Racial and Ethnic Disparities in Cancer Survival: The Contribution of Tumor, Sociodemographic, Institutional, and Neighborhood Characteristics

Impact of environmental temperature on the survival outcomes of breast cancer: A SEER-based study

BACKGROUND

Experimental evidence in tumor-bearing mouse models shows that exposure to cool, that is, sub-thermoneutral environmental temperature is associated with a higher tumor growth rate and an immunosuppressive tumor immune microenvironment than seen at thermoneutral temperatures. However, the translational significance of these findings in humans is unclear. We hypothesized that breast cancer patients living in warmer climates will have better survival outcomes than patients living in colder climates.

METHODS

A retrospective population-based analysis was conducted on 270,496 stage I-III breast cancer patients, who were retrieved from the Surveillance, Epidemiology and End Results (SEER) over the period from 1996 to 2017. The average annual temperature (AAT) was calculated based on city level data from the National Centers for Environmental Information.

RESULTS

A total of 270, 496 patients were analyzed. Temperature as assessed in quartiles. After adjusting for potential confounders, patients who lived in the 3rd and 4th quartile temperature regions with AAT 56.7-62.5°F (3rd quartile) and > 62.5°F (4th quartile) had a 7% increase in the OS compared to patients living at AAT < 48.5°F (1st quartile) (HR 0.93, 95% CI 0.90-0.95 and HR 0.93, 95% CI 0.91-0.96, respectively). For DSS, When comparing AAT quartiles, patients living with AAT in the range of 56.7-62.5°F and > 62.5°F demonstrated a 7% increase each in DSS after adjustment (HR 0.93, 95% CI 0.90-0.96 and HR 0.93, 95% CI 0.90-0.96).

CONCLUSIONS

Higher environmental temperatures are associated with significantly better OS and DSS in breast cancer patients. Future research is warranted to confirm this observation using large datasets to elucidate the underlying mechanisms and investigate novel therapeutic strategies to minimize this geographic disparity in clinical outcomes.

The Interplay of Psycho-Social Determinants on Quality of Life and Health Behaviors Among Hispanic, Non-Hispanic Black Cancer Survivors

OBJECTIVES

This study aimed to explore psycho-social factors (i.e., socio-demographics, health insurance, stress) associated with Quality of life (QOL) and the degree to which self-reported access to healthcare and health behaviors (i.e., fruit and vegetable consumption, physical activity) mediate the effects of psycho-social factors on QOL among Hispanic, non-Hispanic Black (NHB), and other non-White cancer survivors.

METHODS

The descriptive cross-sectional study enrolled a total of 74 Hispanic (n = 26), NHB (n = 42), and other non-White (n = 6) people affected by cancer. QOL, physical activity, diet, stress, and survivorship care data were collected prospectively between June 2022-September 2023.

RESULTS

The mean scores of QOL were moderate for global health (59.4 ± 21.4) and functional status (64.8 ± 22.2) and low for symptom experience (33.6 ± 19.4). Of the participants, 35.1% (n = 24) reported at least one challenge in accessing healthcare. The average daily consumption of fruits and vegetables was 2.44 ± 0.61 cup equivalents. Most participants had insufficient (37.8%) or minimal (47.3%) engagement in physical activity. Men and those with higher stress levels reported lower global health status. Higher stress level was associated with an increased likelihood of lower physical activity. Private insurance and some college education were associated with an increased likelihood of consuming more fruit and vegetables. Self-reported access to healthcare did not mediate the association between any of the variables and the global health score of QOL.

CONCLUSIONS

Hispanic, NHB and other non-White cancer survivors had moderate global health and functional status with lower symptom burden. Further research with a large sample is needed to explore the associations between health behaviors, access to care challenges, and other factors that may better explain determinants of QOL among non-White cancer survivors.

IMPLICATIONS FOR NURSING PRACTICE

Findings suggest that tailored interventions should consider the interplay of psychosocial determinants to optimize health behaviors and QOL.

Does structural racism impact receipt of NCCN guideline-concordant breast cancer treatment?

PURPOSE

Disparities in breast cancer survival remain a challenge. We aimed to analyze the effect of structural racism, as measured by the Index of Concentration at the Extremes (ICE), on receipt of National Cancer Center Network (NCCN) guideline-concordant breast cancer treatment.

METHODS

We identified patients treated at two institutions from 2005 to 2017 with stage I-IV breast cancer. Census tracts served as neighborhood proxies. Using 5-year estimates from the American Community Survey, 5 ICE variables were computed to create 5 models, controlling for economic segregation, non-Hispanic Black (NHB) segregation, NHB/economic segregation, Hispanic segregation, and Hispanic/economic segregation. Multi-level logistic regression models were used to determine the association between individual and neighborhood-level characteristics on receipt of NCCN guideline-concordant breast cancer treatment.

RESULTS

5173 patients were included: 55.2% were Hispanic, 27.5% were NHW, and 17.3% were NHB. Regardless of economic or residential segregation, a NHB patient was less likely to receive appropriate treatment [(OR)Model1 0.58 (0.45-0.74); ORModel2 0.59 (0.46-0.78); ORModel3 0.62 (0.47-0.81); ORModel4 0.53 (0.40-0.69); ORModel5 0.59(0.46-0.76); p < 0.05].

CONCLUSION

To our knowledge, this is the first analysis assessing receipt of NCCN guideline-concordant treatment by ICE, a validated measure for structural racism. While much literature emphasizes neighborhood-level barriers to treatment, our results demonstrate that compared to NHW patients, NHB patients are less likely to receive NCCN guideline-concordant breast cancer treatment, independent of economic or residential segregation. Our study suggests that there are potential unaccounted individual or neighborhood barriers to receipt of appropriate care that go beyond economic or residential segregation.

Area Socioeconomic Status is Associated with Refusal of Recommended Surgery in Patients with Metastatic Bone and Joint Disease

BACKGROUND

This study sought to identify associations between the Yost Index, a geocoded area neighborhood socioeconomic status (nSES) score, and race/ethnicity with patient refusal of recommended surgery for metastatic bone disease.

METHODS

Patients with metastatic bone disease were extracted from the Surveillance, Epidemiology, and End Results database. The Yost Index was geocoded using factor analysis and categorized into quintiles using census tract-level American Community Service (ACS) 5-year estimates and seven nSES measures. Multivariable logistic regression models calculated odds ratios (ORs) of refusal of recommended surgery and 95% confidence intervals (CIs), adjusting for clinical covariates.

RESULTS

A total of 138,257 patients were included, of which 14,943 (10.8%) were recommended for surgical resection. Patients in the lowest nSES quintile had 57% higher odds of refusing surgical treatment than those in the highest quintile (aOR = 1.57, 95% CI 1.30-1.91, p < 0.001). Patients in the lowest nSES quintile also had a 31.2% higher age-adjusted incidence rate of not being recommended for surgery compared with those in the highest quintile (186.4 vs. 142.1 per 1 million, p < 0.001). Black patients had 34% higher odds of refusing treatment compared with White patients (aOR = 1.34, 95% CI 1.14-1.58, p = 0.003). Advanced age, unmarried status, and patients with aggressive cancer subtypes were associated with higher odds of refusing surgery (p < 0.001).

CONCLUSIONS

nSES and race/ethnicity are independent predictors of a patient refusing surgery for metastatic cancer to bone, even after adjusting for various clinical covariates. Effective strategies for addressing these inequalities and improving the access and quality of care of patients with a lower nSES and minority backgrounds are needed.

Racial disparities in outcomes of patients with stage I-III triple-negative breast cancer after adjuvant chemotherapy: a post-hoc analysis of the E5103 randomized trial

PURPOSE

Breast cancer mortality is higher in Black women than other racial groups. This difference has been partially attributed to a higher proportion of triple-negative breast cancer (TNBC). However, it is uncertain if survival disparities exist in racially diverse TNBC patients receiving similar treatments. Here, we examine racial differences in disease-related outcomes in TNBC patients treated on the E5103 clinical trial.

METHODS

From 2007 to 2011, 4,994 patients with stage I-III HER2-negative breast cancer were randomized to adjuvant chemotherapy with or without bevacizumab. This analysis was limited to the subset of 1,742 TNBC patients with known self-reported race. Unadjusted Kaplan-Meier curves and adjusted Cox-Proportional Hazards models were used to determine breast cancer events and survival outcomes.

RESULTS

Of the analysis population, 51 (2.9%) were Asian, 269 (15.4%) Black, and 1422 (81.6%) White. Median age was 51 years. Patient characteristics, treatment arm, and local therapies were similar across racial groups. White women were more commonly node-negative (56% vs. 49% and 44% in Asian and Black women, respectively; p < 0.01). At a median follow-up of 46 months, unadjusted Kaplan-Meier locoregional and distant recurrence, and disease-free and overall survival, did not differ significantly by race. In Cox models adjusted for patient and tumor characteristics and treatment arm, race was not associated with any disease event. Larger tumor size and nodal involvement were consistently associated with breast cancer events.

CONCLUSION

This clinical trial population of similarly treated TNBC patients showed no racial differences in breast cancer outcomes. Disease extent, rather than race, was associated with disease events.

Readability and Information Quality in Cancer Information From a Free vs Paid Chatbot

Importance

The mainstream use of chatbots requires a thorough investigation of their readability and quality of information.

Objective

To identify readability and quality differences in information between a free and paywalled chatbot cancer-related responses, and to explore if more precise prompting can mitigate any observed differences.

Design, Setting, and Participants

This cross-sectional study compared readability and information quality of a chatbot's free vs paywalled responses with Google Trends' top 5 search queries associated with breast, lung, prostate, colorectal, and skin cancers from January 1, 2021, to January 1, 2023. Data were extracted from the search tracker, and responses were produced by free and paywalled ChatGPT. Data were analyzed from December 20, 2023, to January 15, 2024.

Exposures

Free vs paywalled chatbot outputs with and without prompt: "Explain the following at a sixth grade reading level: [nonprompted input]."

Main Outcomes and Measures

The primary outcome measured the readability of a chatbot's responses using Flesch Reading Ease scores (0 [graduate reading level] to 100 [easy fifth grade reading level]). Secondary outcomes included assessing consumer health information quality with the validated DISCERN instrument (overall score from 1 [low quality] to 5 [high quality]) for each response. Scores were compared between the 2 chatbot models with and without prompting.

