Geographic socioeconomic status, race, and advanced-stage breast cancer in New York City

Latent pathway-based Bayesian models to identify intervenable factors of racial disparities in breast cancer stage at diagnosis

PURPOSE

We built Bayesian Network (BN) models to explain roles of different patient-specific factors affecting racial differences in breast cancer stage at diagnosis, and to identify healthcare related factors that can be intervened to reduce racial health disparities.

METHODS

We studied women age 67-74 with initial diagnosis of breast cancer during 2006-2014 in the National Cancer Institute's SEER-Medicare dataset. Our models included four measured variables (tumor grade, hormone receptor status, screening utilization and biopsy delay) expressed through two latent pathways-a tumor biology path, and health-care access/utilization path. We used various Bayesian model assessment tools to evaluate these two latent pathways as well as each of the four measured variables in explaining racial disparities in stage-at-diagnosis.

RESULTS

Among 3,010 Black non-Hispanic (NH) and 30,310 White NH breast cancer patients, respectively 70.2% vs 76.9% were initially diagnosed at local stage, 25.3% vs 20.3% with regional stage, and 4.56% vs 2.80% with distant stage-at-diagnosis. Overall, BN performed approximately 4.7 times better than Classification And Regression Tree (CART) (Breiman L, Friedman JH, Stone CJ, Olshen RA. Classification and regression trees. CRC press; 1984) in predicting stage-at-diagnosis. The utilization of screening mammography is the most prominent contributor to the accuracy of the BN model. Hormone receptor (HR) status and tumor grade are useful for explaining racial disparity in stage-at diagnosis, while log-delay in biopsy impeded good prediction.

CONCLUSIONS

Mammography utilization had a significant effect on racial differences in breast cancer stage-at-diagnosis, while tumor biology factors had less impact. Biopsy delay also aided in predicting local and regional stages-at-diagnosis for Black NH women but not for white NH women.

Racial, ethnic and socioeconomic disparities in diagnosis, treatment, and survival of patients with breast cancer

BACKGROUND

The objective of this study was to determine the influence of race/ethnicity and socioeconomic status (SES) on breast cancer outcomes.

METHODS

A retrospective analysis was performed of Non-Hispanic Black (NHB), Non-Hispanic White (NHW), and Hispanic patients with non-metastatic breast cancer in the SEER cancer registry between 2007 and 2016.

RESULTS

A total of 382,975 patients were identified. On multivariate analysis, NHB (OR 1.18, 95%CI: 1.15-1.20) and Hispanic (OR 1.20, 95%CI: 1.17-1.22) patients were more likely to present with higher stage disease than NHW patients. There was an increased likelihood of not undergoing breast-reconstruction for NHB (OR 1.07, 95%CI: 1.03-1.11) and Hispanic patients (OR 1.60, 95%CI 1.54-1.66). NHB patients had increased hazard for all-cause mortality (HR: 1.13, 95%CI 1.10-1.16). All-cause mortality increased across SES categories (lower SES: HR 1.33, 95%CI 1.30-1.37, middle SES: HR 1.20, 95%CI 1.17-1.23).

CONCLUSIONS

This population-based analysis confirms worse disease presentation, access to surgical therapy, and survival across racial, ethnic, and socioeconomic factors. These disparities were compounded across worsening SES and insurance coverage.

Mobile mammography in New York City: analysis of 32,350 women utilizing a screening mammogram program

Mobile mammography vans (mammovans) may help close the gap to access of breast cancer screening by providing resources to underserved communities. Minimal data exists on the populations served, the ability of mammovans to reach underserved populations, and the outcomes of participants. We sought to determine the demographic characteristics, number of breast cancers diagnosed, and number of women who used the American Italian Cancer Foundation (AICF) Mobile, No-Cost Breast Cancer Screening Program within the five boroughs of New York City. Data were collected by the AICF from 2014 to 2019 on a voluntary basis from participants at each screening location. Women aged 40 to 79 years who had not had a mammogram in the previous 12 months were invited to participate. Each participant underwent a clinical breast exam by a nurse practitioner followed by a screening mammogram. Images were read by a board-certified radiologist contracted by the AICF from Multi Diagnostic Services. There were 32,350 participants in this study. Sixty-three percent reported an annual household income ≤$25,000, and 30% did not have health insurance. More than half of participants identified as either African American (28%) or Hispanic (27%). Additional testing was performed for 5359 women found to have abnormal results on screening. In total, 68 cases of breast cancer were detected. Breast cancer disparities are multifactorial, with the greatest factor being limited access to care. Mobile, no-cost mammogram screening programs show great promise in helping to close the gap to screening access.

Racial and Ethnic Disparities in Obliterative Procedures for the Treatment of Vaginal Prolapse

OBJECTIVES

Although racial disparities are well documented for common gynecologic surgical procedures, few studies have assessed racial disparities in the surgical treatment of vaginal prolapse. This study aimed to compare the use of obliterative procedures for the treatment of vaginal prolapse across racial and ethnic groups.

STUDY DESIGN

This is a retrospective cohort study of surgical cases from 2010 to 2018 from the American College of Surgeons National Surgical Quality Improvement Program, a nationally validated database. Cases were identified by Current Procedural Terminology codes. Modified Poisson regression was used to calculate risk ratios and 95% confidence intervals, adjusting for potential confounders selected a priori.

RESULTS

We identified 45,865 surgical cases, of which 10% involved an obliterative procedure. In the unadjusted model, non-Hispanic Asian and non-Hispanic Black patients were more likely to undergo an obliterative procedure compared with non-Hispanic White patients (risk ratio [95% confidence interval], 2.4 [2.1-2.7] and 1.2 [1.03-1.3], respectively). These relative risks were largely unchanged when controlling for age, body mass index, diabetes, American Society of Anesthesiologists classification, and concurrent hysterectomy.

CONCLUSIONS

Although both obliterative and reconstructive procedures have their respective risks and benefits, the proportion of patients undergoing each procedure differs by race and ethnicity. It is unclear whether such disparities may be attributable to differences in preference or inequity in care.

The multimorbidity profile of South African women newly diagnosed with breast cancer

Multimorbidity in women with breast cancer may delay presentation, affect treatment decisions and outcomes. We described the multimorbidity profile of women with breast cancer, its determinants, associations with stage at diagnosis and treatments received. We collected self-reported data on five chronic conditions (hypertension, diabetes, cerebrovascular diseases, asthma/chronic obstructive pulmonary disease, tuberculosis), determined obesity using body mass index (BMI) and tested HIV status, in women newly diagnosed with breast cancer between January 2016 and April 2018 in five public hospitals in South Africa. We identified determinants of ≥2 of the seven above-mentioned conditions (defined as multimorbidity), multimorbidity itself with stage at diagnosis (advanced [III-IV] vs. early [0-II]) and multimorbidity with treatment modalities received. Among 2,281 women, 1,001 (44%) presented with multimorbidity. Obesity (52.8%), hypertension (41.3%), HIV (22.0%) and diabetes (13.7%) were the chronic conditions that occurred most frequently. Multimorbidity was more common with older age (OR = 1.02; 95% CI 1.01-1.03) and higher household socioeconomic status (HSES) (OR = 1.06; 95% CI 1.00-1.13). Multimorbidity was not associated with advanced-stage breast cancer at diagnosis, but for self-reported hypertension there was less likelihood of being diagnosed with advanced-stage disease in the adjusted model (OR 0.80; 95% CI 0.64-0.98). Multimorbidity was associated with first treatment received in those with early-stage disease, p = 0.003. The prevalence of multimorbidity is high among patients with breast cancer. Our findings suggest that multimorbidity had a significant impact on treatment received in those with early-stage disease. There is need to understand the impact of multimorbidity on breast cancer outcomes.

