). We performed multivariable logistic regressions to assess racial differences for the odds of AET adherence and Cox proportional hazard models to determine the risk of mortality adjusting for potential confounding variables of SES, comorbidities, tumor prognostic factors, and other cancer treatment.

RESULTS

Of the 1,497 women with breast cancer who initiated AET, 56.9%, 42.3%, and 33.3% were adherent for 1, 3, and 5-years, respectively. Hispanics compared to non-Hispanic whites did differ in the proportion that were adherent to 5-years of AET. In the adjusted analysis for long-term adherence to AET, Hispanics did not have a significantly increased risk of death compared to non-Hispanic white patients (HR: 1.13, 95% CI: 0.58-2.21). However, black compared to non-Hispanic white patients had significantly lower odds of three-year adherence (OR: 0.45, 95% CI: 0.28-0.73). After controlling for 5-year adherence to AET, the risk of death for black compared to non-Hispanic white patients was 12% lower (HR: 1.90; 95% CI: 1.03-3.51) and in the fully adjusted model, the disparity was reduced and no longer significant (OR: 1.86, 95% CI: 0.94-3.66).

CONCLUSIONS

Long-term adherence in the Medicaid population is suboptimal and racial/ethnic differences in AET adherence may partially explain disparities in mortality. This study underscores the critical need to ensure long-term adherence to AET for all racial/ethnic groups to decrease disparities in mortality.

The Influence of Ethnic Heterogeneity on Prostate Cancer Mortality After Radical Prostatectomy in Hispanic or Latino Men: A Population-based Analysis

OBJECTIVE

To determine if recently found disparities in prostate cancer-specific mortality (PCSM) among Mexican and Puerto Rican men remained true in patients undergoing radical prostatectomy (RP), where the true grade and extent of cancer are known and can be accounted for.

MATERIALS AND METHODS

Men diagnosed with localized-regional prostate cancer who had undergone RP as primary treatment were identified (N = 180,794). Patients were divided into the following racial and ethnic groups: non-Hispanic white (NHW) (n = 135,358), non-Hispanic black (NHB) (n = 21,882), Hispanic or Latino (n = 15,559), and Asian American or Pacific Islander (n = 7995). Hispanic or Latino men were further categorized into the following subgroups: Mexican (n = 3323) and South or Central American, excluding Brazilian (n = 1296), Puerto Rican (n = 409), and Cuban (n = 218). A multivariable analysis was conducted using competing risk regression in the prediction of PCSM.

RESULTS

This analysis revealed hidden disparities in surgical outcomes for prostate cancer. In the multivariable analysis, Hispanic or Latino men (hazard ratio [HR] = 0.88, P = .207) did not show a significant difference in PCSM compared with NHW men. When breaking Hispanic or Latino men into their country of origin or ancestry, Puerto Rican men were found to have significantly worse PCSM than NHW men (HR = 2.55, P = .004) and NHB men (HR = 2.33, P = .016).

CONCLUSION

Our findings reveal higher rates of PCSM for Puerto Rican men after RP than for both NHW and NHB men. At a minimum, these findings need further validation and should be considered in the screening and management of these men.

Racial and geographic disparities in adherence and discontinuation to adjuvant endocrine therapy in Texas Medicaid-insured patients with breast cancer

The purpose of the study is to examine disparities in AET adherence and discontinuation among Texas Medicaid-insured early-stage breast cancer patients. Texas Cancer Registry Medicaid-linked database was used from 2000 to 2007 for breast cancer patients aged 20-64. Multivariable logistic regression was performed to test the association of race/ethnicity and geographic factors with AET adherence and discontinuation. Of the 1240 women with breast cancer, 60.8% of non-Hispanic white vs 46.6% of Black patients were adherent to AET in the first year. After adjusting for confounding, Black patients had lower odds of adherence compared to non-Hispanic white patients (Odds ratio 0.62, 95% CI 0.44-0.87), but they were not more likely to discontinue therapy during the study period. Patients from the Texas/Mexico border had higher odds of adherence compared to other regions (OR 2.32, 95% CI 1.29-4.18). There are substantial racial and geographic disparities in AET adherence and discontinuation among Texas Medicaid-insured women.