Results

This study evaluated 100 chatbot responses. Nonprompted free chatbot responses had lower readability (median [IQR] Flesh Reading ease scores, 52.60 [44.54-61.46]) than nonprompted paywalled chatbot responses (62.48 [54.83-68.40]) (P < .05). However, prompting the free chatbot to reword responses at a sixth grade reading level was associated with increased reading ease scores than the paywalled chatbot nonprompted responses (median [IQR], 71.55 [68.20-78.99]) (P < .001). Prompting was associated with increases in reading ease in both free (median [IQR], 71.55 [68.20-78.99]; P < .001)and paywalled versions (median [IQR], 75.64 [70.53-81.12]; P < .001). There was no significant difference in overall DISCERN scores between the chatbot models, with and without prompting.

Conclusions and Relevance

In this cross-sectional study, paying for the chatbot was found to provide easier-to-read responses, but prompting the free version of the chatbot was associated with increased response readability without changing information quality. Educating the public on how to prompt chatbots may help promote equitable access to health information.

Demographic differences in early vs. late-stage laryngeal squamous cell carcinoma

PURPOSE

This study aims to evaluate how various demographic factors impact the stage at diagnosis and, therefore, prognosis of laryngeal cancer.

MATERIALS AND METHODS

Using the National Cancer Database, 96,409 patients were diagnosed with laryngeal squamous cell carcinoma between 2004 and 2020. Early (stage 0 or I) vs. late-stage (stage IV) cancers were compared based on demographic variables utilizing Chi-square and multivariate analysis with a significance of p < 0.05.

RESULTS

Female, Black, and generally older patients were more likely to have late-stage cancer than their counterparts. When compared with a community cancer program, patients treated at other facility types were more likely to be diagnosed late. Patients with private insurance, Medicare, or other government insurance were all less likely to have late-stage cancer compared to patients without insurance. Compared to patients in the lowest median household income quartile, patients in the third quartile and fourth quartile were diagnosed earlier. Patients living in an area with the lowest level of high school degree attainment were most likely to be diagnosed late. Living in a more populous area was associated with a lower chance of being diagnosed late. Increasing Charlson-Deyo Score was associated with a stronger likelihood of being diagnosed at a later stage.

CONCLUSION

Patients who are female, Black, uninsured, have a low household income, live in less populated and less educated areas, are treated at non-community cancer programs, and have more comorbid conditions have later stage diagnoses. This data contributes to understanding inequities in healthcare.

Guideline-concordant breast cancer care by patient race and ethnicity accounting for individual-, facility- and area-level characteristics: a SEER-Medicare study

PURPOSE

To examine racial-ethnic variation in adherence to established quality metrics (NCCN guidelines and ASCO quality metrics) for breast cancer, accounting for individual-, facility-, and area-level factors.

METHODS

Data from women diagnosed with invasive breast cancer at 66+ years of age from 2000 to 2017 were examined using SEER-Medicare. Associations between race and ethnicity and guideline-concordant diagnostics, locoregional treatment, systemic therapy, documented stage, and oncologist encounters were estimated using multilevel logistic regression models to account for clustering within facilities or counties.

RESULTS

Black and American Indian/Alaska Native (AIAN) women had consistently lower odds of guideline-recommended care than non-Hispanic White (NHW) women (Diagnostic workup: ORBlack 0.83 (0.79-0.88), ORAIAN 0.66 (0.54-0.81); known stage: ORBlack 0.87 (0.80-0.94), ORAIAN 0.63 (0.47-0.85); seeing an oncologist: ORBlack 0.75 (0.71-0.79), ORAIAN 0.60 (0.47-0.72); locoregional treatment: ORBlack 0.80 (0.76-0.84), ORAIAN 0.84 (0.68-1.02); systemic therapies: ORBlack 0.90 (0.83-0.98), ORAIAN 0.66 (0.48-0.91)). Commission on Cancer accreditation and facility volume were significantly associated with higher odds of guideline-concordant diagnostics, stage, oncologist visits, and systemic therapy. Black residential segregation was associated with significantly lower odds of guideline-concordant locoregional treatment and systemic therapy. Rurality and area SES were associated with significantly lower odds of guideline-concordant diagnostics and oncologist visits.

CONCLUSIONS

This is the first study to examine guideline-concordance across the continuum of breast cancer care from diagnosis to treatment initiation. Disparities were present from the diagnostic phase and persisted throughout the clinical course. Facility and area characteristics may facilitate or pose barriers to guideline-adherent treatment and warrant future investigation as mediators of racial-ethnic disparities in breast cancer care.

Real-world and clinical trial outcomes in large B-cell lymphoma with axicabtagene ciloleucel across race and ethnicity

ABSTRACT

Axicabtagene ciloleucel (axi-cel) is an autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy approved for relapsed/refractory (R/R) large B-cell lymphoma (LBCL). Despite extensive data supporting its use, outcomes stratified by race and ethnicity groups are limited. Here, we report clinical outcomes with axi-cel in patients with R/R LBCL by race and ethnicity in both real-world and clinical trial settings. In the real-world setting, 1290 patients who received axi-cel between 2017 and 2020 were identified from the Center for International Blood and Marrow Transplant Research database; 106 and 169 patients were included from the ZUMA-1 and ZUMA-7 trials, respectively. Overall survival was consistent across race/ethnicity groups. However, non-Hispanic (NH) Black patients had lower overall response rate (OR, 0.37; 95% CI, 0.22-0.63) and lower complete response rate (OR, 0.57; 95% CI, 0.33-0.97) than NH White patients. NH Black patients also had a shorter progression-free survival vs NH White (HR, 1.41; 95% CI, 1.04-1.90) and NH Asian patients (HR, 1.67; 95% CI, 1.08-2.59). NH Asian patients had a longer duration of response than NH White (HR, 0.56; 95% CI, 0.33-0.94) and Hispanic patients (HR, 0.54; 95% CI, 0.30-0.97). There was no difference in cytokine release syndrome by race/ethnicity; however, higher rates of any-grade immune effector cell-associated neurotoxicity syndrome were observed in NH White patients than in other patients. These results provide important context when treating patients with R/R LBCL with CAR T-cell therapy across different racial and ethnic groups. ZUMA-1 and ZUMA-7 (ClinicalTrials.gov identifiers: #NCT02348216 and #NCT03391466, respectively) are registered on ClinicalTrials.gov.

National Trends and Factors Associated with Voluntary Refusal of Glioblastoma Treatment: A Retrospective Review of the National Cancer Database

OBJECTIVE

Adherence to combinatorial treatments are important predictors of improved long-term outcomes for patients with glioblastoma (GB); however, factors associated with refusal of surgery, chemotherapy, or radiotherapy (RT) by patients with GB have not been studied.

METHODS

The National Cancer Database was queried from 2004 to 2018 to identify patients with a primary diagnosis of GB who underwent surgical resection alone or followed by either RT or chemotherapy. Adult patients who voluntarily rejected a physician's recommendations for 1 or more treatment were selected. Multivariable regression was used to identify factors associated with rejection of surgical resection, chemotherapy, and RT. Patients receiving treatment were 3:1 propensity score matched to those rejecting treatment and median overall survival (OS) was compared.

RESULTS

58,788 patients were included in the analysis. Factors associated with voluntary refusal of GB treatment included: old age, nonprivate insurance, female sex, Black race, comorbidities, treatment at a nonacademic facility, and living 55+ miles away from a treatment facility (P < 0.05). On propensity matched analysis, refusal of surgery conferred a 4 month decrease in OS (P < 0.001), RT an 8 month decrease in OS (P < 0.001), and chemotherapy a 7 month decrease in OS (P < 0.001).

CONCLUSIONS

In patients with GB, age, sex, race, nonprivate insurance, medical comorbidities, distance from treatment facility, and geographic location were associated with refusal of surgery, postsurgical RT, and chemotherapy. In addition, treatment refusal had a significant impact on OS length.

Understanding racial differences in financial hardship among older adults surviving cancer

BACKGROUND

Despite Medicare coverage, financial hardship is a prevalent issue among those diagnosed with cancer at age 65 years and older, particularly among those belonging to a racial or ethnic minority group. Sociodemographic, clinical, and area-level factors may mediate this relationship; however, no studies have assessed the extent to which these factors contribute to the racial/ethnic disparities in financial hardship.

METHODS

Surveys assessing financial hardship were completed by 721 White (84%) or Black (16%) patients (aged 65 years and older) who were diagnosed with breast (34%), prostate (27%), lung (17%), or colorectal (14%) cancer or lymphoma (9%) at the University of Alabama at Birmingham between 2000 and 2019. Financial hardship included material, psychological, and behavioral domains. Nonlinear Blinder-Oaxaca effect decomposition methods were used to evaluate the extent to which individual and area-level factors contribute to racial disparities in financial hardship.

RESULTS

Black patients reported lower income (65% vs. 34% earning <$50,000) and greater scores on the Area Deprivation Index (median, 93.0 vs. 55.0). Black patients reported significantly higher rates of overall (39% vs. 18%), material (29% vs. 11%), and psychological (27% vs. 11%) hardship compared with White patients. Overall, the observed characteristics explained 51% of racial differences in financial hardship among cancer survivors, primarily because of differences in income (23%) and area deprivation (11%).

CONCLUSIONS

The current results identify primary contributors to racial disparities in financial hardship among older cancer survivors, which can be used to develop targeted interventions and allocate resources to those at greatest risk for financial hardship.

Association of depressive symptoms and sleep disturbances with survival among US adult cancer survivors

BACKGROUND

Depression and sleep disturbances are associated with increased risks of various diseases and mortality, but their impacts on mortality in cancer survivors remain unclear. The objective of this study was to characterize the independent and joint associations of depressive symptoms and sleep disturbances with mortality outcomes in cancer survivors.

METHODS

This population-based prospective cohort study included cancer survivors aged ≥ 20 years (n = 2947; weighted population, 21,003,811) from the National Health and Nutrition Examination Survey (NHANES) 2007-2018 cycles. Depressive symptoms and sleep disturbances were self-reported. Depressive symptoms were assessed using the Patient Health Questionnaire 9 (PHQ-9). Death outcomes were determined by correlation with National Death Index records through December 31, 2019. Primary outcomes included all-cause, cancer-specific, and noncancer mortality.