Spatial analysis of COVID-19 clusters and contextual factors in New York City

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Proportion positive tests were positively associated with marginalized statuses.

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Low testing and high positivity were associated with public transportation use.

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We recommend testing and health care resources be directed to eastern Brooklyn.

Identifying areas with low access to testing and high case burden is necessary to understand risk and allocate resources in the COVID-19 pandemic. Using zip code level data for New York City, we analyzed testing rates, positivity rates, and proportion positive. A spatial scan statistic identified clusters of high and low testing rates, high positivity rates, and high proportion positive. Boxplots and Pearson correlations determined associations between outcomes, clusters, and contextual factors. Clusters with less testing and low proportion positive tests had higher income, education, and white population, whereas clusters with high testing rates and high proportion positive tests were disproportionately black and without health insurance. Correlations showed inverse associations of white race, education, and income with proportion positive tests, and positive associations with black race, Hispanic ethnicity, and poverty. We recommend testing and health care resources be directed to eastern Brooklyn, which has low testing and high proportion positives.

Community Empowerment Partners (CEPs): A Breast Health Education Program for African-American Women

Peer educators have been shown to provide effective interventions in breast cancer screening. Few studies have compared the effects of peer education on breast cancer knowledge among peer educators and the community members who are subsequently reached through the peer education. Further, little is known as to whether those who received the education then go on to educate others in the community. The purpose of this study is to address those gaps. Using a pre- and post-test study design, we trained peer educators, provided the educators with resources to train community members, and assessed changes in knowledge. We sought to train ten educators and recommended each train ten community members in breast cancer knowledge and screening strategies. A total of 14 peer educators were trained, who subsequently trained a total of 121 community members, of whom 94 were African American women. Peer educators and community members, showed comparable increases in knowledge. Community members who were educated also increased intention to discuss breast cancer and breast cancer screening with their family, friends, and acquaintances. Our study suggests that it is feasible to train peer educators to increase knowledge among community members to the same level that they themselves experience when trained. Further, community members are interested in sharing information learned related to how much they learn from peer educators.

An Investigation of Unmet Socio-Economic Needs Among Arab American Breast Cancer Patients Compared with Other Immigrant and Migrant Patients

Although Arabs are a growing population in the United States, they are a hidden minority when compared to larger, more studied groups like Latinos and Caribbean immigrants of African descent (CIAD). There is limited research pertaining to patients' unmet socioeconomic and supportive care needs when undergoing breast cancer treatment, particularly among immigrants and migrants. This is a comparative study of a nested cohort of 36 Arabs, 145 Latinos and 128 CIAD breast cancer patients participating in the Integrated Cancer Care Access Network and their areas of needed assistance. The patients were recruited from eleven community cancer clinics in New York City and through community based organizations. Patients most commonly reported needing financial, transportation, and food assistance. Arabs were more likely than their CIAD and Latino counterparts to have health insurance and legal aid needs. Arabs also has the highest proportion of patients unaware of their own cancer stage, at odds with their report of lower information needs than the other groups. Additional culturally tailored Arabic language interventions are needed to educate Arabic speaking breast cancer patients to help facilitate access to available services.

Census Tract Poverty and Racial Disparities in HIV Rates in Milwaukee County, Wisconsin, 2009-2014

Previous work has documented associations between poverty and HIV. Understanding of these relationships at local levels could help target prevention efforts; however, HIV surveillance systems do not capture individual-level poverty measures. We utilized the Public Health Disparities Geocoding Project methods to examine HIV rates by census tract poverty. HIV rates and rate ratios were computed by census tract poverty (< 5.0, 5.0-9.9, 10.0-19.9, > 20.0% of individual below the federal poverty level) for all races and stratified by Black and White race using Poisson regression. We observed higher HIV rates in the highest poverty gradient compared to the lowest poverty gradient for all races combined and among White cases. After adjustment, HIV rates were similar across poverty gradients for all comparisons. Our findings suggest that the association between poverty and HIV may differ by subpopulation, while demonstrating the potential for HIV prevention targeting residents of high poverty areas.

On surmounting the barriers to HPV vaccination: we can do better

The major impediment to increased human papillomavirus (HPV) vaccination coverage in young males and females is lack of health care provider recommendation. Despite its efficacy in preventing cervical cancer, HPV vaccination in females (49.5%) and males (37.5%) ages 13 through 17 falls well below the Centers for Disease Control and Prevention's (CDC) Healthy People 2020 target of 80% coverage. Parents' willingness to vaccinate their child has been shown to be much higher when physicians share personal vaccination decisions for their own children as well as what other parents have done at that particular clinic. Furthermore, the vaccine must be presented presumptively as a "bundle" along with the rest of the standard adolescent vaccine panel. Multiple exemplars presented including in several European countries, low-income countries and Rwanda, demonstrate that school-based health care systems dramatically increase vaccination coverage. Finally, acceptability for vaccination of males must improve by increasing provider recommendation and by presenting the HPV vaccine as a penile, anal and oropharyngeal cancer prevention therapy in males and not merely a vaccine to prevent cervical cancers in females. Paediatricians, obstetrician/gynaecologists and primary care physicians should consider these data as a call-to-action. Key messages   • Despite recent efforts in the US, only 49.5% of females and only 37.5% of males ages 13 through 17 have received all recommended HPV vaccine doses. These numbers fall well below the 80% target set forth by the Healthy People 2020 initiative.   • According to the CDC, if health care providers increase HPV vaccination rates in eligible recipients to 80%, it is estimated that an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years. Furthermore, for every year that the vaccination rate does not increase, an additional 4400 women will develop cervical cancer.   • First and foremost, healthcare providers (HCPs) must make a strong recommendation to vaccinate patients and these recommendations must become routine, including for males.   • It is clear that HPV vaccination rates improve significantly when vaccine administration occurs at designated, well-organized sites such as school-based vaccination programmes. Furthermore, HPV vaccination should be a high school requirement and offered in the standard adolescent vaccine panel as a bundle with Tdap and MenACWY vaccines in order to promote maximum adherence.   • Finally, research on immunogenicity and antibody titre longevity needs to be done in newborns. The HPV vaccine may be recommended in the newborn panel of vaccines to avoid any issues of sexualization and misplaced fears of sexual disinhibition, akin to the success of the Hepatitis B vaccine in the 1980s.   • The HPV vaccine is a vaccine against cancer and should be aggressively marketed as such. As healthcare providers, we need to make every effort to overcome barriers, real or perceived, to protecting our population from potential morbidity and mortality associated with this virus.

Urban Neighborhood and Residential Factors Associated with Breast Cancer in African American Women: a Systematic Review

Residential characteristics in urban neighborhoods impact health and might be important factors contributing to health disparities, especially in the African American population. The purpose of this systematic review is to understand the relationship between urban neighborhood and residential factors and breast cancer incidence and prognosis in African American women. Using PubMed and Web of Science, the existing literature was reviewed. Observational, cross-sectional, cohort, and prospective studies until February 2017 were examined. Studies including populations of African American women, setting in "urban" areas, and a measure of a neighborhood or residential factor were reviewed. Four parameters related to neighborhood or residential factors were extracted including: neighborhood socioeconomic status (nSES), residential segregation, spatial access to mammography, and residential pollution. Our analysis showed that African American women living in low nSES have greater odds of late stage diagnosis and mortality. Furthermore, African American women living in segregated areas (higher percentage of Blacks) have higher odds of late stage diagnosis and mortality compared to White and Hispanic women living in less segregated areas (lower percentage of Blacks). Late stage diagnosis was also shown to be significantly higher in areas with poor mammography access and areas with higher Black residential segregation. Lastly, residential pollution did not affect breast cancer risk in African American women. Overall, this systematic review provides a qualitative synthesis of major neighborhood and residential factors on breast cancer outcomes in African American women.