Literature review of data-based models for identification of factors associated with racial disparities in breast cancer mortality

In the United States, early detection methods have contributed to the reduction of overall breast cancer mortality but this pattern has not been observed uniformly across all racial groups. A vast body of research literature shows a set of health care, socio-economic, biological, physical, and behavioural factors influencing the mortality disparity. In this paper, we review the modelling frameworks, statistical tests, and databases used in understanding influential factors, and we discuss the factors documented in the modelling literature. Our findings suggest that disparities research relies on conventional modelling and statistical tools for quantitative analysis, and there exist opportunities to implement data-based modelling frameworks for (1) exploring mechanisms triggering disparities, (2) increasing the collection of behavioural data, and (3) monitoring factors associated with the mortality disparity across time.

Ethnic heterogeneity and prostate cancer mortality in Hispanic/Latino men: a population-based study

BACKGROUND

Few studies focus on prostate cancer (PCa) outcomes in Hispanic/Latino men. Our study explores whether Hispanic/Latino subgroups demonstrate significantly different prostate cancer-specific mortality (PCSM) relative to Non-Hispanic White (NHW) and Non-Hispanic Black (NHB) men.

METHODS

We extracted a population-based cohort of men diagnosed with local-regional PCa from 2000-2013 (n= 486,865). PCSM was measured in racial/ethnic groups: NHW (n=352,886), NHB (n= 70,983), Hispanic/Latino (n= 40,462), and Asian American/Pacific Islander (n= 22,534). PCSM was also measured in Hispanic/Latino subgroups: Mexican (n= 8,077), Puerto Rican (n= 1,284), South or Central American (n= 3,021), Cuban (n= 788), and Dominican (n= 300). We conducted univariable and multivariable analyses (MVA) to compare risk for PCSM.

RESULTS

Compared to NHW men, results showed worse outcomes for NHB men with similar outcomes for Hispanic/Latino men. In MVA with NHW men as a reference, NHB (HR= 1.15, p <0.001) men had significantly worse PCSM and Hispanic/Latino (HR= 1.02, p= 0.534) men did not show a significant difference. In a second MVA, Puerto Rican (HR= 1.71, p <0.001) and Mexican (HR= 1.21, p= 0.008) men had significantly higher PCSM. With NHB men as a reference, the MVA showed Puerto Rican (HR= 1.50, p= 0.006) men with higher PCSM and Mexican (HR= 1.08, p= 0.307) men with no significant difference.

CONCLUSIONS

Our findings indicate previously unknown disparities in PCSM for Puerto Rican and Mexican American men.

The Hispanic Paradox in endometrial cancer: A National Cancer Database study

OBJECTIVE

To compare the overall survival of non-Hispanic white and Hispanic women with endometrial cancer.

METHODS

We performed an observational retrospective cohort study of Hispanic and non-Hispanic women with endometrial cancer from the 2004-2014 National Cancer Database. Baseline characteristics were compared with the Chi-squared test for categorical variables or the Mann-Whitney U test for ordinal or continuous variables. The Kaplan-Meier method was used to estimate unadjusted survival times, which were compared with the log-rank test. Missing data was imputed using multiple imputation with chained equations. A multivariable parametric accelerated failure time model for survival was used. Sensitivity analyses were performed using matched cohort analyses of the overall cohort, and of subgroups based on stage or type.

RESULTS

112,574 non-Hispanic and 6313 Hispanic women met inclusion criteria. Five-year survival was slightly higher for Hispanic women (83.1% (82.1-84.3%) versus 81.4% (81.2-81.7%), P=0.002). Hispanic women were younger, treated at lower volume hospitals, and more often diagnosed with a type II histology and stage II-IV disease compared to non-Hispanic women (all P<0.001). With multivariable adjustment for measured confounders, Hispanic women lived 8% longer than non-Hispanic women (time-ratio (95% CI) 1.08 (1.02-1.14), P=0.01). When bias-reducing matched cohort analyses were used for sensitivity analyses, Hispanic women did not have significantly different survival than non-Hispanic women.