RESULTS

During the median follow-up of 69 months (interquartile range, 37-109 months), 686 deaths occurred: 240 participants died from cancer, 146 from heart disease, and 300 from other causes. Separate analyses revealed that compared with a PHQ-9 score (0-4), a PHQ-9 score (5-9) was associated with a greater risk of all-cause mortality (hazard ratio [HR], 1.28; 95% CI, 1.03-1.59), and a PHQ-9 score (≥ 10) was associated with greater risk of all-cause mortality (HR, 1.37; 95% CI, 1.04-1.80) and noncancer mortality (HR, 1.45; 95% CI, 1.01-2.10). Single sleep disturbances were not associated with mortality risk. In joint analyses, the combination of a PHQ-9 score ≥ 5 and no sleep disturbances, but not sleep disturbances, was associated with increased risks of all-cause mortality, cancer-specific mortality, and noncancer mortality. Specifically, compared with individuals with a PHQ-9 score of 0-4 and no sleep disturbances, HRs for all-cause mortality and noncancer mortality in individuals with a PHQ-9 score of 5-9 and no sleep disturbances were 1.72 (1.21-2.44) and 1.69 (1.10-2.61), respectively, and 2.61 (1.43-4.78) and 2.77 (1.27-6.07), respectively, in individuals with a PHQ-9 score ≥ 10 and no sleep disturbances; HRs for cancer-specific mortality in individuals with a PHQ-9 score ≥ 5 and no sleep disturbances were 1.95 (1.16-3.27).

CONCLUSIONS

Depressive symptoms were linked to a high risk of mortality in cancer survivors. The combination of a PHQ-9 score (≥ 5) and an absence of self-perceived sleep disturbances was associated with greater all-cause mortality, cancer-specific mortality, and noncancer mortality risks, particularly in individuals with a PHQ-9 score (≥ 10).

Neighborhood Deprivation and Breast Cancer Mortality Among Black and White Women

Importance

Neighborhood deprivation has been associated with increased breast cancer mortality among White women, but findings are inconsistent among Black women, who experience different neighborhood contexts. Accounting for interactions among neighborhood deprivation, race, and other neighborhood characteristics may enhance understanding of the association.

Objective

To investigate whether neighborhood deprivation is associated with breast cancer mortality among Black and White women and whether interactions with rurality, residential mobility, and racial composition, which are markers of access, social cohesion, and segregation, respectively, modify the association.

Design, Setting, and Participants

This population-based cohort study used Georgia Cancer Registry (GCR) data on women with breast cancer diagnosed in 2010 to 2017 and followed-up until December 31, 2022. Data were analyzed between January 2023 and October 2023. The study included non-Hispanic Black and White women with invasive early-stage (I-IIIA) breast cancer diagnosed between 2010 and 2017 and identified through the GCR.

Exposures

The Neighborhood Deprivation Index (NDI), assessed in quintiles, was derived through principal component analysis of 2011 to 2015 block group-level American Community Survey (ACS) data. Rurality, neighborhood residential mobility, and racial composition were measured using Georgia Public Health Department or ACS data.

Main Outcomes and Measures

The primary outcome was breast cancer-specific mortality identified by the GCR through linkage to the Georgia vital statistics registry and National Death Index. Cox proportional hazards regression was used to estimate age-adjusted and multivariable-adjusted hazard ratios (HRs) and 95% CIs for the association between neighborhood deprivation and breast cancer mortality.

Results

Among the 36 795 patients with breast cancer (mean [SD] age at diagnosis, 60.3 [13.1] years), 11 044 (30.0%) were non-Hispanic Black, and 25 751 (70.0%) were non-Hispanic White. During follow-up, 2942 breast cancer deaths occurred (1214 [41.3%] non-Hispanic Black women; 1728 [58.7%] non-Hispanic White women). NDI was associated with an increase in breast cancer mortality (quintile 5 vs 1, HR, 1.36; 95% CI, 1.19-1.55) in Cox proportional hazards models. The association was present only among non-Hispanic White women (quintile 5 vs 1, HR, 1.47; 95% CI, 1.21-1.79). Similar race-specific patterns were observed in jointly stratified analyses, such that NDI was associated with increased breast cancer mortality among non-Hispanic White women, but not non-Hispanic Black women, irrespective of the additional neighborhood characteristics considered.

Conclusions and Relevance

In this cohort study, neighborhood deprivation was associated with increased breast cancer mortality among non-Hispanic White women. Neighborhood racial composition, residential mobility, and rurality did not explain the lack of association among non-Hispanic Black women, suggesting that factors beyond those explored here may contribute to breast cancer mortality in this racial group.

Residential Redlining, Neighborhood Trajectory, and Equity of Breast and Colorectal Cancer Care

OBJECTIVE

To determine the influence of structural racism, vis-à-vis neighborhood socioeconomic trajectory, on colorectal and breast cancer diagnosis and treatment.

BACKGROUND

Inequities in cancer care are well-documented in the United States but less is understood about how historical policies like residential redlining and evolving neighborhood characteristics influence current gaps in care.

METHODS

This retrospective cohort study included adult patients diagnosed with colorectal or breast cancer between 2010 and 2015 in 7 Indiana cities with available historic redlining data. Current neighborhood socioeconomic status was determined by the Area Deprivation Index. Based on historic redlining maps and the current Area Deprivation Index, we created 4 "neighborhood trajectory" categories: advantage stable, advantage reduced, disadvantage stable, and disadvantage reduced. Modified Poisson regression models estimated the relative risks (RRs) of neighborhood trajectory on cancer stage at diagnosis and receipt of cancer-directed surgery (CDS).

RESULTS

A final cohort derivation identified 4862 cancer patients with colorectal or breast cancer. Compared with "advantage stable" neighborhoods, "disadvantage stable" neighborhood was associated with a late-stage diagnosis for both colorectal and breast cancer [RR = 1.30 (95% CI: 1.05-1.59); RR = 1.41 (1.09-1.83), respectively]. Black patients had a lower likelihood of receiving CDS in "disadvantage reduced" neighborhoods [RR = 0.92 (0.86-0.99)] than White patients.

CONCLUSIONS

Disadvantage stable neighborhoods were associated with late-stage diagnoses of breast and colorectal cancer. "Disadvantage reduced" (gentrified) neighborhoods were associated with racial inequity in CDS. Improved neighborhood socioeconomic conditions may improve timely diagnosis but could contribute to racial inequities in surgical treatment.

Race/Ethnicity and Social Determinants of Health and Their Impact on the Timely Receipt of Appropriate Operative Treatment of Colon Cancer

INTRODUCTION

Rates of appropriate surgical treatment of colon cancer are historically worse in traditionally marginalized populations. We sought to examine which social determinants of health may be associated with longer time to appropriate operative intervention.

METHODS

The National Cancer Databank was queried for this retrospective study. Adult patients (18 to 90 years of age) diagnosed between 2004 and 2018 with single or primary, stage III colon cancer were included. Patient demographic variables included age at diagnosis, sex, ethnicity (Hispanic or non-Hispanic), comorbidity score, median household income, education status, rural/urban status, treatment facility type and location, and insurance status. Disease characteristics include stage (stage 3), primary site, surgical margins, tumor size, and number of nodes resected. Reported descriptive statistics include means and 95% confidence intervals for continuous variables and frequency and proportions for categorical variables. Univariate and multivariate analyses were performed.

RESULTS

A total of 134,601 individuals diagnosed with stage 3 colon cancer were included. Time to surgery in all cases had a mean of 26.4 ± 19.0 days. Multivariate analysis of time to surgery indicated that receiving surgery at a Community Cancer Program, Charlson-Deyo Score of 0, younger age, and non-Hispanic-White race/ethnicity are associated with decreased time to surgery (P < .001).

CONCLUSION

Patients who receive surgery at a Community Cancer Program, have fewer comorbidities, have lower household income, are younger, and receive surgery within 50 miles of their primary residence are more likely to have timely surgery.

Patient- and system-level factors associated with racial/ethnic disparities in the delivery of guideline-concordant therapy among US patients with gastric cancer

BACKGROUND

Disparities in gastric cancer (GC) outcomes show a higher disease burden among minorities. We aimed to evaluate the associations between sociodemographic and system-level factors and guideline-concordant treatment among GC patients.

METHODS

Cohort study with GC patients in the National Cancer Data Base (2006-2018) treated with upfront resection or neoadjuvant therapy (NAT). We used logistic regression to identify associations between deviations from guideline-concordant therapy and patient- and system-level factors, and Cox regression models to assess risk of death.

RESULTS

The cohort included 43 597 GC patients treated with endoscopic resection (8.9%), surgery only (47.1%), surgery and adjuvant therapy (20.6%), or NAT followed by surgery (23.5%). A total of 31 470 patients (72.2%) received guideline-concordant therapy. Relative to Non-Hispanic Whites (NHWs), Non-Hispanic Blacks (NHBs) (odds ratio [OR] 1.19, [95% confidence intervals 1.10-1.28]) and Asian/Pacific Islanders (APIs) (OR 1.12 [1.03-1.23]) had an increased risk of deviations from treatment guidelines. Medicare/Medicaid increased the risk of deviations while treatment at high-volume facilities decreased its risk for all races/ethnicities. Deviations from guidelines were associated with an increased risk of death (hazard ratio 1.56 [1.50-1.63].

CONCLUSIONS

Racial disparities in the delivery of guideline-concordant therapy among GC patients are affected by several sociodemographic factors at the patient- and system-level.

Social Determinants of Health in Cardio-Oncology: Multi-Level Strategies to Overcome Disparities in Care: JACC: CardioOncology State-of-the-Art Review

Addressing the need for more equitable cardio-oncology care requires attention to existing disparities in cardio-oncologic disease prevention and outcomes. This is particularly important among those affected by adverse social determinants of health (SDOH). The intricate relationship of SDOH, cancer diagnosis, and outcomes from cardiotoxicities associated with oncologic therapies is influenced by sociopolitical, economic, and cultural factors. Furthermore, mechanisms in cell signaling and epigenetic effects on gene expression link adverse SDOH to cancer and the CVD-related complications of oncologic therapies. To mitigate these disparities, a multifaceted strategy is needed that includes attention to health care access, policy, and community engagement for improved disease screening and management. Interdisciplinary teams must also promote cultural humility and competency and leverage new health technology to foster collaboration in addressing the impact of adverse SDOH in cardio-oncologic outcomes.

The association between neighborhood obesogenic factors and prostate cancer risk and mortality: the Southern Community Cohort Study

Background

Prostate cancer is one of the leading causes of cancer-related mortality among men in the United States. We examined the role of neighborhood obesogenic attributes on prostate cancer risk and mortality in the Southern Community Cohort Study (SCCS).