Estimated and Interactively Visualized Female Breast Cancer Incidence Rates in Missouri Senate Districts: 2008-2012

Objectives

To measure and interactively visualize female breast cancer (FBC) incidence rates in Missouri by age, race, stage and grade, and senate district of residence at diagnosis from 2008 to 2012.

Methods

An observational epidemiological study. The FBC cases in counties split by senate districts were geocoded. Population database was created. A database was created within SEER*Stat. The incidence rates and the 95% Confidence Interval (CI) were age standardized using US 2000 Standard Population. The Census Bureau’s Cartographic Boundary Files were used to create maps showing Missouri senate districts. Incidence results were loaded along with the maps into InstantAtlas™ software to produce interactive reports.

Results

Cancer profiles were created for all 34 Missouri senate districts. An area profile and a double map that included interactive maps, graphs, and tables for the 34 Missouri senate districts were built.

Conclusion

The results may provide an estimation of social inequality within the state and could provide clues about the impact of level of coverage and accessibility to screening and health care services on disease prevention and early diagnosis.

Anxiety, Depression and Quality of Life in Breast Cancer Patients in the Levant

Background:

Limited data are currently available regarding the psychological well-being and quality of life of breast cancer patients after active treatment in Lebanon and the Arab region in general. The objective of this study was to determine the prevalence of anxiety and depression among Arab breast cancer patients and assess the quality of life with reference to socio-demographic and clinical characteristics.

Methods:

This cross-sectional study was conducted among female breast cancer patients diagnosed between January 2009 and March 2014, who were recruited from the outpatient clinics of Naef K. Basile Cancer Institute at the American University of Beirut Medical Center (AUBMC) from November 2015 till December 2016. An interview was conducted utilizing two validated questionnaires: the Hospital Anxiety and Depression Scale (HADS) and the Functional Assessment of Cancer Therapy-Breast (FACT-B). Socio-demographic and clinical characteristics that might predict patient quality of life were collected and summarized.

Results:

A total of 150 patients were interviewed (median age 53.5±10.4 years). Most were assessed 3 to 5 years (68.7%) after initial diagnosis and had undergone surgery, chemotherapy, radiation, or hormonal therapy (97.3%, 79.3%, 80.7% and 86.0%, respectively). The median total HADS score was 10.0 ± 8.0, with approximately 41.3% of study participants having abnormal scores on the anxiety subscale and 24.7% on the depression subscale. Significant predictors of total HADS score were nationality and level of education (p=0.001, p=0.001 respectively; R²=0.181). Participants who were Iraqi, had stage IV disease, had a household monthly income below 1000 USD, or had received chemotherapy exhibited significantly lower total FACT-B scores, these being highly negatively correlated with total HADS scores (r_s= -0.73, p=0.001).

Conclusion:

There is a vital need for the development of individualized interventions and psychosocial support programs tailored to the physical and psychological well-being of breast cancer patients in the Levant region.

Area-based socioeconomic factors and Human Papillomavirus (HPV) vaccination among teen boys in the United States

BACKGROUND

This study is the first to examine associations between several area-based socioeconomic factors and human papillomavirus (HPV) vaccine uptake among boys in the United States (U.S.).

METHODS

Data from the 2012-2013 National Immunization Survey-Teen restricted-use data were analyzed to examine associations of HPV vaccination initiation (receipt of ≥1 dose) and series completion (receipt of three doses) among boys aged 13-17 years (N = 19,518) with several individual-level and ZIP Code Tabulation Area (ZCTA) census measures. Multivariable logistic regression was used to estimate the odds of HPV vaccination initiation and series completion separately.

RESULTS

In 2012-2013 approximately 27.9% (95% CI 26.6%-29.2%) of boys initiated and 10.38% (95% CI 9.48%-11.29%) completed the HPV vaccine series. Area-based poverty was not statistically significantly associated with HPV vaccination initiation. It was, however, associated with series completion, with boys living in high-poverty areas (≥20% of residents living below poverty) having higher odds of completing the series (AOR 1.22, 95% CI 1.01-1.48) than boys in low-poverty areas (0-4.99%). Interactions between race/ethnicity and ZIP code-level poverty indicated that Hispanic boys living in high-poverty areas had a statistically significantly higher odds of  HPV vaccine initiation (AOR 1.43, 95% CI 1.03-1.97) and series completion (AOR 1.56, 95% CI 1.05-2.32)  than Hispanic boys in  low-poverty areas. Non-Hispanic Black boys in high poverty areas had higher odds of initiation (AOR 2.23, 95% CI 1.33-3.75) and completion (AOR 2.61, 95% CI 1.06-6.44) than non-Hispanic Black boys in low-poverty areas. Rural/urban residence and population density were also significant factors, with boys from urban or densely populated areas having higher odds of initiation and completion compared to boys living in non-urban, less densely populated areas.

CONCLUSION

Higher HPV vaccination coverage in urban areas and among racial/ethnic minorities in areas with high poverty may be attributable to factors such as vaccine acceptance, health-care practices, and their access to HPV vaccines through the Vaccines for Children Program, which provides free vaccines to uninsured and under-insured children. Given the low HPV vaccination rates among boys in the U.S., these results provide important evidence to inform public health interventions to increase HPV vaccination.

Determinants of Advanced Stage at Initial Diagnosis of Breast Cancer in Pakistan: Adverse Tumor Biology vs Delay in Diagnosis

BACKGROUND

Breast cancer is the most frequent cancer of women in Pakistan with the majority presenting with stage III or IV lesionsat initial diagnosis. Patient and health system related factors are well known determinants of delay in presentation and diagnosis. Additionally, breast cancer being a heterogeneous disease, the various molecular subtypes featuring different aggressiveness also need to be considered. The present study evaluated the association of stage at initial diagnosis of breast cancer with these two factors in local women at a tertiary level health care facility in Lahore, Pakistan.

MATERIALS AND METHODS

Patient and tumor features were recorded separately during diagnostic workup in Breast Clinics at INMOL and at Services Hospital, Lahore. Data were entered in MS Excel and analyzed by descriptive statistics and Chi-Square test.

RESULTS

Among the 261 patients, 64% were staged as late breast cancer (LBC), the mean age was 46.8 with standard deviation of 13 years. Some 92% had invasive ductal carcinoma (IDC), 61% had luminal types (LT) of non-aggressive tumor while 39% had the non-luminal types (NLT) of of HER2-enriched or basal aggressive tumors. While 70% of patients presented within one year of symptomatic disease (early report group "ERG"), 30% reported after a mean delay of 4 years with a standard deviation of 3.75 years. The stage distribution among ERG patients was not statistically different from those reporting late (P=0.123). Statistically larger proportion of patients with NLT presented as LBC as compared to the LT (P =0.034). Among the ERG, statistically different stage distribution of disease was observed for the NLT versus LT (P=0.047). Among those presenting late, this difference was insignificant (P=0.416).