CONCLUSION

Hispanic ethnicity was not associated with a clinically meaningful difference in survival among women with endometrial cancer.

Hispanic and Immigrant Paradoxes in U.S. Breast Cancer Mortality: Impact of Neighborhood Poverty and Hispanic Density

To test the Hispanic and Immigrant Paradoxes-i.e., survival advantages despite a worse risk factor profile-and the modifying role of neighborhood context, we examined associations between patient ethnicity, birthplace, neighborhood Hispanic density and neighborhood poverty among 166,254 female breast cancer patients diagnosed 1995-2009 in Texas, U.S. Of all, 79.9% were non-Hispanic White, 15.8% Hispanic U.S.-born, and 4.2% Hispanic foreign-born. We imputed birthplace for the 60.7% of Hispanics missing birthplace data using multiple imputation. Shared frailty Cox proportional hazard models (patients nested within census tracts) adjusted for age, diagnosis year, stage, grade, histology, urban/rural residence, and local mammography capacity. Whites (vs. U.S.-born Hispanics) had increased all-cause and breast cancer mortality. Foreign-born (vs. U.S.-born) Hispanics had increased all-cause and breast cancer mortality. Living in higher Hispanic density neighborhoods was generally associated with increased mortality, although associations differed slightly in magnitude and significance by ethnicity, birthplace, and neighborhood poverty. We found no evidence of an Immigrant Paradox and some evidence of a Hispanic Paradox where protective effects were limited to U.S.-born Hispanics. Contrary to prior studies, foreign birthplace and residence in higher Hispanic density neighborhoods were associated with increased mortality. More research on intersections between ethnicity, birthplace and neighborhood context are needed.

Why Wait Until Our Community Gets Cancer?: Exploring CRC Screening Barriers and Facilitators in the Spanish-Speaking Community in North Carolina

Colorectal cancer (CRC) is a leading cause of death among Hispanics in the United States. Despite the benefits of CRC screening, many Hispanics are not being screened. Using a combined methodology of focus groups and discrete choice experiment (DCE) surveys, the objectives for this research were as follows: (1) to improve understanding of preferences regarding potential CRC screening program characteristics, and (2) to improve understanding of the barriers and facilitators around CRC screening with the Hispanic, immigrant community in North Carolina. Four gender-stratified focus groups were conducted and DCE surveys were administered to 38 Spanish-speaking individuals across four counties in North Carolina. In-depth content analysis was used to examine the focus group data; descriptive analyses and mean attribute importance scores for cost of screening and follow-up care, travel time, and test options were calculated from DCE data. Data analyses showed that this population has a strong interest in CRC screening but experience barriers such as lack of access to resources, cost uncertainty, and stigma. Some of these barriers are unique to their cultural experiences in the United States, such as an expressed lack of tailored CRC information. Based on the DCE, cost variables were more important than testing options or travel time. This study suggests that Hispanics may have a general awareness of and interest in CRC screening, but multiple barriers prevent them from getting screened. Special attention should be given to designing culturally and linguistically appropriate programs to improve access to healthcare resources, insurance, and associated costs among Hispanics.

Influence of insurance status on survival of adults with glioblastoma multiforme: A population-based study

BACKGROUND

To the authors' knowledge, the impact of insurance status on the survival time of patients with glioblastoma multiforme (GBM) has not been fully understood. The objective of the current study was to clarify the association between insurance status and survival of patients with GBM by analyzing population-based data.

METHODS

The authors performed a cohort study using data from the Surveillance, Epidemiology, and End Results program. They included adult patients (aged ≥18 years) with GBM as their primary diagnosis from the years 2007 to 2012. Patients without information regarding insurance status were excluded. A survival analysis between insurance status and GBM-related death was performed using an accelerated failure time model. Demographic and clinical variables were included to adjust for confounding effects.

