Geographical Disparities in Screening and Cancer-Related Health Behaviour

Biological Basis of Breast Cancer-Related Disparities in Precision Oncology Era

Precision oncology is based on deep knowledge of the molecular profile of tumors, allowing for more accurate and personalized therapy for specific groups of patients who are different in disease susceptibility as well as treatment response. Thus, onco-breastomics is able to discover novel biomarkers that have been found to have racial and ethnic differences, among other types of disparities such as chronological or biological age-, sex/gender- or environmental-related ones. Usually, evidence suggests that breast cancer (BC) disparities are due to ethnicity, aging rate, socioeconomic position, environmental or chemical exposures, psycho-social stressors, comorbidities, Western lifestyle, poverty and rurality, or organizational and health care system factors or access. The aim of this review was to deepen the understanding of BC-related disparities, mainly from a biomedical perspective, which includes genomic-based differences, disparities in breast tumor biology and developmental biology, differences in breast tumors' immune and metabolic landscapes, ecological factors involved in these disparities as well as microbiomics- and metagenomics-based disparities in BC. We can conclude that onco-breastomics, in principle, based on genomics, proteomics, epigenomics, hormonomics, metabolomics and exposomics data, is able to characterize the multiple biological processes and molecular pathways involved in BC disparities, clarifying the differences in incidence, mortality and treatment response for different groups of BC patients.

A randomized controlled trial of Promoting Physical Activity in Regional and Remote Cancer Survivors (PPARCS)

BACKGROUND

Physical activity (PA) is important for cancer survivors. Trials of remotely delivered interventions are needed to assist in reaching under-served non-metropolitan cancer survivors. The objective of this study was to ascertain whether wearable technology, coupled with health coaching was effective in increasing PA in breast and colorectal cancer survivors living in regional and remote areas in Australia.

METHODS

Cancer survivors from 5 states were randomized to intervention and control arms. Intervention participants were given a Fitbit Charge 2TM and received up to 6 telephone health coaching sessions. Control participants received PA print materials. Accelerometer assessments at baseline and 12 weeks measured moderate-to-vigorous PA (MVPA), light PA, and sedentary behavior.

RESULTS

Eighty-seven participants were recruited (age = 63 ± 11 years; 74 (85%) female). There was a significant net improvement in MVPA of 49.8 min/week, favoring the intervention group (95% confidence interval (95%CI): 13.6-86.1, p = 0.007). There was also a net increase in MVPA bouts of 39.5 min/week (95%CI: 11.9-67.1, p = 0.005), favoring the intervention group. Both groups improved light PA and sedentary behavior, but there were no between-group differences.

CONCLUSION

This is the first study to demonstrate that, when compared to standard practice (i.e., PA education), a wearable technology intervention coupled with distance-based health coaching, improves MVPA in non-metropolitan cancer survivors. The results display promise for the use of scalable interventions using smart wearable technology in conjunction with phone-based health coaching to foster increased PA in geographically disadvantaged cancer survivors.

Role of geographic characteristics in the spatial cluster detection of cancer: Evidence in South Korea, 1999-2013

BACKGROUND

Identification of high-risk areas of cancer, referred to as spatial clusters, can inform targeted policies for cancer control. Although cancer cluster detection could be affected by various geographic characteristics including sociodemographic and environmental factors which impacts could also vary over time, studies accounting for such influence remain limited. This study aims to assess the role of geographic characteristics in the spatial cluster detection for lung and stomach cancer over an extended period.

METHODS

We obtained sex-specific age-standardized incidence and mortality rates of lung and stomach cancer as well as geographic characteristics across 233 districts in South Korea for three five-year periods between 1999 and 2013. We classified geographic characteristics of each district into four categories: demography, socioeconomic status, behaviors, and physical environments. Specifically, we quantified physical environments using measures of greenness, concentrations of particulate matter and nitrogen dioxide, and air pollution emissions. Finally, we conducted cluster detection analyses using weighted normal spatial scan statistics with the residuals from multiple regression analyses performed with the four progressive sets of geographic attributes.

RESULTS

We found that the size of clusters reduced as we progressively adjusted for geographic covariates. Among the four categories, physical environments had the greatest impact on the reduction or disappearance of clusters particularly for lung cancer consistently over time. Whereas older population affected a decrease of lung cancer clusters in the early period, the contribution of education was large in the recent period. The impact was less clear in stomach cancer than lung cancer.