Methods

From the total of 34,166 SCCS male participants, 28,356 were included in the analysis. We assessed the relationship between neighborhood obesogenic factors [neighborhood socioeconomic status (nSES) and neighborhood obesogenic environment indices including the restaurant environment index, the retail food environment index, parks, recreational facilities, and businesses] and prostate cancer risk and mortality by controlling for individual-level factors using a multivariable Cox proportional hazards model. We further stratified prostate cancer risk analysis by race and body mass index (BMI).

Results

Median follow-up time was 133 months [interquartile range (IQR): 103, 152], and the mean age was 51.62 (SD: ± 8.42) years. There were 1,524 (5.37%) prostate cancer diagnoses and 98 (6.43%) prostate cancer deaths during follow-up. Compared to participants residing in the wealthiest quintile, those residing in the poorest quintile had a higher risk of prostate cancer (aHR = 1.32, 95% CI 1.12-1.57, p = 0.001), particularly among non-obese men with a BMI < 30 (aHR = 1.46, 95% CI 1.07-1.98, p = 0.016). The restaurant environment index was associated with a higher prostate cancer risk in overweight (BMI ≥ 25) White men (aHR = 3.37, 95% CI 1.04-10.94, p = 0.043, quintile 1 vs. None). Obese Black individuals without any neighborhood recreational facilities had a 42% higher risk (aHR = 1.42, 95% CI 1.04-1.94, p = 0.026) compared to those with any access. Compared to residents in the wealthiest quintile and most walkable area, those residing within the poorest quintile (aHR = 3.43, 95% CI 1.54-7.64, p = 0.003) or the least walkable area (aHR = 3.45, 95% CI 1.22-9.78, p = 0.020) had a higher risk of prostate cancer death.

Conclusion

Living in a lower-nSES area was associated with a higher prostate cancer risk, particularly among Black men. Restaurant and retail food environment indices were also associated with a higher prostate cancer risk, with stronger associations within overweight White individuals. Finally, residing in a low-SES neighborhood or the least walkable areas were associated with a higher risk of prostate cancer mortality.

Aspiring toward equitable benefits from genomic advances to individuals of ancestrally diverse backgrounds

Advancements in genomic technologies have shown remarkable promise for improving health trajectories. The Human Genome Project has catalyzed the integration of genomic tools into clinical practice, such as disease risk assessment, prenatal testing and reproductive genomics, cancer diagnostics and prognostication, and therapeutic decision making. Despite the promise of genomic technologies, their full potential remains untapped without including individuals of diverse ancestries and integrating social determinants of health (SDOHs). The NHGRI launched the 2020 Strategic Vision with ten bold predictions by 2030, including "individuals from ancestrally diverse backgrounds will benefit equitably from advances in human genomics." Meeting this goal requires a holistic approach that brings together genomic advancements with careful consideration to healthcare access as well as SDOHs to ensure that translation of genetics research is inclusive, affordable, and accessible and ultimately narrows rather than widens health disparities. With this prediction in mind, this review delves into the two paramount applications of genetic testing-reproductive genomics and precision oncology. When discussing these applications of genomic advancements, we evaluate current accessibility limitations, highlight challenges in achieving representativeness, and propose paths forward to realize the ultimate goal of their equitable applications.

Disparities in Cancer Stage Outcomes by Catchment Areas for a Comprehensive Cancer Center

Importance

The National Cancer Institute comprehensive cancer centers (CCCs) lack spatial and temporal evaluation of their self-designated catchment areas.

Objective

To identify disparities in cancer stage at diagnosis within and outside a CCC's catchment area across a 10-year period using spatial and statistical analyses.

Design, Setting, and Participants

This cross-sectional, population-based study conducted between 2010 and 2019 utilized cancer registry data for the Johns Hopkins Sidney Kimmel CCC (SKCCC). Eligible participants included patients with cancer in the contiguous US who received treatment for cancer, a diagnosis of cancer, or both at SKCCC. Patients were geocoded to zip code tabulation areas (ZCTAs). Individual-level variables included sociodemographic characteristics, smoking and alcohol use, treatment type, cancer site, and insurance type. Data analysis was performed between March and July 2023.

Exposures

Distance between SKCCC and ZCTAs were computed to generate a catchment area of the closest 75% of patients and outer zones in 5% increments for comparison.

Main Outcomes and Measures

The primary outcome was cancer stage at diagnosis, defined as early-stage, late-stage, or unknown stage. Multinomial logistic regression was used to determine associations of catchment area with stage at diagnosis.

Results

This study had a total of 94 007 participants (46 009 male [48.94%] and 47 998 female [51.06%]; 30 195 aged 22-45 years [32.12%]; 4209 Asian [4.48%]; 2408 Hispanic [2.56%]; 16 004 non-Hispanic Black [17.02%]; 69 052 non-Hispanic White [73.45%]; and 2334 with other or unknown race or ethnicity [2.48%]), including 47 245 patients (50.26%) who received a diagnosis of early-stage cancer, 19 491 (20.73%) who received a diagnosis of late-stage cancer , and 27 271 (29.01%) with unknown stage. Living outside the main catchment area was associated with higher odds of late-stage cancers for those who received only a diagnosis (odds ratio [OR], 1.50; 95% CI, 1.10-2.05) or only treatment (OR, 1.44; 95% CI, 1.28-1.61) at SKCCC. Non-Hispanic Black patients (OR, 1.16; 95% CI, 1.10-1.23) and those with Medicaid (OR, 1.65; 95% CI, 1.46-1.86) and no insurance at time of treatment (OR, 2.12; 95% CI, 1.79-2.51) also had higher odds of receiving a late-stage cancer diagnosis.

Conclusions and Relevance

In this cross-sectional study of CCC data from 2010 to 2019, patients residing outside the main catchment area, non-Hispanic Black patients, and patients with Medicaid or no insurance had higher odds of late-stage diagnoses. These findings suggest that disadvantaged populations and those living outside of the main catchment area of a CCC may face barriers to screening and treatment. Care-sharing agreements among CCCs could address these issues.

Variation in Hospital Mortality After Complex Cancer Surgery: Patient, Volume, Hospital or Social Determinants?

INTRODUCTION

We sought to define the individual contributions of patient characteristics (PCs), hospital characteristics (HCs), case volume (CV), and social determinants of health (SDoH) on in-hospital mortality (IHM) after complex cancer surgery.

METHODS

The California Department of Health Care Access and Information database identified patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PD), or proctectomy (PR) for a malignant diagnosis between 2010 and 2020. Multi-level multivariable regression was performed to assess the proportion of variance explained by PCs, HCs, CV and SDoH on IHM.

RESULTS

A total of 52,838 patients underwent cancer surgery (ES: n = 2,700, 5.1%; PN: n = 30,822, 58.3%; PD: n = 7530, 14.3%; PR: n = 11,786, 22.3%) across 294 hospitals. The IHM for the overall cohort was 1.7% and varied from 4.4% for ES to 0.8% for PR. On multivariable regression, PCs contributed the most to the variance in IHM (overall: 32.0%; ES: 21.6%; PN: 28.0%; PD: 20.3%; PR: 39.9%). Among the overall cohort, CV contributed 2.4%, HCs contributed 1.3%, and SDoH contributed 1.2% to the variation in IHM. CV was the second highest contributor to IHM among ES (5.3%), PN (5.3%), and PD (5.9%); however, HCs were a more important contributor among patients who underwent PR (8.0%). The unexplained variance in IHM was highest among ES (72.4%), followed by the PD (67.5%) and PN (64.6%) patient groups.

CONCLUSIONS

PCs are the greatest underlying contributor to variations in IHM following cancer surgery. These data highlight the need to focus on optimizing patients and exploring unexplained sources of IHM to improve quality of surgical care.

Assessment of Social Vulnerabilities of Care and Prognosis in Adult Ocular Melanomas in the US

BACKGROUND

Prior works have studied the impact of social determinants on various cancers but there is limited analysis on eye-orbit cancers. Current literature tends to focus on socioeconomic status and race, with sparse analysis of interdisciplinary contributions. We examined social determinants as measured by the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), quantifying eye and orbit melanoma disparities across the United States.

METHODS

A retrospective review of 15,157 patients diagnosed with eye-orbit cancers in the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2017 was performed, extracting 6139 ocular melanomas. SVI scores were abstracted and matched to SEER patient data, with scores generated by weighted averages per population density of county's census tracts. Primary outcome was months survived, while secondary outcomes were advanced staging, high grading, and primary surgery receipt.

RESULTS

With increased total SVI score, indicating more vulnerability, we observed significant decreases of 23.1% in months survival for melanoma histology (p < 0.001) and 19.6-39.7% by primary site. Increasing total SVI showed increased odds of higher grading (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.02-1.43) and decreased odds of surgical intervention (OR 0.94, 95% CI 0.92-0.96). Of the four themes, higher magnitude contributions were observed with socioeconomic status (26.0%) and housing transportation (14.4%), while lesser magnitude contributions were observed with minority language status (13.5%) and household composition (9.0%).

CONCLUSIONS

Increasing social vulnerability, as measured by the CDC SVI and its subscores, displayed significant detrimental trends in prognostic and treatment factors for adult eye-orbit melanoma. Subscores quantified which social determinants contributed most to disparities. This lays groundwork for providers to target the highest-impact social determinant for non-clinical factors in patient care.

The association between neighborhood obesogenic factors and prostate cancer risk and mortality: the Southern Community Cohort Study

Background

Prostate cancer is one of the leading causes of cancer-related mortality among men in the United States. We examined the role of neighborhood obesogenic attributes on prostate cancer risk and mortality in the Southern Community Cohort Study (SCCS).

Methods

From the total of 34,166 SCCS male participants, 28,356 were included in the analysis. We assessed the relationship between neighborhood obesogenic factors [neighborhood socioeconomic status (nSES) and neighborhood obesogenic environment indices including the restaurant environment index, the retail food environment index, parks, recreational facilities, and businesses] and prostate cancer risk and mortality by controlling for individual-level factors using a multivariable Cox proportional hazards model. We further stratified prostate cancer risk analysis by race and body mass index (BMI).

Results

Median follow-up time was 133 months [interquartile range (IQR): 103, 152], and the mean age was 51.62 (SD: ± 8.42) years. There were 1,524 (5.37%) prostate cancer diagnoses and 98 (6.43%) prostate cancer deaths during follow-up. Compared to participants residing in the wealthiest quintile, those residing in the poorest quintile had a higher risk of prostate cancer (aHR = 1.32, 95% CI 1.12-1.57, p = 0.001), particularly among non-obese men with a BMI < 30 (aHR = 1.46, 95% CI 1.07-1.98, p = 0.016). The restaurant environment index was associated with a higher prostate cancer risk in overweight (BMI ≥ 25) White men (aHR = 3.37, 95% CI 1.04-10.94, p = 0.043, quintile 1 vs. None). Obese Black individuals without any neighborhood recreational facilities had a 42% higher risk (aHR = 1.42, 95% CI 1.04-1.94, p = 0.026) compared to those with any access. Compared to residents in the wealthiest quintile and most walkable area, those residing within the poorest quintile (aHR = 3.43, 95% CI 1.54-7.64, p = 0.003) or the least walkable area (aHR = 3.45, 95% CI 1.22-9.78, p = 0.020) had a higher risk of prostate cancer death.