CONCLUSIONS

Breast cancer is a distinct disease in Pakistan with a high frequency of aggressive molecular types affecting younger women, with the majority presenting as LBC. Association of NLT with higher stage at diagnosis is statistically significant whereas time delay in diagnosis is not. Further research is required to define the risk profile and features in local patients. The burden of LBC can be reduced by promoting breast health awareness and by establishing easily accessible dedicated breast care set ups in the hospitals.

Geographic Factors and Human Papillomavirus (HPV) Vaccination Initiation among Adolescent Girls in the United States

BACKGROUND

This study is among the first to explore geographic factors that may be associated with human papillomavirus (HPV) vaccine uptake in the United States.

METHODS

Data from the 2011 and 2012 National Immunization Survey-Teen for 20,565 female adolescents aged 13 to 17 years were analyzed to examine associations of HPV vaccine initiation (receipt of at least one dose) with ZIP code-level geographic factors. Logistic regression including individual and geographic factors was used to estimate the odds of HPV vaccine initiation.

RESULTS

Approximately 53% of girls initiated the HPV vaccine in both years. Girls in high poverty communities had higher HPV vaccine initiation compared with those in low poverty communities [61.1% vs. 52.4%; adjusted OR (AOR), 1.18; 95% confidence intervals (CI), 1.04-1.33]. Initiation was higher among girls in communities where the majority of the population was Hispanic (69.0% vs. 49.9%; AOR, 1.64; 95% CI, 1.43-1.87) or non-Hispanic mixed race (60.4% vs. 49.9%; AOR, 1.30; 95% CI, 1.17-1.44) compared with majority non-Hispanic white communities. Interactions between individual-level race/ethnicity and community racial-ethnic composition indicated significantly higher odds of initiation among Hispanic girls living in Hispanic communities compared with Hispanic girls living in predominantly non-Hispanic White (NHW) (AOR, 2.23; 95% CI, 1.87-2.65) or non-Hispanic Black (NHB) (AOR, 1.90; 95% CI, 1.20-3.04) communities, respectively.

CONCLUSION

Initiation rates of HPV vaccination among teen girls were highest in the poorest communities and among Hispanics living in communities where the racial-ethnic composition was predominantly Hispanic or mixed race.

IMPACT

Given low HPV vaccination rates in the United States, these results provide important evidence to inform public health interventions to increase HPV vaccination.

Small-area spatio-temporal analyses of participation rates in the mammography screening program in the city of Dortmund (NW Germany)

Background

The population-based mammography screening program (MSP) was implemented by the end of 2005 in Germany, and all women between 50 and 69 years are actively invited to a free biennial screening examination. However, despite the expected benefits, the overall participation rates range only between 50 and 55 %. There is also increasing evidence that belonging to a vulnerable population, such as ethnic minorities or low income groups, is associated with a decreased likelihood of participating in screening programs. This study aimed to analyze in more detail the intra-urban variation of MSP uptake at the neighborhood level (i.e. statistical districts) for the city of Dortmund in northwest Germany and to identify demographic and socioeconomic risk factors that contribute to non-response to screening invitations.

Methods

The numbers of participants by statistical district were aggregated over the three periods 2007/2008, 2009/2010, and 2011/2012. Participation rates were calculated as numbers of participants per female resident population averaged over each 2-year period. Bayesian hierarchical spatial models extended with a temporal and spatio-temporal interaction effect were used to analyze the participation rates applying integrated nested Laplace approximations (INLA). The model included explanatory covariates taken from the atlas of social structure of Dortmund.

Results

Generally, participation rates rose for all districts over the time periods. However, participation was persistently lowest in the inner city of Dortmund. Multivariable regression analysis showed that migrant status and long-term unemployment were associated with significant increases of non-attendance in the MSP.

Conclusion

Low income groups and immigrant populations are clustered in the inner city of Dortmund and the observed spatial pattern of persistently low participation in the city center is likely linked to the underlying socioeconomic gradient. This corresponds with the findings of the ecological regression analysis manifesting socioeconomically deprived neighborhoods as risk factors for low attendance in the MSP. Spatio-temporal surveillance of participation in cancer screening programs may be used to identify spatial inequalities in screening uptake and plan spatially focused interventions.

Getting Black Men to Undergo Prostate Cancer Screening: The Role of Social Capital

Despite higher rates of prostate cancer-related mortality and later stage of prostate cancer diagnosis, Black/African American men are significantly less likely than non-Hispanic White men to use early detection screening tools, like prostate-specific antigen (PSA) testing for prostate cancer. Lower screening rates may be due, in part, to controversy over the value of prostate cancer screenings as part of routine preventive care for men, but Black men represent a high-risk group for prostate cancer that may still benefit from PSA testing. Exploring the role of social factors that might be associated with PSA testing can increase knowledge of what might promote screening behaviors for prostate cancer and other health conditions for which Black men are at high risk. Using multilevel logistic regression, this study analyzed self-report lifetime use of PSA test for 829 Black men older than 45 years across 381 Philadelphia census tracts. This study included individual demographic and aggregated social capital data from the Public Health Management Corporation's 2004, 2006, and 2008 waves of the Community Health Database, and sociodemographic characteristics from the 2000 U.S. Census. Each unit increase in community participation was associated with a 3 to 3.5 times greater likelihood of having had a PSA test (odds ratio = 3.35). Findings suggest that structural forms of social capital may play a role in screening behaviors for Black men in Philadelphia. A better understanding of the mechanism underlying the link between social capital and screening behaviors can inform how researchers and interventionists develop tools to promote screening for those who need it.

Epidemiological and Clinicopathological Trends of Breast Cancer in Chinese Patients During 1993 to 2013: A Retrospective Study

This study aimed to summarize the epidemiological and pathological trends of breast cancer in Chinese women.The clinical data of 4968 breast cancer patients treated at the Chinese PLA General Hospital from 1993 to 2013 were retrospectively reviewed.The mean ± standard deviation (SD) age was 47.4 ± 11.3 years before the year 2001, 49.2 ± 11.2 years during 2001 to 2010, and 50.6 ± 11.4 years after the year 2010, respectively (P < 0.001). The ratio of premenopausal women to postmenopausal women was 1.6 and no significant changes were found during the period (P = 0.121). The proportion of patients with Scarff Bloom Richardson III breast cancer showed significant increase along with time (P = 0.015). The breast cancer was accounting for 31.7% at stage I and DCIS/LCIS and tend to be diagnosed with early stage around time (P < 0.001). The proportion of DCIS/LCIS and stage I increased with time during the 20 years from 14.6% to 33.2%, whereas the proportion of stage III to IV decreased.The proportion of Luminal A-like subtype gradually reduced and Luminal B-like (HER2-negative) increased and developed to the predominant type. Older age and earlier stage at diagnosis, as well as the alternation of predominant molecular subtypes, have become the developed trends of breast cancer.

A comparative analysis of breast cancer stage between women enrolled in the National Breast and Cervical Cancer Early Detection Program and women not participating in the program

PURPOSE

To determine the proportional distribution of early- and late-stage breast cancers diagnosed in years 2004-2009 among women enrolled in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and to compare this distribution to that of geographically comparable non-enrolled women diagnosed with breast cancer.

METHODS

Using data from the National Program of Cancer Registries, we compared the demographic characteristics and cancer stage distribution of women enrollees and non-enrollees by use of conditional logistic regression using the odds ratio as a measure of association.