CONCLUSION

Our findings highlight the importance of geographic characteristics in explaining the existing cancer clusters and identifying new clusters, which jointly provides practical guidance to cancer control.

Racial disparities in cancer care, an eyeopener for developing better global cancer management strategies

BACKGROUND

In the last few decades, advancements in cancer research, both in the field of cancer diagnostics as well as treatment of the disease have been extensive and multidimensional. Increased availability of health care resources and growing awareness has resulted in the reduction of consumption of carcinogens such as tobacco; adopting various prophylactic measures; cancer testing on regular basis and improved targeted therapies have greatly reduced cancer mortality among populations, globally. However, this notable reduction in cancer mortality is discriminate and reflective of disparities between various ethnic populations and economic classes. Several factors contribute to this systemic inequity, at the level of diagnosis, cancer prognosis, therapeutics, and even point-of-care facilities.

RECENT FINDINGS

In this review, we have highlighted cancer health disparities among different populations around the globe. It encompasses social determinants such as status in society, poverty, education, diagnostic approaches including biomarkers and molecular testing, treatment as well as palliative care. Cancer treatment is an active area of constant progress and newer targeted treatments like immunotherapy, personalized treatment, and combinatorial therapies are emerging but these also show biases in their implementation in various sections of society. The involvement of populations in clinical trials and trial management is also a hotbed for racial discrimination. The immense progress in cancer management and its worldwide application needs a careful evaluation by identifying the biases in racial discrimination in healthcare facilities.

CONCLUSION

Our review gives a comprehensive evaluation of this global racial discrimination in cancer care and would be helpful in designing better strategies for cancer management and decreasing mortality.

Feasibility of implementing a supervised telehealth exercise intervention in frail survivors of hematopoietic cell transplantation: a pilot randomized trial

BACKGROUND

Patients undergoing hematopoietic cell transplantation (HCT) are at high risk of chronic health complications, including frailty and physical dysfunction. Conventional exercise programs have been shown to improve frailty in other cancer populations, but these have largely been based out of rehabilitation facilities that may act as geographic and logistical barriers. There is a paucity of information on the feasibility of implementing telehealth exercise interventions in long-term HCT survivors.

METHODS

We conducted a pilot randomized trial to assess the feasibility of an 8-week telehealth exercise intervention in 20 pre-frail or frail HCT survivors. Participants were randomized to either a telehealth exercise (N = 10) or delayed control (N = 10). We administered a remote physical function assessment at baseline, followed by an 8-week telehealth exercise intervention (30-60 min/session, 3 sessions/week), and post-intervention. The primary endpoint was feasibility as determined by 1) > 70% of participants completing all remote physical functional assessments, and 2) > 70% of participants in the exercise group completing > 70% (17/24) of the prescribed exercise sessions. Exploratory outcomes included changes in gait speed, handgrip strength, and short physical performance battery.

RESULTS

The mean [standard deviation] age at study enrollment was 64.7 [9.1] years old. Twelve had undergone allogenic and 8 had undergone autologous HCT at an average of 17 years from study enrollment. Both feasibility criteria were achieved. Nineteen patients (95%) completed all remote study outcome assessments at baseline and post-intervention, and nine participants in the exercise group completed > 70% of prescribed exercise sessions. Overall, no significant group x time interaction was observed on handgrip strength, fatigue, body mass index, and short physical performance battery test (P < 0.05). However, there were significant within-group improvements in four-meter gait speed (+ 13.9%; P = 0.004) and 5-minute gait speed (+ 25.4%; P = 0.04) in the exercise group whereas non-significant changes in four-meter gait speed (-3.8%) and 5-minute gait speed (-5.8%) were observed after 8 weeks.

CONCLUSION

Implementing an 8-week telehealth exercise intervention for long-term HCT survivors was feasible. Our findings set the stage for innovative delivery of supervised exercise intervention that reduces the burden of frailty in HCT survivors as well as other at-risk cancer survivors.

TRIAL REGISTRATION

The protocol and informed consent were approved by the institutional IRB (IRB#20731) and registered (ClinicalTrials.gov NCT04968119; date of registration: 20/07/2021).