Conclusion

Living in a lower-nSES area was associated with a higher prostate cancer risk, particularly among Black men. Restaurant and retail food environment indices were also associated with a higher prostate cancer risk, with stronger associations within overweight White individuals. Finally, residing in a low-SES neighborhood or the least walkable areas were associated with a higher risk of prostate cancer mortality.

Associations Between Race and Survival Outcomes Among Veterans With Head and Neck Cancer in a Racially Diverse Setting

Objective

There is limited data on the impact of clinical-demographic factors on survival outcomes among veterans with head and neck squamous cell carcinoma (HNSCC). This study was undertaken to evaluate the impact of race and other factors on overall survival (OS) in a population of veterans with HNSCC treated with curative intent.

Methods

Demographic and clinical data were collected on veterans with HNSCC treated with curative intent at our institution between 1999 and 2021. The primary outcome was 3-year OS. Secondary outcomes included treatment delay intervals, including time to treatment initiation (TTI), total package time, and duration of chemoradiation (DCRT).

Results

Of 260 veterans with HNSCC, black veterans had significantly lower 3-year OS (49.4%) compared to white veterans (65%, P = .019). Black veterans were also more likely to experience delays in treatment initiation (median TTI 46 vs 41 days; P = .047). Black patients were more likely to receive radiation alone (25.8% [black] vs 8.4% [white]; P < .001) and less likely to receive adjuvant therapy if treated surgically (11.1% [black] vs 22.4% [white]; P = .004), despite any statistically significant difference in stage of their tumor at presentation (Stage I: 21.2% [black] vs 19.6% [white]; P = .372); (Stage IV: 44.4% [black] vs 48.6% [white]; P = .487). Other factors associated with worse 3-year OS included older age (P = .023), lower body mass index (P = .026), neurocognitive disorder/dementia (P = .037), mental health disorders (P = .020), hypopharyngeal primary (P = .001), higher stage disease (P = .002), treatment type (P = .001), need for prophylactic gastrostomy tube (P = .048) or tracheotomy (P = .005), recurrent disease (P = .036), persistent disease (P < .001), distant metastases (P = .002), longer TTI (P = .0362), and longer DCRT (P = .004).

Discussion

Black race appears to be an independent predictor of 3-year OS in veterans with HNSCC. Further studies are warranted to determine the factors responsible for disparities in survival.

Implications for Practice

This study evaluated the ways in which race affects survival for US veterans with head and neck cancer. The authors found that black veterans had an increased risk of death compared to white patients, and also experienced delays when receiving treatment.

Level of Evidence

Level IV.

The role of race and ethnicity in health care crowdfunding: an exploratory analysis

Medical crowdfunding is a key source of financing for individuals facing high out-of-pocket costs, including organ-transplant candidates. However, little is known about racial disparities in campaigning activity and outcomes, or how these relate to access to care. In this exploratory, nationwide, cross-sectional study, we examined racial disparities in campaigning activity across states and the association between US campaigners' race and ethnicity and crowdfunding outcomes using a novel database of organ-transplant-related campaigns, and an algorithm to identify race and ethnicity based on name and geographic location. This analysis suggests that there are racial disparities in individuals' ability to successfully raise requested funds, with Black and Hispanic campaigners fundraising lower amounts and less likely to achieve their monetary goals. We also found that crowdfunding among White, Black, and Hispanic populations exhibits different patterns of activity at the state level, and in relation to race-specific uninsurance and waitlist additions, highlighting potential differences in fundraising need across the 3 groups. Policy efforts should consider not only how inequalities in fundraising ability for associated costs influence accessibility to care but also how to identify clinical need among minorities.

Analysis of Breast Cancer Screening Results and Influencing Factors of Breast Cancer in Guangdong Province from 2017 to 2021

BACKGROUNDS

Breast cancer screening plays an important role in the early detection, diagnosis and treatment of breast cancer. The aim of this study was to evaluate the screening results and explore the influencing factors of breast cancer detection rate in Guangdong.

METHODS

This cross-sectional study was conducted among 2,024,960 women aged 35-64 in Guangdong Province during 2017-2021. The data about breast cancer screening information were collected from the Guangdong maternal and child health information system. Descriptive statistical analysis was used to explain demographic characteristics and results of breast cancer screening. The generalized linear regression model was applied to analyze the related influencing factors of breast cancer detection rate.

RESULTS

The estimated detection rate of breast cancer in Guangdong Province is 70.32/105, with an early diagnosis rate of 82.06%. After adjusting covariates, those women with older age (45-55 [OR (95% CI) 2.174 (1.872, 2.526)], 55-65 [OR (95% CI) 2.162 (1.760, 2.657)]), education for high school ([OR (95% CI) 1.491 (1.254, 1.773)]) and older age at first birth ([OR (95% CI) 1.632 (1.445, 1.844)]) were more likely to have higher detection rate of breast cancer. No history of surgery or biopsy ([OR (95% CI) 0.527 (0.387, 0.718)]), no history of breast cancer check ([OR (95% CI) 0.873 (0.774, 0.985)]) and no family history of breast cancer ([OR (95% CI) 0.255 (0.151, 0.432)]) women were more likely to screen negative for breast cancer (P < 0.05).

CONCLUSION

The detection rate of breast cancer in screening showed an increasing trend year by year in Guangdong Province. Older age, education for high school and older age at first birth were risk factors for breast cancer detection rate, while no surgery or biopsy history, no family history of breast cancer and no history of breast cancer check were protective factors.

A Mixed-Method Approach to Explore Successful Recruitment and Treatment of Minority Patients on Therapeutic Cancer Clinical Trials at a Tertiary Referral Center Using Photo-Elicitation Interviews

Introduction

Under-represented minority patients (URM) enroll in cancer clinical trials (CCT) at low rates. To gain insight into barriers and facilitators to CCT enrollment, we conducted a mixed method study of URM patients who were successfully treated on a therapeutic CCT from 2018-2021 at all institutional sites.

Methods

A retrospective chart review of 270 minority patients was conducted to identify patient demographics and characteristics. All living URM patients were requested to participate in a survey and qualitative interview using a photo elicitation technique.

Results

Most patients who participated in a CCT were patients with solid tumors, metastatic disease, and did not live in a rural area. Survey data showed that the two most significant drivers of CCT enrollment were potential of benefit to self and to others (altruism). Direct recommendation from a healthcare provider to participate in CCT was critical. URM patients enrolled on a CCT experience a significant burden of symptoms and financial distress. Key themes identified from the interviews that motivated patients to participate included chance for cure, staying positive, altruism and advancement of science, and having diverse representation in research. Patient-level facilitators to participation included social support, cost coverage, and limited treatment options. Sytematic facilitators identified included minimizing logistical barriers, decentralizing cancer clinical trials, increasing awareness via patient narratives, diversifying research staff, minimizing cost, and being clear on puropose and benefit of the trial.

Conclusion

Success stories of minority recruitment can provide useful information to enhance minority accrual. Photo elicitation interviews provide rich narratives of patient experience.

Association between treatment and improvements in overall survival of patients with advanced/metastatic non-small cell lung cancer since 2011: A study in the United States, Canada, and Germany using retrospective real-world databases

BACKGROUND

This study aimed to describe treatment patterns and overall survival (OS) in patients with advanced non-small cell lung cancer (aNSCLC) in three countries between 2011 and 2020.

METHODS

Three databases (US, Canada, Germany) were used to identify incident aNSCLC patients. OS was assessed from the date of incident aNSCLC diagnosis and, for patients who received at least a first line of therapy (1LOT), from the date of 1LOT initiation. In multivariable analyses, we analyzed the influence of index year and type of prescribed treatment on OS.

FINDINGS

We included 51,318 patients with an incident aNSCLC diagnosis. The percentage of patients treated with a 1LOT differed substantially between countries, whereas the number of patients receiving immunotherapies/targeted treatments increased over time in all three countries. Median OS from the date of incident diagnosis was 9.9 months in the United States vs. 4.1 months in Canada. When measured from the start of 1LOT, patients had a median OS of 10.7 months in the United States, 10.9 months in Canada, and 10.9 months in Germany. OS from the start of 1LOT improved in all three countries from 2011 to 2020 by approximately 3 to 4 months.

CONCLUSIONS

Observed continuous improvement in OS among patients receiving at least a 1LOT from 2011 to 2020 was likely driven by improved care and changes in the treatment landscape. The difference in the proportion of patients receiving a 1LOT in the observed countries requires further investigation.

Managing Colorectal Cancer from Ethology to Interdisciplinary Treatment: The Gains and Challenges of Modern Medicine

Colorectal cancer (CRC) is a common malignant tumor of the gastrointestinal tract, which has become a serious threat to human health worldwide. This article exhaustively reviews colorectal cancer's incidence and relevance, carcinogenesis molecular pathways, up-to-date treatment opportunities, prophylaxis, and screening program achievements, with attention paid to its regional variations and changes over time. This paper provides a concise overview of known CRC risk factors, including familial, hereditary, and environmental lifestyle-related risk factors. The authors take a closer look into CRC's molecular genetic pathways and the role of specific enzymes involved in carcinogenesis. Moreover, the role of the general practitioner and multidisciplinary approach in CRC treatment is summarized and highlighted based on recent recommendations and experience. This article gives a clear understanding and review of the gains and challenges of modern medicine towards CRC. The authors believe that understanding the current patterns of CRC and its revolution is imperative to the prospects of reducing its burden through cancer prevention and cancer-adjusted treatment.

A Multiscale Spatiotemporal Epidemiological Analysis of Neighborhood Correlates of Triple-Negative Breast Cancer

BACKGROUND

Women living in disadvantaged neighborhoods present with increased prevalence rates of triple-negative breast cancer (TNBC). This study takes a spatiotemporal epidemiological approach to understand the impact of socioenvironmental contextual factors on TNBC prevalence rates.