RESULTS

NBCCEDP enrollees were slightly younger and more likely to identify as African-American, API and AIAN than were non-enrollees. The proportion of late-stage breast cancer (regional and distant) decreased slightly over the study period. NBCCEDP enrollees generally were diagnosed at a later stage of breast cancer than were those not enrolled in the NBCCEDP.

CONCLUSIONS

The NBCCEDP has been effective in achieving its goal of enrolling racial and ethnic populations; however, enrollees had a poorer stage distribution of breast cancer than did non-enrollees underscoring the need to expand breast cancer control efforts among low-income, underserved populations.

The role of social capital in African-American women's use of mammography

Black/African-American women are more likely to get breast cancer at a young age and/or be diagnosed at a late disease stage, pointing to a greater need to promote mammography for Black women at earlier ages than are currently recommended. This study explores how perceived neighborhood social capital, that is, perceptions of how tight-knit a neighborhood is and what power that confers to neighborhood members, relates to use of mammography for Black women in Philadelphia. Living in a community with tight social ties (social cohesion) or that have a collective motivation for community change (collective efficacy) may increase the likelihood that an individual woman in that community will hear health messages from other community members and neighbors (diffusion of information) and will have access to health-related resources that allow them to engage in healthy behaviors. No prior studies have explored the role of social capital in decisions for mammography use. Using multilevel logistic regression, we analyzed self-report of mammography in the past year for 2586, Black women over age 40 across 381 Philadelphia, Pennsylvania USA census tracts. Our study included individual demographic and aggregates of individual-level social capital data from the Public Health Management Corporation's 2004, 2006, and 2008 Community Health Database waves, and 2000 US Census sociodemographic characteristics. Individual perceptions that a Black woman's neighborhood had high social capital, specifically collective efficacy, had a positive and statistically significant association with mammography use (OR = 1.40, CI: 1.05, 1.85). Our findings suggest that an individual woman's perception of greater neighborhood social capital may be related to increased mammography use. Although this analysis could not determine the direction of causality, it suggests that social capital may play a role in cancer preventive screening for African-American women in Philadelphia, which warrants further study.

Effect of race/ethnicity and socioeconomic status on pandemic H1N1-related outcomes in Massachusetts

OBJECTIVES

We linked hospital discharge and American Community Survey and US Census data to investigate 2009 H1N1 influenza (H1N1)-related outcomes by racial/ethnic groups and socioeconomic status (SES).

METHODS

We examined the population discharged from any acute care hospital in Massachusetts and calculated rates of intensive care unit (ICU) stay by racial/ethnic and SES groups between April 26 and September 30, 2009. We used logistic regression models to identify predictors of ICU stay.

RESULTS

Of 4874 H1N1-related hospitalizations, 526 (11%) were admitted to the ICU. Those in less affluent SES groups had lower risk of ICU stay than the most affluent SES group. Compared with Whites, Hispanics had significantly lower risk of 2009 H1N1-related ICU stay (odds ratio = 0.52; 95% confidence interval = 0.32, 0.86). Only 13% of Whites admitted to the ICU were in the lowest SES group, compared with 63% of Hispanics and 43% of Blacks.

CONCLUSIONS

To our knowledge, this is the first statewide description of 2009 H1N1 influenza-related ICU stays according to racial/ethnic group and SES in the United States. Future work should investigate evidence related to social determinants of health among racial/ethnic groups to reduce disparities in relation to pandemic influenza.

Impact of obesity on cancer survivorship and the potential relevance of race and ethnicity

Evidence that obesity is associated with cancer incidence and mortality is compelling. By contrast, the role of obesity in cancer survival is less well understood. There is inconsistent support for the role of obesity in breast cancer survival, and evidence for other tumor sites is scant. The variability in findings may be due in part to comorbidities associated with obesity itself rather than with cancer, but it is also possible that obesity creates a physiological setting that meaningfully alters cancer treatment efficacy. In addition, the effects of obesity at diagnosis may be distinct from the effects of weight change after diagnosis. Obesity and related comorbid conditions may also increase risk for common adverse treatment effects, including breast cancer-related lymphedema, fatigue, poor health-related quality of life, and worse functional health. Racial and ethnic groups with worse cancer survival outcomes are also the groups for whom obesity and related comorbidities are more prevalent, but findings from the few studies that have addressed these complexities are inconsistent. We outline a broad theoretical framework for future research to clarify the specifics of the biological-social-environmental feedback loop for the combined and independent contributions of race, comorbid conditions, and obesity on cancer survival and adverse treatment effects. If upstream issues related to comorbidities, race, and ethnicity partly explain the purported link between obesity and cancer survival outcomes, these factors should be among those on which interventions are focused to reduce the burden of cancer.

Desigualdades socioeconômicas na incidência e mortalidade por câncer: revisão de estudos ecológicos, 1998-2008

INTRODUÇÃO: Desigualdades socioeconômicas se manifestam na incidência e mortalidade por neoplasias malignas. Estudos ecológicos representam abordagem essencial em epidemiologia e podem contribuir na investigação dos determinantes sociais dos eventos em saúde. OBJETIVO: Investigar associações entre nível socioeconômico e incidência e mortalidade por câncer e seus tipos, através de revisão de estudos ecológicos. Definir a real importância desempenhada pelos estudos ecológicos na investigação dessa relação. MÉTODO: As principais bases de dados regionais e internacionais foram pesquisadas na seleção de artigos em português, espanhol e inglês, publicados entre 1998 e 2008. RESULTADOS: 32 estudos elegíveis foram incluídos. Verificou-se associação positiva e consistente do nível socioeconômico da área de residência com incidência de câncer de próstata e mortalidade pelo de cólon nos homens, e com incidência e mortalidade por câncer de mama e mortalidade pelo de cólon nas mulheres. Associação consistente e negativa foi encontrada para incidência e mortalidade por cânceres de esôfago e estômago, para incidência dos de cólon e pulmão e mortalidade pelos de laringe e cavidade oral, nos homens, e para incidência e a mortalidade pelos de esôfago, estômago e colo uterino e para incidência dos de cólon e pulmão, nas mulheres. CONCLUSÃO: Apesar da presença de efeito residual de área e de viés relacionado à medida agregada de nível socioeconômico, estudos ecológicos podem ser eficientemente utilizados na mensuração das desigualdades socioeconômicas em câncer. Uso de pequenas unidades geográficas e de dados de registros de câncer em países em desenvolvimento pode contribuir para melhor conhecimento de suas desigualdades em saúde.

Efficient mapping and geographic disparities in breast cancer mortality at the county-level by race and age in the U.S

This study identified geographic disparities in breast cancer mortality across the U.S. using kriging to overcome unavailability of data because of confidentiality and reliability concerns. A structured additive regression model was used to detect where breast cancer mortality rates were elevated across nine divisions with 3109 U.S. counties during 1982-2004. Our analysis identified at least 25.8% of counties where breast cancer mortality rates were elevated. High-risk counties compared to lower-risk counties had higher relative risks for African American women than for White women. Greater geographic disparities more likely present in African American women and younger women. To sum up, our statistical approach reduced the impact of unavailable data, and identified the number and location of counties with high breast cancer mortality risk by race and age across the U.S.