Supportive care needs and psychosocial outcomes of rural versus urban women with breast cancer

OBJECTIVE

To identify whether supportive care needs vary according to remoteness and area-level socio-economic status (SES) and to identify the combinations of socio-demographic, area-level and health factors that are associated with poorer quality of life, psychological distress and severity of unmet supportive care needs METHODS: Cross sectional data was collected from women with a breast cancer diagnosis (n=2,635) in Queensland, Australia, through a telephone survey including socio-demographic, health, psychosocial and supportive care needs measures. Hierarchical regression and cluster analyses were applied to assess the predictors of unmet need and psychosocial outcomes and to identify socio-demographic and health status profiles of women, comparing their level of unmet needs and psychosocial outcomes.

RESULTS

Women living in outer regional areas reported the highest severity of unmet need in the patient care domain. Greater unmet need for health systems and information and patient care was also evident for those in moderately and most disadvantaged areas. Three clusters were identified reflecting (1) older women with poorer health and lower education (19%); (2) younger educated women with better health and private insurance (61%); and (3) physically active women with localised cancer who had completed treatment (20%). Poorer outcomes were evident in the first two of these clusters.

CONCLUSIONS

This better understanding of the combinations of characteristics associated with poorer psychosocial outcomes and higher unmet need can be used to identify women with higher supportive care needs early and to target interventions. This article is protected by copyright. All rights reserved.

Attitudes of Australian breast cancer patients toward the secondary use of administrative and clinical trial data

AIM

Little is known about the attitudes of Australian patients with a history of breast cancer toward the reuse of administrative health data and clinical trial data. Issues of consent, privacy, and information security are key to the discussion. Cancer care and research provides an opportune setting to develop an understanding of attitudes toward data sharing and reuse in individuals with a history of breast cancer.

METHODS

An anonymous, online questionnaire for individuals with a history or diagnosis of breast cancer was distributed by two peak bodies (Breast Cancer Trials [BCT] and Breast Cancer Network of Australia [BCNA]) to their memberships between July 14, 2020 and October 17, 2020. Results were captured in RedCap; data analysis was undertaken using Stata, and a thematic analysis of free text responses was undertaken using NVivo.

RESULTS

One hundred and thirty-two complete responses were received. Twenty-three percent of respondents had participated in a clinical trial, and 12% were currently receiving treatment (chemotherapy, radiotherapy, surgery, or endocrine). Respondents were supportive of the secondary use of de-identified administrative health data and clinical trial data, but showed concern about data security and privacy. Respondents emphasized that the reuse of data should be for improved societal health outcomes, not profit. Many assumed secondary analysis was already undertaken on de-identified administrative health data and clinical trial data.

CONCLUSIONS

Respondents were supportive of the secondary use of de-identified administrative health and clinal trial data within the established bounds of good clinical practice and ethical oversight.

Income Disparities in Cancer Screening: A Cross-Sectional Study of the Korean National Health and Nutrition Examination Survey, 2013–2019

Background

Cancer is one of the leading chronic diseases, which causes premature mortality in Korea. Early detection has been reported to be associated with reduced mortality and morbidity. Consistent evidence reports that lower screening rates are associated with socioeconomic-based disparities. This study aimed to examine income-related disparities in cancer screening services and to analyze the association between utilization of cancer screening and individual characteristics, including income levels.

Methods

This study utilized the data from the Korea National Health and Nutrition Examination Survey (KNHANES), a population-based survey from 2013 to 2019. The study population included individuals aged 40 years or over. The variables were socioeconomic characteristics and perceived health status. Household income was categorized into quartiles from Q1 (the lowest income group) to Q4 (the highest income group). Multivariate logistic regression analysis was performed to analyze the association between cancer screening and individual characteristics and household income levels.

Results

There were 20,347 individuals included in this study. Among these, 14,741 (72.4%) had undergone cancer screening. There existed a gap in the utilization of cancer screening between the lowest (Q1) and highest (Q4) income quintiles owing to evident income disparities; Q4 thus had a significantly higher likelihood of undergoing cancer screening than other quintiles. Female sex, university and over education, number of chronic diseases, and private insurance coverage were positively associated with cancer screening (p < 0.001).

Conclusion

Our findings suggest that policymakers should develop and design strategies to increase awareness and efforts to improve the education and promotion of cancer screening among lower-income target groups.