RESULTS

Among the 13,665 adult patients in the study cohort, 558 (4.1%) were uninsured, 1516 (11.1%) had Medicaid coverage, and 11,591 (84.8%) had non-Medicaid insurance. Compared with patients who were uninsured, insured patients were more likely to be older, female, white, married, and with a smaller tumor size at diagnosis. Accelerated failure time analysis demonstrated that older age (hazard ratio [HR], 1.04; P<.001), male sex (HR, 1.08; P<.001), large tumor size at the time of diagnosis (HR, 1.26; P<.001), uninsured status (HR, 1.14; P =.018), and Medicaid insurance (HR, 1.10; P =.006) were independent risk factors for shorter survival among patients with GBM, whereas radiotherapy (HR, 0.40; P<.001) and married status (HR, 0.86; P<.001) indicated a better outcome. The authors discovered an overall yearly progressive improvement in survival in patients with non-Medicaid insurance who were diagnosed from 2007 through 2011 (P =.015), but not in uninsured or Medicaid-insured patients.

CONCLUSIONS

Variations existed in insurance status within the GBM population. Uninsured status and Medicaid insurance suggested shorter survival compared with non-Medicaid insurance among a population of patients with GBM. Cancer 2016;122:3157-65. © 2016 American Cancer Society.

Variability in Cancer Risk and Outcomes Within US Latinos by National Origin and Genetic Ancestry

Latinos have lower rates for most common cancer sites and higher rates of some less common cancers (gallbladder, liver, gastric, and cervical) than other ethnic/racial groups. Latinos are a highly heterogeneous population with diverse national origins, unique genetic admixture patterns, and wide spectrum of socio-demographic characteristics. Across the major cancers (breast, colorectal, prostate, lung, and liver) US-born Latinos have higher incidence and worse survival than foreign-born, and those with low-socioeconomic status have the lowest incidence. Puerto Rican and Cuban Latinos have higher incidence rates than Mexican Latinos. We have identified the following themes as understudied and critical to reduce the cancer burden among US Latinos: (1) etiological studies considering key sources of heterogeneity, (2) culturally sensitive cancer prevention strategies, (3) description of the molecular tumor landscape to guide treatments and improve outcomes, and (4) development of prediction models of disease risk and outcomes accounting for heterogeneity of Latinos.

Review: Increasing Awareness and Education on Health Disparities for Health Care Providers

The focus of this review is to highlight health care disparities and trends in several common diseases in selected populations while offering evidence-based approaches to mitigating health care disparities. Health care disparities cross many barriers and affect multiple populations and diseases. Ethnic minorities, the elderly, and those of lower socioeconomic status (SES) are more at-risk than others. However, many low SES Whites and higher SES racial minorities have poorer health than their racial or SES peers. Also, recent immigrant groups and Hispanics, in particular, maintain high health ratings. The so-called Hispanic Paradox provides an example of how culture and social background can be used to improve health outcomes. These groups have unique determinants of disparity that are based on a wide range of cultural and societal factors. Providing improved access to care and reducing the social determinants of disparity is crucial to improving public health. At the same time, for providers, increasing an understanding of the social determinants promotes better models of individualized care to encourage more equitable care. These approaches include increasing provider education on disparities encountered by different populations, practicing active listening skills, and utilizing a patient's cultural background to promote healthy behaviors.

Counties eliminating racial disparities in colorectal cancer mortality

BACKGROUND

Although colorectal cancer (CRC) mortality rates are declining, racial-ethnic disparities in CRC mortality nationally are widening. Herein, the authors attempted to identify county-level variations in this pattern, and to characterize counties with improving disparity trends.

METHODS

The authors examined 20-year trends in US county-level black-white disparities in CRC age-adjusted mortality rates during the study period between 1989 and 2010. Using a mixed linear model, counties were grouped into mutually exclusive patterns of black-white racial disparity trends in age-adjusted CRC mortality across 20 three-year rolling average data points. County-level characteristics from census data and from the Area Health Resources File were normalized and entered into a principal component analysis. Multinomial logistic regression models were used to test the relation between these factors (clusters of related contextual variables) and the disparity trend pattern group for each county.