The joint effects of census tract poverty and geographic access on late-stage breast cancer diagnosis in 10 US States

This study evaluated independent and joint effects of census tract (CT) poverty and geographic access to mammography on stage at diagnosis for breast cancer. The study included 161,619 women 40+ years old diagnosed with breast cancer between 2004 -2006 in ten participating US states. Multilevel logistic regression was used to estimate the odds of late-stage breast cancer diagnosis for the entire study population and by state. Poverty was independently associated with late-stage in the overall population (poverty rates >20% OR=1.30, 95% CI=1.26- 1.35) and for 9 of the 10 states. Geographic access was not associated with late-stage diagnosis after adjusting for CT poverty. State-specific analysis provided little evidence that geographic access was associated with breast cancer stage at diagnosis, and after adjusting for poverty, geographic access mattered in only 1 state. Overall, compared to women with private insurance, the adjusted odds ratios for late stage at diagnosis among women with either no insurance, Medicaid, or Medicare were 1.80 (95% CI = 1.65, 1.96), 1.75 (95% CI = 1.68, 1.84), and 1.05 (95% CI 1.01, 1.08), respectively. Although geographic access to mammography was not a significant predictor of late-stage breast cancer diagnosis, women in high poverty areas or uninsured are at greatest risk of being diagnosed with late-stage breast cancer regardless of geographic location and may benefit from targeted interventions.

Association between community socioeconomic position and HIV diagnosis rate among adults and adolescents in the United States, 2005 to 2009

OBJECTIVES

We examined the association between socioeconomic position (SEP) and HIV diagnosis rates in the United States and whether racial/ethnic disparities in diagnosis rates persist after control for SEP.

METHODS

We used cases of HIV infection among persons aged 13 years and older, diagnosed 2005 through 2009 in 37 states and reported to national HIV surveillance through June 2010, and US Census data, to examine associations between county-level SEP measures and 5-year average annual HIV diagnosis rates overall and among race/ethnicity-sex groups.

RESULTS

The HIV diagnosis rate was significantly higher for individuals in the low-SEP tertile than for those in the high-SEP tertile (rate ratios for low- vs high-SEP tertiles range = 1.68-3.38) except for White males and Hispanic females. The SEP disparities were larger for minorities than for Whites. Racial disparities persisted after we controlled for SEP, urbanicity, and percentage of population aged 20 to 50 years, and were high in the low-SEP tertile for males and in low- and high-SEP tertiles for females.

CONCLUSIONS

Findings support continued prioritization of HIV testing, prevention, and treatment to persons in economically deprived areas, and Blacks of all SEP levels.

Clinicopathologic profile of breast cancer patients in Pakistan: ten years data of a local cancer hospital

Breast cancer is the most frequent cancer of women worldwide, with considerable geographic and racial/ethnic variation. Data are generally derived from population based cancer registries in the developed countries but hospital data are the most reliable source in the developing countries. Ten years data from 1st Jan 2000 to 31st Dec 2009 of a cancer hospital in Pakistan were here analyzed by descriptive statistics to evaluate the clinicopathologic profile of local breast cancer patients. Among 28,740 cancer patients, 6,718 were registered as breast cancer. The female to male ratio was 100:2. Breast cancer accounted for 23% of all and 41% of female cancers. Some 46% were residents of Lahore, with a mean age of 47±12 years. Less than 1% were at Stage 0 and 10%, 32%, 35% and 23% were at Stage I, II, III and IV respectively. Histopathology was unknown in 4% while 91%, 2% and 1% had invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC) and mucinous carcinoma respectively. Rare carcinomas accounted for the rest. Tumor grade 1, 2 and 3 was 11%, 55% and 34% among the known. Profile of breast cancer patients in Pakistan follows a pattern similar to that of other developing countries with earlier peak age and advanced disease stage at presentation. The male breast cancer accounts for higher proportion in the local population. Local women have higher frequency of IDC and lower frequency of ILC and DCIS, owing probably to a different risk profile. Use of hospital information systems and establishment of population based cancer registry is required to have accurate and detailed local data. Promotion of breast health awareness and better health care system is required to decrease the burden of advanced disease.

Influence of primary care physician availability and socioeconomic deprivation on breast cancer from 1988 to 2008: a spatio-temporal analysis

Background

Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among women in the United States. It is unclear how county-level primary care physician (PCP) availability and socioeconomic deprivation affect the spatial and temporal variation of breast cancer incidence and mortality.

Methods

We used the 1988–2008 public-use county-based data from nine Surveillance, Epidemiology, and End Results (SEER) programs to analyze the temporal and spatial disparity of PCP availability and socioeconomic deprivation on early-stage incidence, advanced-stage incidence and breast cancer mortality. The spatio-temporal analysis was implemented by a novel structural additive modeling approach.

Results

Greater PCP availability was significantly associated with higher early-stage incidence, advanced-stage incidence and mortality during the entire study period while socioeconomic deprivation was significantly negatively associated with early-stage incidence, advanced-stage incidence, and mortality up to 1992. However, the observed influence of PCP availability and socioeconomic deprivation varied by county.

Conclusions

We showed important associations of PCP availability and socioeconomic deprivation with the three breast cancer indicators. However, the effect of these associations varied over time and across counties. The association of PCP availability and socioeconomic deprivation was stronger in selected counties.

Breast cancer stage at diagnosis and area-based socioeconomic status: a multicenter 10-year retrospective clinical epidemiological study in China

Background

Although socioeconomic status (SES) has been focused on as a key determinant of cancer stage at diagosis in western countries, there has been no systemic study on the relationship of SES and breast cancer stage at diagnosis in China.

Methods

The medical charts of 4,211 eligible breast cancer patients from 7 areas across China who were diagnosed between 1999 and 2008 were reviewed. Four area-based socioeconomic indicators were used to calculate area-based SES by cluster analysis. The associations between area-based SES and stage at diagnosis were analyzed by trend chi-square tests. Binary logistic regression was performed to estimate odds ratios for individual demographic characteristics' effects on cancer stages, stratified by area-based SES.

Results

The individual demographic and pathologic characteristics of breast cancer cases were significantly different among the seven areas studied. More breast cancer cases in low SES areas (25.5%) were diagnosed later (stages III & IV) than those in high (20.4%) or highest (14.8%) SES areas (χ² for trend = 80.79, P < 0.001). When area-based SES is controlled for, in high SES areas, cases with less education were more likely to be diagnosed at later stages compared with more educated cases. In low SES areas, working women appeared to be diagnosed at earlier breast cancer stages than were homemakers (OR: 0.18-0.26).

Conclusions

In China, women in low SES areas are more likely to be diagnosed at later breast cancer stages than those in high SES areas.

Breast cancer stage at diagnosis: is travel time important?

Recent studies have produced inconsistent results in their examination of the potential association between proximity to healthcare or mammography facilities and breast cancer stage at diagnosis. Using a multistate dataset, we re-examine this issue by investigating whether travel time to a patient's diagnosing facility or nearest mammography facility impacts breast cancer stage at diagnosis. We studied 161,619 women 40 years and older diagnosed with invasive breast cancer from ten state population based cancer registries in the United States. For each woman, we calculated travel time to their diagnosing facility and nearest mammography facility. Logistic multilevel models of late versus early stage were fitted, and odds ratios were calculated for travel times, controlling for age, race/ethnicity, census tract poverty, rural/urban residence, health insurance, and state random effects. Seventy-six percent of women in the study lived less than 20 min from their diagnosing facility, and 93 percent lived less than 20 min from the nearest mammography facility. Late stage at diagnosis was not associated with increasing travel time to diagnosing facility or nearest mammography facility. Diagnosis age under 50, Hispanic and Non-Hispanic Black race/ethnicity, high census tract poverty, and no health insurance were all significantly associated with late stage at diagnosis. Travel time to diagnosing facility or nearest mammography facility was not a determinant of late stage of breast cancer at diagnosis, and better geographic proximity did not assure more favorable stage distributions. Other factors beyond geographic proximity that can affect access should be evaluated more closely, including facility capacity, insurance acceptance, public transportation, and travel costs.