METHODS

We analyzed 935 TNBC cases from a major cancer center registry, between 2005 and 2017, to explore spatial and space-time clusters of TNBC prevalence rates at the census tract and neighborhood scales. Spatial regression analysis was performed to examine relationships between nine socioenvironmental factors and TNBC prevalence rates at both ecological scales.

RESULTS

We observed spatial clustering of high TNBC prevalence rates along a north-south corridor of Miami-Dade County along Interstate 95, a region containing several majority non-Hispanic Black neighborhoods. Among the ecologic measures, the percent of a region designated as a brownfield was associated with TNBC prevalence rates at the tract-level (β = 4.27; SE = 1.08; P < 0.001) and neighborhood-level (β = 8.61; SE = 2.20; P < 0.001).

CONCLUSIONS

Our spatiotemporal analysis identified robust patterns of hot spots of TNBC prevalence rates in a corridor of several disadvantaged neighborhoods in the northern half of the county. These patterns of TNBC align with the literature regarding at-risk groups and neighborhood-level effects on TNBC; however, remain to be validated in a population-based sample.

IMPACT

Spatial epidemiological approaches can help public health officials and cancer care providers improve place-specific screening, patient care, and understanding of socioenvironmental factors that may shape breast cancer subtype through gene-environment and epigenetic interactions.

Historical Redlining, Persistent Mortgage Discrimination, and Race in Breast Cancer Outcomes

Importance

Inequities created by historical and contemporary mortgage discriminatory policies have implications for health disparities. The role of persistent mortgage discrimination (PMD) in breast cancer (BC) outcomes has not been studied.

Objective

To estimate the race-specific association of historical redlining (HRL) with the development of BC subtypes and late-stage disease and a novel measure of PMD in BC mortality.

Design, Setting, and Participants

This population-based cohort study used Georgia Cancer Registry data. A total of 1764 non-Hispanic Black and White women with a BC diagnosis and residing in an area graded by the Home Owners' Loan Corporation (HOLC) in Georgia were included. Patients were excluded if they did not have a known subtype or a derived American Joint Committee on Cancer stage or if diagnosed solely by death certificate or autopsy. Participants were diagnosed with a first primary BC between January 1, 2010, to December 31, 2017, and were followed through December 31, 2019. Data were analyzed between May 1, 2022, and August 31, 2023.

Exposures

Scores for HRL were examined dichotomously as less than 2.5 (ie, nonredlined) vs 2.5 or greater (ie, redlined). Contemporary mortgage discrimination (CMD) scores were calculated, and PMD index was created using the combination of HRL and CMD scores.

Main Outcomes and Measures

Estrogen receptor (ER) status, late stage at diagnosis, and BC-specific death.

Results

This study included 1764 women diagnosed with BC within census tracts that were HOLC graded in Georgia. Of these, 856 women (48.5%) were non-Hispanic Black and 908 (51.5%) were non-Hispanic White; 1148 (65.1%) were diagnosed at 55 years or older; 538 (30.5%) resided in tracts with HRL scores less than 2.5; and 1226 (69.5%) resided in tracts with HRL scores 2.5 or greater. Living in HRL areas with HRL scores 2.5 or greater was associated with a 62% increased odds of ER-negative BC among non-Hispanic Black women (odds ratio [OR], 1.62 [95% CI, 1.01-2.60]), a 97% increased odds of late-stage diagnosis among non-Hispanic White women (OR, 1.97 [95% CI, 1.15-3.36]), and a 60% increase in BC mortality overall (hazard ratio, 1.60 [95% CI, 1.17-2.18]). Similarly, PMD was associated with BC mortality among non-Hispanic White women but not among non-Hispanic Black women.

Conclusions and Relevance

The findings of this cohort study suggest that historical racist policies and persistent discrimination have modern-day implications for BC outcomes that differ by race. These findings emphasize the need for a more nuanced investigation of the social and structural drivers of disparate BC outcomes.

Racial disparities in the relationship of regional socioeconomic status and colorectal cancer survival in the five regions of Georgia

INTRODUCTION

The study's purpose was to examine 5-year colorectal cancer (CRC) survival rates between White and Black patients. We also determined whether regional socioeconomic status (SES) is associated with CRC survival between White and Black patients in the Clayton, West Central, East Central, Southeast, and Northeast Georgia public health districts.

METHODS

We performed a retrospective cohort analysis using data from the 1975 to 2016 Surveillance, Epidemiology, and End Results program. The 2015 United States Department of Agriculture Economic Research Services county typology codes were used to identify region-level SES with persistent poverty, low employment, and low education. Kaplan-Meier method and Cox proportional hazard regression were performed.

RESULTS

Among 10,876 CRC patients (31.1% Black patients), 5-year CRC survival rates were lower among Black patients compared to White patients (65.4% vs. 69.9%; p < 0.001). In multivariable analysis, White patients living in regions with persistent poverty had a 1.1-fold increased risk of CRC death (HR, 1.12; 95% CI, 1.00-1.25) compared to those living in non-persistent poverty regions. Among Black patients, those living in regions with low education were at a 1.2-fold increased risk of CRC death (HR, 1.19; 95% CI, 1.01-1.40) compared to those living in non-low education regions.

DISCUSSION AND CONCLUSIONS

Black patients demonstrated lower CRC survival rates in Georgia compared to their White counterparts. White patients living in regions with persistent poverty, and Black patients living in regions with low education had an increased risk of CRC death. Our findings provide important evidence to all relevant stakeholders in allocating health resources aimed at CRC early detection and prevention and timely referral for CRC treatment by considering the patient's regional SES in Georgia.

Climate change and cancer: the Environmental Justice perspective

Despite advances in cancer control-prevention, screening, diagnosis, treatment, and survivorship-racial disparities in cancer incidence and survival persist and, in some cases, are widening in the United States. Since 2020, there's been growing recognition of the role of structural racism, including structurally racist policies and practices, as the main factor contributing to historical and contemporary disparities. Structurally racist policies and practices have been present since the genesis of the United States and are also at the root of environmental injustices, which result in disproportionately high exposure to environmental hazards among communities targeted for marginalization, increased cancer risk, disruptions in access to care, and worsening health outcomes. In addition to widening cancer disparities, environmental injustices enable the development of polluting infrastructure, which contribute to detrimental health outcomes in the entire population, and to climate change, the most pressing public health challenge of our time. In this commentary, we describe the connections between climate change and cancer through an Environmental Justice perspective (defined as the fair treatment and meaningful involvement of people of all racialized groups, nationalities, or income, in all aspects, including development, implementation, and enforcement, of policies and practices that affect the environment and public health), highlighting how the expertise developed in communities targeted for marginalization is crucial for addressing health disparities, tackling climate change, and advancing cancer control efforts for the entire population.

Ethnic disparities in the incidence of gynecologic malignancies among Israeli Women of Arab and Jewish Ethnicity: a 10-year study (2010-2019)

Background

Ethnic disparities in healthcare outcomes persist, even when populations share the same environmental factors and healthcare infrastructure. Gynecologic malignancies are a significant health concern, making it essential to explore how these disparities manifest in terms of their incidence among different ethnic groups.

Objective

To investigate ethnic disparities in the incidence of gynecologic malignancies incidence among Israeli women of Arab and Jewish ethnicity.

Design

Our research employs a longitudinal, population-based retrospective cohort design.

Method

Data on gynecologic cancer diagnoses among the Israeli population from 2010 to 2019 was obtained from a National Registry. Disease incidence rates and age standardization were calculated. A comparison between Arab and Jewish patients was performed, with Poisson regression models being used to analyze significant rate changes.

Results

Among Jewish women, the age-standardized ratio (ASR) for gynecologic malignancies decreased from 288 to 251 (p < 0.001) between 2014 and 2019. However, there was no significant change in the ASR among Arab women during the same period, with rates going from 192 to 186 (p = 0.802). During the study period, the incidence of ovarian cancer decreased significantly among Jewish women (p = 0.042), while the rate remained stable among Arab women (p = 0.102). A similar trend was observed for uterine cancer. The ASR of CIN III (Cervical Intraepithelial Neoplasia Grade 3) in Jewish women notably increased from 2017 to 2019, with an annual growth rate of 43.3% (p < 0.001). A similar substantial rise was observed among Arab women, with an annual growth rate of 40.5% (p < 0.001). In contrast, the incidence of invasive cervical cancer remained stable from 2010 to 2019 among women of both ethnic backgrounds.

Conclusion

Our findings indicate that Arab women in Israel have a lower incidence rate of gynecologic cancers, warranting further investigation into protective factors. Both ethnic groups demonstrate effective utilization of cervical screening.

The Association of Oncology Provider Density With Black-White Disparities in Cancer Mortality in US Counties

BACKGROUND

Black-White racial disparities in cancer mortality are well-documented in the US. Given the estimated shortage of oncologists over the next decade, understanding how access to oncology care might influence cancer disparities is of considerable importance. We aim to examine the association between oncology provider density in a county and Black-White cancer mortality disparities.

METHODS

An ecological study of 1048 US counties was performed. Oncology provider density was estimated using the 2013 National Plan and Provider Enumeration System data. Black:White cancer mortality ratio was calculated using 2014-2018 age-standardized cancer mortality rates from State Cancer Profiles. Linear regression with covariate adjustment was constructed to assess the association of provider density with (1) Black:White cancer mortality ratio, and (2) cancer mortality rates overall, and separately among Black and White persons.

RESULTS

The mean Black:White cancer mortality ratio was 1.12, indicating that cancer mortality rate among Black persons was on average 12% higher than that among White persons. Oncology provider density was significantly associated with greater cancer mortality disparities: every 5 additional oncology providers per 100 000 in a county was associated with a .02 increase in the Black:White cancer mortality ratio (95% CI: .007 to .03); however, the unexpected finding may be explained by further analysis showing that the relationship between oncology provider density and cancer mortality was different by race group. Every 5 additional oncologists per 100 000 was associated with a 1.6 decrease per 100 000 in cancer mortality rates among White persons (95% CI: -3.0 to -.2), whereas oncology provider density was not associated with cancer mortality among Black persons.

CONCLUSION

Greater oncology provider density was associated with significantly lower cancer mortality among White persons, but not among Black persons. Higher oncology provider density alone may not resolve cancer mortality disparities, thus attention to ensuring equitable care is critical.

Social Deprivation and End-of-Life Care Use Among Adults With Cancer

PURPOSE

Socioeconomic differences are partially responsible for racial inequities in cancer outcomes, yet the association of area-level socioeconomic disadvantage and race with end-of-life (EOL) cancer care quality is poorly understood.