RESULTS

Counties were grouped into 4 disparity trend pattern groups: 1) persistent disparity (parallel black and white trend lines); 2) diverging (widening disparity); 3) sustained equality; and 4) converging (moving from disparate outcomes toward equality). The initial principal component analysis clustered the 82 independent variables into a smaller number of components, 6 of which explained 47% of the county-level variation in disparity trend patterns.

CONCLUSIONS

County-level variation in social determinants, health care workforce, and health systems all were found to contribute to variations in cancer mortality disparity trend patterns from 1990 through 2010. Counties sustaining equality over time or moving from disparities to equality in cancer mortality suggest that disparities are not inevitable, and provide hope that more communities can achieve optimal and equitable cancer outcomes for all. Cancer 2016;122:1735-48. © 2016 American Cancer Society.

Socioeconomic status, human papillomavirus, and overall survival in head and neck squamous cell carcinomas in Toronto, Canada

BACKGROUND

Despite universal healthcare in some countries, lower socioeconomic status (SES) has been associated with worse cancer survival. The influence of SES on head and neck cancer (HNC) survival is of immense interest, since SES is associated with the risk and prognostic factors associated with this disease.

PATIENTS AND METHODS

Newly diagnosed HNC patients from 2003 to 2010 (n=2124) were identified at Toronto's Princess Margaret Cancer Centre. Principal component analysis was used to calculate a composite score using neighbourhood-level SES variables obtained from the 2006 Canada Census. Associations of SES with overall survival were evaluated in HNC subsets and by p16 status (surrogate for human papillomavirus).

RESULTS

SES score was higher for oral cavity (n=423) and p16-positive oropharyngeal cancer (OPC, n=404) patients compared with other disease sites. Lower SES was associated with worse survival [HR 1.14 (1.06-1.22), p=0.0002], larger tumor staging (p<0.001), current smoking (p<0.0001), heavier alcohol consumption (p<0.0001), and greater comorbidity (p<0.0002), but not with treatment regimen (p>0.20). After adjusting for age, sex, and stage, the lowest SES quintile was associated with the worst survival only for OPC patients [HR 1.66 (1.09-2.53), n=832], primarily in the p16-negative subset [HR 1.63 (0.96-2.79)]. The predictive ability of the prognostic models improved when smoking/alcohol was added to the model (c-index 0.71 vs. 0.69), but addition of SES did not (c-index 0.69).

CONCLUSION

SES was associated with survival, but this effect was lost after accounting for other factors (age, sex, TNM stage, smoking/alcohol). Lower SES was associated with greater smoking, alcohol consumption, comorbidity, and stage.

Care and survival of Mexican American women with node negative breast cancer: historical cohort evidence of health insurance and barrio advantages

We hypothesized 3-way ethnicity by barrio by health insurance interactions such that the advantages of having adequate health insurance were greatest among Mexican American (MA) women who lived in barrios. Barrios were neighborhoods with relatively high concentrations of MAs (60% or more). Data were analyzed for 194 MA and 2,846 non-Hispanic white women diagnosed with, very treatable, node negative breast cancer in California between 1996 and 2000 and followed until 2011. Significant interactions were observed such that the protective effects of Medicare or private health insurance on radiation therapy access and long term survival were largest for MA women who resided in MA barrios, neighborhoods that also tended to be extremely poor. These paradoxical findings are consistent with the theory that more facilitative social and economic capital available to MA women in barrios enables them to better absorb the indirect and direct, but uncovered, costs of breast cancer care.

Variation in insurance status by patient demographics and tumor site among nonelderly adult patients with cancer

BACKGROUND

In the United States, an estimated 48 million individuals live without health insurance. The purpose of the current study was to explore the Variation in insurance status by patient demographics and tumor site among nonelderly adult patients with cancer.

METHODS

A total of 688,794 patients aged 18 to 64 years who were diagnosed with one of the top 25 incident cancers (representing 95% of all cancer diagnoses) between 2007 and 2010 in the Surveillance, Epidemiology, and End Results (SEER) database were analyzed. Patient characteristics included age, race, sex, marital status, and rural or urban residence. County-level demographics included percent poverty level. Insurance status was defined as having non-Medicaid insurance, Medicaid coverage, or no insurance.