Rural - urban inequalities in late-stage breast cancer: spatial and social dimensions of risk and access

Rural - urban inequalities in health and access to health care have long been of concern in health-policy formulation. Understanding these inequalities is critically important in efforts to plan a more effective geographical distribution of public health resources and programs. Socially and ethnically diverse populations are likely to exhibit different rural - urban gradients in health and well-being because of their varying experiences of place environments, yet little is known about the interplay between social and spatial inequalities. Using data from the Illinois State Cancer Registry, we investigate rural - urban inequalities in late-stage breast cancer diagnosis both for the overall population and for African-Americans, and the impacts of socioeconomic deprivation and spatial access to health care. Changes over time are analyzed from 1988 - 92 to 1998 - 2002, periods of heightened breast cancer awareness and increased access to screening. In both time periods, the risk of late-stage diagnosis is highest among patients living in the most urbanized areas, an indication of urban disadvantage. Multilevel modeling results indicate that rural - urban inequalities in risk are associated with differences in the demographic characteristics of area populations and differences in the social and spatial characteristics of the places in which they live. For African-American breast cancer patients, the rural - urban gradient is reversed, with higher risks among patients living outside the city of Chicago, suggesting a distinct set of health-related risks and place experiences that inhibit early breast cancer detection. Findings emphasize the need for combining spatial and social targeting in locating cancer prevention and treatment programs.

Identification of racial disparities in breast cancer mortality: does scale matter?

Background

This paper investigates the impact of geographic scale (census tract, zip code, and county) on the detection of disparities in breast cancer mortality among three ethnic groups in Texas (period 1995-2005). Racial disparities were quantified using both relative (RR) and absolute (RD) statistics that account for the population size and correct for unreliable rates typically observed for minority groups and smaller geographic units. Results were then correlated with socio-economic status measured by the percentage of habitants living below the poverty level.

Results

African-American and Hispanic women generally experience higher mortality than White non-Hispanics, and these differences are especially significant in the southeast metropolitan areas and southwest border of Texas. The proportion and location of significant racial disparities however changed depending on the type of statistic (RR versus RD) and the geographic level. The largest proportion of significant results was observed for the RD statistic and census tract data. Geographic regions with significant racial disparities for African-Americans and Hispanics frequently had a poverty rate above 10.00%.

Conclusions

This study investigates both relative and absolute racial disparities in breast cancer mortality between White non-Hispanic and African-American/Hispanic women at the census tract, zip code and county levels. Analysis at the census tract level generally led to a larger proportion of geographical units experiencing significantly higher mortality rates for minority groups, although results varied depending on the use of the relative versus absolute statistics. Additional research is needed before general conclusions can be formulated regarding the choice of optimal geographic regions for the detection of racial disparities.

Variation in Provider Identification of Obesity by Individual- and Neighborhood-Level Characteristics among an Insured Population

Objective. The purpose of this study was to examine whether neighborhood- and individual-level characteristics affect providers' likelihood of providing an obesity diagnosis code in their obese patients' claims. Methods. Logistic regressions were performed with obesity diagnosis code serving as the outcome variable and neighborhood characteristics and member characteristics serving as the independent variables (N = 16,151 obese plan members). Results. Only 7.7 percent of obese plan members had an obesity diagnosis code listed in their claims. Members living in neighborhoods with the largest proportions of Blacks were 29 percent less likely to receive an obesity diagnosis (P < .05). The odds of having an obesity diagnosis code were greater among members who were female, aged 44 or below, hypertensive, dyslipidemic, BMI >/= 35 kg/m(2), had a larger number of provider visits, or who lived in an urban area (all P < .05). Conclusions. Most health care providers do not include an obesity diagnosis code in their obese patients' claims. Rates of obesity identification were strongly related to individual characteristics and somewhat associated with neighborhood characteristics.

Healthcare access, socioeconomic factors and late-stage cancer diagnosis: an exploratory spatial analysis and public policy implication

Patients diagnosed with late-stage cancer have lower survival rates than those with early-stage cancer. This paper examines possible associations between several risk factors and late-stage diagnosis for four types of cancer in Illinois: breast cancer, prostate cancer, colorectal cancer, and lung cancer. Potential risk factors are composed of spatial factors and nonspatial factors. The spatial factors include accessibility to primary healthcare and distance or travel time to the nearest cancer screening facility. A set of demographic and socioeconomic variables are consolidated into three nonspatial factors by factor analysis. The Bayesian model with convolution priors is utilised to analyse the relationship between the above risk factors and each type of late-stage cancer while controlling for spatial autocorrelation. The results for breast cancer suggest that people living in neighbourhoods with socioeconomic disadvantages and cultural barriers are more likely to be diagnosed at a late stage. In regard to prostate cancer, people in regions with low socioeconomic status are also more likely to be diagnosed at a late stage. Diagnosis of late-stage colorectal or lung cancer is not significantly associated with any of the abovementioned risk factors. The results have important implications in public policy.

A local area analysis of racial, ethnic, and neighborhood disparities in breast cancer staging

Few studies have examined the role of neighborhood socioeconomic condition in shaping breast cancer disparities in defined local areas. We tested associations between three measures of neighborhood socioeconomic condition (poverty, median income, and a composite neighborhood score) on breast cancer staging in two urban counties of the state of New Jersey. Data for these counties were obtained from the New Jersey Surveillance, Epidemiology, and End Results tumor registry and were selected because of their large racial/ethnic and socioeconomic diversity and pilot prevention efforts taking place in these areas. Our study population included Black, Latina, and White women (N = 4,589) diagnosed with breast cancer from 1999 to 2004. Each cancer case was geocoded and linked to socioeconomic data obtained from the 2000 U.S. census. Census tracts served as proxies for neighborhoods. Logistic regression models accounting for clustering of individuals within neighborhoods were fitted with Generalized Estimating Equations. Women living in neighborhoods with lower versus higher neighborhood scores were significantly more likely to have advanced-stage disease (odds ratio, 1.6; confidence intervals, 1.1-2.3), after adjusting for age at diagnosis and race/ethnicity. In analyses stratified by race/ethnicity, results remained significant for all neighborhood measures for White and Black women, but not for Latinas. Moreover, neighborhood poverty showed a weaker socioeconomic gradient in breast cancer staging among White women. Our study findings support the use of a multidimensional neighborhood index to better capture differences in cancer staging risk across racial/ethnic groups and provides evidence that population-based cancer data could be used to identify local needs specific to local populations.

Patterns of Breast Cancer Presentation in the United States: Does Geography Matter?