METHODS

This retrospective study used electronic medical records from an academic health system to identify 33,635 adults with cancer who died between 2013 and 2019. Using multivariable logistic regression, we examined associations between decedent characteristics and EOL care, including emergency department (ED) visits, intensive care unit (ICU) stays, palliative care consultation (PCC), hospice order, and in-hospital deaths. Social deprivation index was used to measure socioeconomic disadvantages.

RESULTS

Racially minoritized decedents had higher odds of ICU stay than the least deprived White decedents (eg, other race Q3: aOR, 2.06 [99% CI, 1.26 to 0.3.39]). White and Black decedents from more deprived areas had lower odds of ED visit (White Q3: aOR, 0.382 [99% CI, 0.263 to 0.556]; Black Q3: aOR, 0.566 [99% CI, 0.373 to 0.858]) than least deprived White decedents. Compared with White decedents living in least deprived areas, racially minoritized decedents had higher odds of receiving PCC and hospice order, whereas White decedents in most deprived areas had lower odds of PCC (aOR, 0.727 [99% CI, 0.592 to 0.893]) and hospice order (aOR, 0.845 [99% CI, 0.724 to 0.986]). Greater deprivation was associated with greater odds of hospital death relative to least deprived White decedents, but only among minoritized decedents (eg, Black Q4: aOR, 2.16 [99% CI, 1.82 to 2.56]).

CONCLUSION

Area-level socioeconomic disadvantage is not uniformly associated with poorer EOL cancer care, with differences among decedents of different racial groups.

Do people with disabilities experience disparities in cancer care? A systematic review

BACKGROUND

Over 1.3 billion people, or 16% of the world's population, live with some form of disability. Recent studies have reported that people with disabilities (PwD) might not be receiving state-of-the-art treatment for cancer as their non-disabled peers; our objective was to systematically review this topic.

METHODS

A systematic review was undertaken to compare cancer outcomes and quality of cancer care between adults with and without disabilities (NIHR Prospero register ID number: CRD42022281506). A search of the literature was performed in July 2022 across five databases: EMBASE, Medline, Cochrane Library, Web of Science and CINAHL databases. Peer-reviewed quantitative research articles, published in English from 2000 to 2022, with interventional or observational study designs, comparing cancer outcomes between a sample of adult patients with disabilities and a sample without disabilities were included. Studies focused on cancer screening and not treatment were excluded, as well as editorials, commentaries, opinion papers, reviews, case reports, case series under 10 patients and conference abstracts. Studies were evaluated by one reviewer for risk of bias based on a set of criteria according to the SIGN 50 guidelines. A narrative synthesis was conducted according to the Cochrane SWiM guidelines, with tables summarizing study characteristics and outcomes. This research received no external funding.

RESULTS

Thirty-one studies were included in the systematic review. Compared to people without disabilities, PwD had worse cancer outcomes, in terms of poorer survival and higher overall and cancer-specific mortality. There was also evidence that PwD received poorer quality cancer care, including lower access to state-of-the-art care or curative-intent therapies, treatment delays, undertreatment or excessively invasive treatment, worse access to in-hospital services, less specialist healthcare utilization, less access to pain medications and inadequate end-of-life quality of care.

DISCUSSION

Limitations of this work include the exclusion of qualitative research, no assessment of publication bias, selection performed by only one reviewer, results from high-income countries only, no meta-analysis and a high risk of bias in 15% of included studies. In spite of these limitations, our results show that PwD often experience severe disparities in cancer care with less guideline-consistent care and higher mortality than people without disabilities. These findings raise urgent questions about how to ensure equitable care for PwD; in order to prevent avoidable morbidity and mortality, cancer care programs need to be evaluated and urgently improved, with specific training of clinical staff, more disability inclusive research, better communication and shared decision-making with patients and elimination of physical, social and cultural barriers.

Effect of a same day appointment initiative on racial disparities in access for radiation oncology

PURPOSE

We present our single-institution experience with the development of a same day access scheduling initiative for an outpatient radiation oncology unit, focusing on its potential influence on ameliorating racial disparities.

METHODS AND MATERIALS

From March 2021 to August 2022, a pilot initiative was conducted such that all new patients referred to a tertiary care-based radiation oncology department were offered the ability to be seen as a same day consultation. The timespan of this analysis was categorized into 2 distinct successive periods over 36 months-a 18-month pre-initiative period (September 2019 to February 2021) and another subsequent one (March 2021 to August 2022). Descriptive statistics were used to study the impact of this initiative on access-related benchmarks.

RESULTS

A total of 2897 patients were referred. Among the 2107 patients scheduled, three hundred and sixteen (15 %) opted for same day appointments. Black, Latino, and Asian patients were significantly more likely to use the same day access initiative versus Caucasian patients (p = 0.01). The same day access initiative increased the proportion of patients seen within 5 days from referral from 8 % to 34 % for Blacks, 12-57 % for Latinos, and 18-67 % for Asians, compared to 39-55 % for Caucasians (p < 0.001). The no-show rate was reduced from 20 % to 7 % and 14-5 %, for Black and Latino patients, respectively (p < 0.001).

CONCLUSIONS

The implementation of a same day access initiative narrowed disparities with respect to access-related benchmarks.

Racial Disparities in Locoregional Recurrence in Postmenopausal Patients with Stage I-III, Hormone Receptor-Positive Breast Cancer Enrolled in the NSABP B-42 Clinical Trial

BACKGROUND

There are limited data examining racial disparities in locoregional recurrence (LRR) among women with access to high-quality care. We aimed to examine differences in late LRR by race in patients with stage I-IIIA, hormone receptor-positive (HR+) breast cancer enrolled in the National Surgical Adjuvant Breast and Bowel (NSABP) B-42 trial.

METHODS

From 2006 to 2010, 3966 postmenopausal women with stage I-IIIA HR+ breast cancer who were disease-free after 5 years of endocrine therapy were randomized to an additional 5 years of endocrine therapy or placebo. Patients were excluded if multi-racial or if race was unknown. Kaplan-Meier curves were used to estimate 6-year LRR from the time of trial registration and according to race. Cox proportional hazards models were used for adjusted survival analyses.

RESULTS

Overall, 3929 NSABP B-42 patients were included: 3688 (93.9%) White, 151 (3.8%) Black, and 90 (2.3%) Asian patients. Median follow-up was 75.2 months. Overall estimated 6-year LRR from trial registration was 1.8% and differed by race: LRR rates were 1.7% in White women, 4.9% in Black women, and 0% in Asian women (p = 0.046). Adjusted Cox proportional hazards analysis found Black race to be independently associated with LRR (hazard ratio [HzR] 2.36, 95% confidence interval [CI] 1.01-5.49; p = 0.047). Node-positivity was also associated with increased LRR (HzR 1.75, 95% CI 1.07-2.86; p = 0.025). Adjusted Cox analysis found LRR (HzR 2.32, 95% CI 1.33-4.06; p = 0.003) to be associated with increased overall mortality; however, race was not independently associated with mortality.

CONCLUSION

Among postmenopausal patients with stage I-IIIA HR+ breast cancer in the NSABP B-42 trial, racial differences in late LRR were present, with the highest LRR in Black women.

Housing Status, Cancer Care, and Associated Outcomes Among US Veterans

Importance

Cancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described.

Objective

To characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer.

Design, Setting, and Participants

This retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023.

Exposures

Veterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing.

Main Outcomes and Measures

The major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities.

Results

This study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively.

Conclusions and Relevance

In this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.

Establishment and assessment of a nomogram for predicting prognosis in bone-metastatic prostate cancer

OBJECTIVE

For the purposes of patients' consultation, condition assessments, and guidance for clinicians' choices, we developed a prognostic predictive model to evaluate the 1-, 3-, and 5-year overall survival (OS) rates of bone-metastatic prostate cancer (PCa) patients.

METHODS

We gathered data from 5522 patients with bone metastatic PCa registered in the Surveillance, Epidemiology, and End Results (SEER) database to develop a nomogram. A total of 359 bone metastatic PCas were collected from 2 hospitals to validate the nomogram and assess its discriminatory ability. In addition, we plotted the actual survival against the predicted risk to assess the calibration accuracy. Moreover, we designed a web calculator to quickly obtain accurate survival probability outcomes.

RESULTS

Univariate and multivariate Cox hazard regression analyses suggested that age, marital status, prostate-specific antigen (PSA) level, Gleason score, clinical T stage, N stage, surgery, and chemotherapy were closely associated with OS rates. The calibration charts of the training and validation groups showed a high accuracy and reliability. The decision curve analysis (DCA) suggested a favorable clinical net benefit.

CONCLUSION

Based on demography and clinical pathology, we developed a reliable nomogram to help clinicians more accurately predict the 1-, 3-, and 5-year OS rates of patients with bone metastatic PCa to guide evaluation and treatment.

Racial and Ethnic Variation in Diagnostic Mammography Performance among Women Reporting a Breast Lump

BACKGROUND

We evaluated diagnostic mammography among women with a breast lump to determine whether performance varied across racial and ethnic groups.

METHODS

This study included 51,014 diagnostic mammograms performed between 2005 and 2018 in the Breast Cancer Surveillance Consortium among Asian/Pacific Islander (12%), Black (7%), Hispanic/Latina (6%), and White (75%) women reporting a lump. Breast cancers occurring within 1 year were ascertained from cancer registry linkages. Multivariable regression was used to adjust performance statistic comparisons for breast cancer risk factors, mammogram modality, demographics, additional imaging, and imaging facility.

RESULTS

Cancer detection rates were highest among Asian/Pacific Islander [per 1,000 exams, 84.2 (95% confidence interval (CI): 72.0-98.2)] and Black women [81.4 (95% CI: 69.4-95.2)] and lowest among Hispanic/Latina women [42.9 (95% CI: 34.2-53.6)]. Positive predictive values (PPV) were higher among Black [37.0% (95% CI: 31.2-43.3)] and White [37.0% (95% CI: 30.0-44.6)] women and lowest among Hispanic/Latina women [22.0% (95% CI: 17.2-27.7)]. False-positive results were most common among Asian/Pacific Islander women [per 1,000 exams, 183.9 (95% CI: 126.7-259.2)] and lowest among White women [112.4 (95% CI: 86.1-145.5)]. After adjustment, false-positive and cancer detection rates remained higher for Asian/Pacific Islander and Black women (vs. Hispanic/Latina and White). Adjusted PPV was highest among Asian/Pacific Islander women.