RESULTS

On multivariate logistic regression analyses, younger age, male sex, nonwhite race, being unmarried, residence in counties with higher levels of poverty, and rural residence were associated with being uninsured versus having non-Medicaid insurance (all P <.001). The highest rates of non-Medicaid insurance were noted among patients with prostate cancer (92.3%), melanoma of the skin (92.5%), and thyroid cancer (89.5%), whereas the lowest rates of non-Medicaid insurance were observed among patients with cervical cancer (64.2%), liver cancer (67.9%), and stomach cancer (70.9%) (P <.001). Among uninsured individuals, the most prevalent cancers were lung cancer (14.9%), colorectal cancer (12.1%), and breast cancer (10.2%) (P <.001). Lung cancer caused the majority of cancer mortality in all insurance groups.

CONCLUSIONS

Rates of insurance coverage vary greatly by demographics and by cancer type. The expansion of health insurance coverage would be expected to disproportionally benefit certain demographic populations and cancer types.

Can economic deprivation protect health? Paradoxical multilevel effects of poverty on Hispanic children's wheezing

Prior research suggests that economic deprivation has a generally negative influence on residents’ health. We employ hierarchical logistic regression modeling to test if economic deprivation presents respiratory health risks or benefits to Hispanic children living in the City of El Paso (Texas, USA) at neighborhood- and individual-levels, and whether individual-level health effects of economic deprivation vary based on neighborhood-level economic deprivation. Data come from the US Census Bureau and a population-based survey of El Paso schoolchildren. The dependent variable is children’s current wheezing, an established respiratory morbidity measure, which is appropriate for use with economically-deprived children with an increased likelihood of not receiving a doctor’s asthma diagnosis. Results reveal that economic deprivation (measured based on poverty status) at both neighborhood- and individual-levels is associated with reduced odds of wheezing for Hispanic children. A sensitivity analysis revealed similar significant effects of individual- and neighborhood-level poverty on the odds of doctor-diagnosed asthma. Neighborhood-level poverty did not significantly modify the observed association between individual-level poverty and Hispanic children’s wheezing; however, greater neighborhood poverty tends to be more protective for poor (as opposed to non-poor) Hispanic children. These findings support a novel, multilevel understanding of seemingly paradoxical effects of economic deprivation on Hispanic health.

Race and breast cancer survival by intrinsic subtype based on PAM50 gene expression

To evaluate whether differences in PAM50 breast cancer (BC) intrinsic (Luminal A, Luminal B, Basal-like, and HER2-enriched) subtypes help explain the Black-White BC survival disparity. Utilizing a stratified case-cohort design, this study included 1,635 women from the Pathways and Life After Cancer Epidemiology cohorts, selecting women with tumors based upon IHC classification, recurrences, and deaths.One millimeter punches were obtained from tumor tissue, and expression of the PAM50 genes for molecular subtype was determined by RT-qPCR of extracted RNA. Cox proportional hazards models were used to analyze associations between race and BC outcomes, adjusted for PAM50 BC subtype. All tests of statistical significance were two-sided. Black women had a higher prevalence of the Basal-like BC subtype. Adjusted for potential confounding variables and disease characteristics at diagnosis, Black women had higher risks of recurrence (HR 1.65, 95 % CI 1.06-2.57) and breast cancer-specific mortality (HR 1.71, 95 % CI 1.02-2.86) than White women, but adjusting further for subtype did not attenuate survival disparities. By contrast, Hispanic women had a lower risk of recurrence (HR 0.54, 95 % CI 0.30-0.96) than Whites. Among those with the Basal-like subtype, Black women had a similar recurrence risk as women in other race groups but a higher recurrence risk for all other subtypes. Hispanic women had a lower recurrence risk within each subtype, though associations were not significant, given limited power. Although Black women had a higher risk of the Basal-like subtype, which has poor prognosis, this did not explain the Black-White BC survival disparity.