Distribution of breast cancer varies widely throughout the United States. The factors that influence this geographic variability have not been completely defined. In addition, though a number of studies look at regional and state-to-state variability, few studies have examined this issue with regard to the nation as a whole. State-specific breast cancer data were available from the American College of Surgeons National Cancer Data Base in a series of Benchmark Reports. These data were reviewed and stratified with regard to: age at the time of presentation, race, and stage at the time of presentation. The data were further collected into regional cohorts that corresponded to the United States Census Bureau regions. Statistical analyses were then performed to identify any linked or related variables. A total of 811,652 patients with breast cancer were reported. There was a statistically significant relationship between stage at the time of presentation and census region. The greatest percentage of early-stage disease was recorded in the Northeast and the lowest in the South. There was no significant association between age at presentation and geographic region, but there was a significant relationship between race and stage. The nonwhite subgroup had a greater percentage of patients presenting with advanced-stage disease. Finally, regions with a larger percentage of nonurban population had a higher percentage of later-stage disease at presentation. A relationship exists between the pattern of breast cancer presentation and geographical location within the United States. The Northeast–with the highest percentage of urban areas and white population–reported the highest percentage of early-stage breast cancer at presentation, suggesting a link between these variables. Conversely, the South–with more rural and nonwhite population–had the highest percentage of later-stage disease. The causal relationships are not clear-cut, however, and the relationship between geography and breast cancer presentation is likely multifactorial. Further analysis is indicated to uncover any link between geographic variability and overall breast cancer treatment and survival.

Rural reversal? Rural-urban disparities in late-stage cancer risk in Illinois

BACKGROUND

Differences in late-stage cancer risk between urban and rural residents are a key component of cancer disparities. Using data from the Illinois State Cancer Registry from 1998 through 2002, the authors investigated the rural-urban gradient in late-stage cancer risk for 4 major types of cancer: breast, colorectal, lung, and prostate.

METHODS

Multilevel modeling was used to evaluate the role of population composition and area-based contextual factors in accounting for rural-urban variation. Instead of a simple binary rural-urban classification, a finer grained classification was used that differentiated the densely populated City of Chicago from its suburbs and from smaller metropolitan areas, large towns, and rural settings.

RESULTS

For all 4 cancers, the risk was highest in the most highly urbanized area and decreased as rurality increases, following a J-shaped progression that included a small upturn in risk in the most isolated rural areas. For some cancers, these geographic disparities were associated with differences in population age and race; for others, the disparities remained after controlling for differences in population composition, zip code socioeconomic characteristics, and spatial access to healthcare.

CONCLUSIONS

The observed pattern of urban disadvantage emphasized the need for more extensive urban-based cancer screening and education programs.

Inequalities in breast cancer stage at diagnosis in the Trent region, and implications for the NHS Breast Screening Programme

BACKGROUND

This study investigates risk factors for diagnosis with late-stage breast cancer in order to identify inequalities and inform the understanding of barriers affecting access to mammography screening.

METHODS

Data from the Trent Cancer Registry were used to identify all women with invasive breast cancer, diagnosed in 1998-2006. Risk of diagnosis with late-stage breast cancer was calculated to quantify strength of association between exposure and outcome.

RESULTS

Women outside the age group for routine screening were approximately 30% [<50 years, relative risk (RR) = 1.34 (95% confidence interval, CI: 1.26-1.43) and >70 years, RR = 1.27 (95% CI: 1.19-1.36)] more likely to be diagnosed with late-stage breast cancer; the most deprived women were 37% [RR = 1.37 (95% CI: 1.01-2.56)] more likely to be diagnosed with Stage IV breast cancer; ethnic minority women were 15% [RR = 1.15 (95% CI: 1.09-1.22)] more likely to be diagnosed with late-stage breast cancer and women resident in 5 of 11 Trent Primary Care Trusts (PCT) had a greater than 30% increased risk of diagnosis with late-stage breast cancer than those in Nottingham City PCT.

CONCLUSION

These findings highlight the need for appropriate targeted interventions to address compositional and contextual inequalities that are evident in breast cancer stage at diagnosis.

Impact of socioeconomic status on cancer incidence and stage at diagnosis: selected findings from the surveillance, epidemiology, and end results: National Longitudinal Mortality Study

BACKGROUND

Population-based cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute (NCI) are mainly based on medical records and administrative information. Individual-level socioeconomic data are not routinely reported by cancer registries in the United States because they are not available in patient hospital records. The U.S. representative National Longitudinal Mortality Study (NLMS) data provide self-reported, detailed demographic and socioeconomic data from the Social and Economic Supplement to the Census Bureau's Current Population Survey (CPS). In 1999, the NCI initiated the SEER-NLMS study, linking the population-based SEER cancer registry data to NLMS data. The SEER-NLMS data provide a new unique research resource that is valuable for health disparity research on cancer burden. We describe the design, methods, and limitations of this data set. We also present findings on cancer-related health disparities according to individual-level socioeconomic status (SES) and demographic characteristics for all cancers combined and for cancers of the lung, breast, prostate, cervix, and melanoma.

METHODS

Records of cancer patients diagnosed in 1973-2001 when residing 1 of 11 SEER registries were linked with 26 NLMS cohorts. The total number of SEER matched cancer patients that were also members of an NLMS cohort was 26,844. Of these 26,844 matched patients, 11,464 were included in the incidence analyses and 15,357 in the late-stage diagnosis analyses. Matched patients (used in the incidence analyses) and unmatched patients were compared by age group, sex, race, ethnicity, residence area, year of diagnosis, and cancer anatomic site. Cohort-based age-adjusted cancer incidence rates were computed. The impact of socioeconomic status on cancer incidence and stage of diagnosis was evaluated.

RESULTS

Men and women with less than a high school education had elevated lung cancer rate ratios of 3.01 and 2.02, respectively, relative to their college educated counterparts. Those with family annual incomes less than $12,500 had incidence rates that were more than 1.7 times the lung cancer incidence rate of those with incomes $50,000 or higher. Lower income was also associated with a statistically significantly increased risk of distant-stage breast cancer among women and distant-stage prostate cancer among men.

CONCLUSIONS

Socioeconomic patterns in incidence varied for specific cancers, while such patterns for stage were generally consistent across cancers, with late-stage diagnoses being associated with lower SES. These findings illustrate the potential for analyzing disparities in cancer outcomes according to a variety of individual-level socioeconomic, demographic, and health care characteristics, as well as by area measures available in the linked database.

Economic, racial and ethnic disparities in breast cancer in the US: towards a more comprehensive model

Using cancer registry data, we focus on racial and ethnic disparities in stage of breast cancer diagnosis in Cook County, IL. The county health system is the "last resort" health-care provider for low-income persons. Socioeconomic status is measured using empirical Bayes estimates of tract-level poverty, specific to non-Hispanic whites, non-Hispanic blacks or Hispanics in one of three age groups. We use ordinal logistic regression with non-proportional odds to model stage. Blacks and Hispanics are at greater risk for regional and distant stage diagnosis, but the disparity declines with age. Women in high-poverty areas are at substantially greater risk for late-stage diagnosis. The effects of poverty do not differ by age or across racial and ethnic groups.

Colorectal cancer stage at diagnosis and area socioeconomic characteristics in New Jersey

Despite effective screening methods, research suggests consistently higher rates of late stage colorectal cancer (CRC) among persons living in low socioeconomic areas compared to those living in affluent areas. This population-based study evaluated the association between area-based socioeconomic measures (ABSMs) and CRC stage at diagnosis in New Jersey. Cases of CRC among persons 50 years and older, diagnosed from 2000-2005, were obtained from the New Jersey State Cancer Registry. Associations between census tract-level ABSMs and CRC stage at diagnosis were evaluated using logistic regression and geographic variation assessed using a spatial scan statistic. After adjusting for covariates, including individual-level health insurance, ABSMs were significantly associated with stage at diagnosis. As area socioeconomic conditions worsened, the odds of being diagnosed at a late stage increased. While increasing CRC screening services for all New Jersey populations is warranted, this study suggests that persons living in low socioeconomic areas could benefit the most from enhanced CRC education, screening efforts, and guided interventions.