Self-reported skin cancer-related behaviours in rural Victoria: results from repeat cross-sectional studies in 2001-2003 and 2016-2018

OBJECTIVE

To assess whether self-reported use of sun-protective measures and skin examination have changed between 2001 and 2018 in a rural setting.

METHODS

Repeat cross-sectional survey of randomly selected households in four rural Victorian towns. People aged 16 years and older were eligible to participate. Logistic regression was used to identify demographic factors associated with sun-protective measures and skin examination.

RESULTS

Overall, 5,328 participated in 2001-2003 and 2,680 in 2016-2018. Among participants who go out in the sun, the mean number of reported sun-protective measures (2.6±1.3 vs. 2.6±1.6, p=0.867) and the proportion of participants reporting usually/always using sun protection (65.1% vs. 63.9%, p=0.307) were unchanged between the two surveys. However, an increased proportion of participants reported avoiding the sun when outdoors in the more recent survey (from 18.8% to 34.3%, p<0.001). Avoiding the sun was associated with being older, female, of European origin and having post-secondary school education. Skin examination rates increased between the two surveys (32.7% to 40.8%, p<0.001). Skin examinations were associated with older age groups, European origin and post-secondary school education and being male.

CONCLUSIONS

Given the small changes in sun protection over time, updated skin cancer campaigns are needed to encourage increased sun-protective behaviours and skin examinations among rural residents. Implications for public health: Results suggest that updated health promotion campaigns targeted to rural areas are warranted.

What can We Learn From High-Performing Screening Programs to Increase Bowel Cancer Screening Participation in Australia?

Background

Colorectal cancer (CRC) is the second most diagnosed cancer in men and women and second most common cause of cancer death in Australia; Australia’s CRC incidence and mortality are among the world’s highest. The Australian National Bowel Cancer Screening Program began in 2006; however, only 33% of those approached for the first time by the Program between 2018 and 2019 returned the kit. Of the 5.7 million kits sent during this period, only 44% were returned. Our aim was to identify practices and features of national bowel cancer screening programs in countries with similar programs but higher screening participation, to identify potential interventions for optimising Australian CRC screening participation.

Methods

We searched published and grey literature for CRC screening programs reporting at least 50% screening participation using postal invitation and free return of iFOBT home kits. Interviews were conducted with cancer registry staff and academic researchers, focused on participant and practitioner engagement in screening.

Results

National programs in Netherlands, Scotland, Denmark, and Finland reported over 50% screening participation rates for all invitation rounds. Shared characteristics include small populations within small geographic areas relative to Australia; relatively high literacy; a one-sample iFOBT kit; national registration systems for population cancer screening research; and screening program research including randomised trials of program features.

Conclusions

Apart from the one-sample kit, we identified no single solution to persistent Australian low uptake of screening. Research including randomised trials within the program promises to increase participation.

Impact

This screening program comparison suggests that within-program intervention trials will lead to increased Australian screening participation.

Sex and Gender Influences on Cancer Immunotherapy Response

The global burden of cancer is growing and a wide disparity in the incidence, malignancy and mortality of different types of cancer between each sex has been demonstrated. The sex specificity of cancer appears to be a relevant issue in the management of the disease, and studies investigating the role of sex and gender are becoming extremely urgent. Sex hormones are presumably the leading actors of sex differences in cancer, especially estrogens. They modulate gene expression, alter molecules and generate disparities in effectiveness and side effects of anticancer therapies. Recently immunotherapy aims to improve anticancer treatment strategies reducing off-target effects of chemotherapy and direct cancer cells killing. It is recognized as a fruitful strategy to treat and possible to cure cancer. Immunotherapeutic agents are used to activate or boost the activation of the immune system to fight cancer cells through physiological mechanisms often evaded in the offensive march of the disease. These therapeutic strategies have allowed new successes, but also have serious adverse effects including non-specific inflammation and autoimmunity. Sex and gender issues are of primary importance in this field, due to their recognized role in inflammation, immunity and cancer, and the clarification and understanding of these aspects is a necessary step to increase the responses and to diminish the adverse effects of immunotherapy. This review describes the available knowledge on the role of sex and gender in cancer immunotherapy, and will offer insights to stimulate the attention and practice of clinicians and researchers in a gender perspective of new cancer treatment strategies.