CONCLUSIONS

Among women with a lump, Asian/Pacific Islander and Black women were more likely to have cancer detected and more likely to receive a false-positive result compared with White and Hispanic/Latina women.

IMPACT

Strategies for optimizing diagnostic mammography among women with a lump may vary by racial/ethnic group, but additional factors that influence performance differences need to be identified. See related In the Spotlight, p. 1479.

Exercise as Medicine in Cardio-Oncology: Reducing Health Disparities in Hispanic and Latina Breast Cancer Survivors

PURPOSE OF REVIEW

This review aims to access the current state of the evidence in exercise as medicine for cardio-oncology in Hispanic and Latina breast cancer survivors and to provide our preliminary data on the effects of supervised aerobic and resistance training on cardiovascular disease (CVD) risk in this population.

RECENT FINDINGS

Breast cancer survivors have a higher risk of CVD; particularly Hispanic and Latina breast cancer survivors have a higher burden than their White counterparts. Exercise has been shown to reduce CVD risk in breast cancer survivors; however, evidence in Hispanic and Latina breast cancer survivors is scarce. Our review highlights a clear need for exercise oncology clinical trials in Hispanic and Latina breast cancer survivors targeting CVD risk factors. Moreover, our exploratory results highlight that 16 weeks of aerobic and resistance training may reduce the 10-year risk of developing CVD by 15% in Hispanic and Latina breast cancer survivors.

Temporal Trends of Stages and Survival of Biliary Tract Cancers in the United States and Associations with Demographic Factors

BACKGROUND

The incidence of cholangiocarcinoma and gallbladder cancer has been increasing and decreasing respectively in the United States, whereas their mortality has been declining since 1980, which suggests improved overall survival of biliary tract cancers (BTC). We aimed to investigate temporal trends of BTC stages and survival and their associations with demographic factors.

METHODS

A total of 55,163 patients with BTC collected from 2000 to 2018 from the NCI Surveillance, Epidemiology, and End Results 18 registry were included in this study. We assessed the temporal trend of BTC stages with diagnosis years using the annual percentage of change (APC) in the proportion of the stages. We estimated the association of BTC survival and stages with diagnosis years and demographic factors using the Cox regression models.

RESULTS

While localized BTC proportion remained little changed from 2006 to 2018, the proportion of regional and distant BTCs significantly decreased (APC = -2.3%) and increased (APC = 2.7%), respectively, through the years. The overall and cancer-specific survival increased from 41.0% and 47.3% in 2000 to 2004 to 51.2% and 53.8% in 2015 to 2018, respectively. Patients with BTC who were older, Black, unmarried, or had lower socioeconomic status (SES) had significantly poorer overall survival.

CONCLUSIONS

We found that distant and regional BTC significantly increased and decreased, respectively, and the BTC survival significantly improved over time. Age, sex, race, SES, and marital status were significantly associated with overall survival and less evidently with cancer-specific survival of patients with BTC.

IMPACT

Our findings suggest that demographic factors were associated with BTC stages and BTC survival.

Disparities in cardio-oncology: Implication of angiogenesis, inflammation, and chemotherapy

Cancers and cardiovascular diseases are the top two causes of death in the United States. Over the past decades, novel therapies have slowed the cancer mortality rate, yet cardiac failures have risen due to the toxicity of cancer treatments. The mechanisms behind this relationship are poorly understood and it is crucial that we properly treat patients at risk of developing cardiac failure in response to cancer treatments. Currently, we rely on early-stage biomarkers of inflammation and angiogenesis to detect cardiotoxicity before it becomes irreversible. Identification of such biomarkers allows healthcare professionals to decrease the adverse effects of cancer therapies. Angiogenesis and inflammation have a systemic influence on the heart and vasculature following cancer therapy. In the field of cardio-oncology, there has been a recent emphasis on gender and racial disparities in cardiotoxicity and the impact of these disparities on disease outcomes, but there is a scarcity of data on how cardiotoxicity varies across diverse populations. Here, we will discuss how current markers of angiogenesis and inflammation induced by cancer therapy are related to disparities in cardiovascular health.

Time to Endoscopy or Colonoscopy Among Adults Younger Than 50 Years With Iron-Deficiency Anemia and/or Hematochezia in the VHA

Importance

To date, the diagnostic test completion rate and the time to diagnostic endoscopy or colonoscopy among adults with iron-deficiency anemia (IDA) and/or hematochezia have not been well characterized.

Objective

To evaluate the diagnostic test completion rate and the time to diagnostic testing among veterans younger than 50 years with IDA and/or hematochezia.

Design, Setting, and Participants

This cohort study was conducted within the Veterans Health Administration between October 1, 1999, and December 31, 2019, among US veterans aged 18 to 49 years from 2 separate cohorts: those with a diagnosis of IDA (n = 59 169) and those with a diagnosis of hematochezia (n = 189 185). Statistical analysis was conducted from August 2021 to August 2023.

Exposures

Diagnostic testing factors included age, sex, race and ethnicity, Veterans Health Administration geographic region, and hemoglobin test value (IDA cohort only).

Main Outcomes and Measures

Primary outcomes of diagnostic testing were (1) bidirectional endoscopy after diagnosis of IDA and (2) colonoscopy or sigmoidoscopy after diagnosis of hematochezia. The association between diagnostic testing factors and diagnostic test completion was examined using Poisson models.

Results

There were 59 169 veterans with a diagnosis of IDA (mean [SD] age, 40.7 [7.1] years; 30 502 men [51.6%]), 189 185 veterans with a diagnosis of hematochezia (mean [SD] age, 39.4 [7.6] years; 163 690 men [86.5%]), and 2287 veterans with IDA and hematochezia (mean [SD] age, 41.6 [6.9] years; 1856 men [81.2%]). The cumulative 2-year diagnostic workup completion rate was 22% (95% CI, 22%-22%) among veterans with IDA and 40% (95% CI, 40%-40%) among veterans with hematochezia. Veterans with IDA were mostly aged 40 to 49 years (37 719 [63.7%]) and disproportionately Black (24 480 [41.4%]). Women with IDA (rate ratio [RR], 0.42; 95% CI, 0.40-0.43) had a lower likelihood of diagnostic test completion compared with men with IDA. Black (RR, 0.65; 95% CI, 0.62-0.68) and Hispanic (RR, 0.88; 95% CI, 0.82-0.94) veterans with IDA were less likely to receive diagnostic testing compared with White veterans with IDA. Veterans with hematochezia were mostly White (105 341 [55.7%]). Among veterans with hematochezia, those aged 30 to 49 years were more likely to receive diagnostic testing than adults younger than 30 years of age (age 30-39 years: RR, 1.15; 95% CI, 1.12-1.18; age 40-49 years: RR, 1.36; 95% CI, 1.33-1.40). Hispanic veterans with hematochezia were less likely to receive diagnostic testing compared with White veterans with hematochezia (RR, 0.96; 95% CI, 0.93-0.98).

Conclusions and Relevance

In the cohorts of veterans younger than 50 years with IDA and/or hematochezia, the diagnostic test completion rate was low. Follow-up was less likely among female, Black, and Hispanic veterans with IDA and Hispanic veterans with hematochezia. Optimizing timely follow-up across social and demographic groups may contribute to improving colorectal cancer outcomes and mitigate disparities.

Pan-cancer mutational signature surveys correlated mutational signature with geospatial environmental exposures and viral infections

Background

Cancer has been disproportionally affecting minorities. Genomic-based cancer disparity analyses have been less common than conventional epidemiological studies. In the past decade, mutational signatures have been established as characteristic footprints of endogenous or exogenous carcinogens.

Methods

Integrating datasets of diverse cancer types from The Cancer Genome Atlas and geospatial environmental risks of the registry hospitals from the United States Environmental Protection Agency, we explored mutational signatures from the aspect of racial disparity concerning pollutant exposures. The raw geospatial environmental exposure data were refined to 449 air pollutants archived and modeled from 2007 to 2017 and aggregated to the census county level. Additionally, hepatitis B and C viruses and human papillomavirus infection statuses were incorporated into analyses for skin cancer, cervical cancer, and liver cancer.

Results

Mutation frequencies of key oncogenic genes varied substantially between different races. These differences were further translated into differences in mutational signatures. Survival analysis revealed that the increased pollution level is associated with worse survival. The analysis of the oncogenic virus revealed that aflatoxin, an affirmed carcinogen for liver cancer, was higher in Asian liver cancer patients than in White patients. The aflatoxin mutational signature was exacerbated by hepatitis infection for Asian patients but not for White patients, suggesting a predisposed genetic or genomic disadvantage for Asians concerning aflatoxin.

Conclusions

Environmental pollutant exposures increase a mutational signature level and worsen cancer prognosis, presenting a definite adverse risk factor for cancer patients.

Development and validation of a nomogram to predict cancer-specific survival in nonsurgically treated elderly patients with prostate cancer

Prostate Cancer (PC) is the most common male nonskin tumour in the world, and most diagnosed patients are over 65 years old. The main treatment for PC includes surgical treatment and nonsurgical treatment. Currently, for nonsurgically treated elderly patients, few studies have evaluated their prognostic factors. Our aim was to construct a nomogram that could predict cancer-specific survival (CSS) in nonsurgically treated elderly PC patients to assess their prognosis-related independent risk factors. Patient information was obtained from the Surveillance, Epidemiology and End Results (SEER) database, and our target population was nonsurgically treated PC patients who were over 65 years old. Independent risk factors were determined using both univariate and multivariate Cox regression models. A nomogram was built using a multivariate Cox regression model. The accuracy and discrimination of the prediction model were tested using the consistency index (C-index), the area under the subject operating characteristic curve (AUC), and the calibration curve. Decision curve analysis (DCA) was used to examine the potential clinical value of this model. A total of 87,831 elderly PC patients with nonsurgical treatment in 2010-2018 were included in the study and were randomly assigned to the training set (N = 61,595) and the validation set (N = 26,236). Univariate and multivariate Cox regression model analyses showed that age, race, marital status, TNM stage, chemotherapy, radiotherapy modality, PSA and GS were independent risk factors for predicting CSS in nonsurgically treated elderly PC patients. The C-index of the training set and the validation set was 0.894 (95% CI 0.888-0.900) and 0.897 (95% CI 0.887-0.907), respectively, indicating the good discrimination ability of the nomogram. The AUC and the calibration curves also show good accuracy and discriminability. We developed a new nomogram to predict CSS in elderly PC patients with nonsurgical treatment. The model is internally validated with good accuracy and reliability, as well as potential clinical value, and can be used for clinical aid in decision-making.