Changes in mortality associated with different hematologic malignancies during the pandemic in the United States

Patients with hematologic malignancies are at increased risk of adverse COVID-19 outcomes; nonetheless, only sparse population-based data are available on mortality related to hematologic cancers during the pandemic. Number of deaths and age-standardized mortality rates for specific hematologic malignancies selected either as the underlying cause of death (UCOD), or mentioned in death certificates (multiple causes of death-MCOD) were extracted from the US National Center for Health Statistics, CDC WONDER Online Database. Joinpoint analysis was applied to identify changes in mortality trends from 1999 to 2021, and to estimate the annual percent change with 95% Confidence Intervals (CI) across time segments. Among the most common malignancies, chronic lymphocytic leukemia showed marked peaks in the monthly number of deaths attributed to COVID-19 during epidemic waves; acute myeloid leukemia showed the least variation, and non-Hodgkin lymphoma and multiple myeloma were characterized by an intermediate pattern. Age-standardized death rates relying solely on the UCOD did not show significant variations during pandemic years. By contrast, rates based on MCOD increased by 14.0% (CI, 10.2-17.9%) per year for chronic lymphocytic leukemia, by 5.1% (CI, 3.1-7.2%) for non-Hodgkin lymphoma and by 3.2% (CI, 0.3-6.1%) per year for multiple myeloma. Surveillance of mortality based on MCOD is warranted to accurately measure the impact of the COVID-19 pandemic and of other epidemics, including seasonal flu, on patients with hematologic malignancies, and to assess the effects of vaccination campaigns and other preventive measures.

Lung cancer statistics, 2023

Despite decades of declining mortality rates, lung cancer remains the leading cause of cancer death in the United States. This article examines lung cancer incidence, stage at diagnosis, survival, and mortality using population-based data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries. Over the past 5 years, declines in lung cancer mortality became considerably greater than declines in incidence among men (5.0% vs. 2.6% annually) and women (4.3% vs. 1.1% annually), reflecting absolute gains in 2-year relative survival of 1.4% annually. Improved outcomes likely reflect advances in treatment, increased access to care through the Patient Protection and Affordable Care Act, and earlier stage diagnosis; for example, compared with a 4.6% annual decrease for distant-stage disease incidence during 2013-2019, the rate for localized-stage disease rose by 3.6% annually. Localized disease incidence increased more steeply in states with the highest lung cancer screening prevalence (by 3%-5% annually) than in those with the lowest (by 1%-2% annually). Despite progress, disparities remain. For example, Native Americans have the highest incidence and the slowest decline (less than 1% annually among men and stagnant rates among women) of any group. In addition, mortality rates in Mississippi and Kentucky are two to three times higher than in most western states, largely because of elevated historic smoking prevalence that remains. Racial and geographic inequalities highlight longstanding opportunities for more concerted tobacco-control efforts targeted at high-risk populations, including improved access to smoking-cessation treatments and lung cancer screening, as well as state-of-the-art treatment.

Colorectal cancer screening test exposure patterns in US adults 45 to 49 years of age, 2019-2021

Several organizations now recommend that individuals at average risk for colorectal cancer (CRC) begin screening at 45 rather than 50 years of age. We present contemporary estimates of CRC screening in newly eligible adults aged 45 to 49 years between 2019 and 2021. Nationally representative prevalence estimates and population number screened were estimated based on the National Health Interview Survey. A logistic regression model assessed CRC screening prevalence differences by survey year and sociodemographic characteristics. In 2021, 19.7%-that is, fewer than 4 million of the eligible 19 million adults aged 45 to 49 years-were up-to-date on CRC screening. Screening was lowest in those who were uninsured (7.6%), had less than a high school diploma (15.4%), and Asian (13.1%). Additionally, fecal occult blood test and/or fecal immunochemical testing was underused, with only 2.4% (<460 000 people) reporting being up-to-date with screening using this modality in 2021. CRC screening in eligible young adults remains low. Concerted efforts to improve screening are warranted, particularly in underserved populations.

Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries

This article presents global cancer statistics by world region for the year 2022 based on updated estimates from the International Agency for Research on Cancer (IARC). There were close to 20 million new cases of cancer in the year 2022 (including nonmelanoma skin cancers [NMSCs]) alongside 9.7 million deaths from cancer (including NMSC). The estimates suggest that approximately one in five men or women develop cancer in a lifetime, whereas around one in nine men and one in 12 women die from it. Lung cancer was the most frequently diagnosed cancer in 2022, responsible for almost 2.5 million new cases, or one in eight cancers worldwide (12.4% of all cancers globally), followed by cancers of the female breast (11.6%), colorectum (9.6%), prostate (7.3%), and stomach (4.9%). Lung cancer was also the leading cause of cancer death, with an estimated 1.8 million deaths (18.7%), followed by colorectal (9.3%), liver (7.8%), female breast (6.9%), and stomach (6.8%) cancers. Breast cancer and lung cancer were the most frequent cancers in women and men, respectively (both cases and deaths). Incidence rates (including NMSC) varied from four-fold to five-fold across world regions, from over 500 in Australia/New Zealand (507.9 per 100,000) to under 100 in Western Africa (97.1 per 100,000) among men, and from over 400 in Australia/New Zealand (410.5 per 100,000) to close to 100 in South-Central Asia (103.3 per 100,000) among women. The authors examine the geographic variability across 20 world regions for the 10 leading cancer types, discussing recent trends, the underlying determinants, and the prospects for global cancer prevention and control. With demographics-based predictions indicating that the number of new cases of cancer will reach 35 million by 2050, investments in prevention, including the targeting of key risk factors for cancer (including smoking, overweight and obesity, and infection), could avert millions of future cancer diagnoses and save many lives worldwide, bringing huge economic as well as societal dividends to countries over the forthcoming decades.

Factors contributing to differences in cervical cancer screening in rural and urban community health centers

INTRODUCTION

Community health centers (CHCs) provide historically marginalized populations with primary care, including cancer screening. Previous studies have reported that women living in rural areas are less likely to be up to date with cervical cancer screening than women living in urban areas. However, little is known about rural-urban differences in cervical cancer screening in CHCs and the contributing factors, and whether such differences changed during the COVID-19 pandemic.

METHODS

Using 8-year pooled Uniform Data System (2014-2021) data and Oaxaca-Blinder decomposition, the extent to which CHC- and catchment area-level characteristics explained rural-urban differences in up-to-date cervical cancer screening was estimated.

RESULTS

Up-to-date cervical cancer screening was lower in rural CHCs than urban CHCs (38.2% vs 43.0% during 2014-2019), and this difference increased during the pandemic (43.5% vs 49.0%). The rural-urban difference in cervical cancer screening in 2014-2019 was mostly explained by differences in CHC-level proportions of patients with limited English proficiency (55.9%) or income below the poverty level (12.3%) and females aged 21 to 64 years (9.8%), and catchment area-level's unemployment (3.4%) and primary care physician density (3.2%). However, Medicaid (-48.5%) or no insurance (-19.6%) counterbalanced the differences between rural-urban CHCs. The contribution of these factors to rural-urban differences in cervical cancer screening generally increased in 2020-2021.

CONCLUSIONS

Rural-urban differences in cervical cancer screening were mostly explained by multiple CHC-level and catchment area-level characteristics. The findings call for tailored interventions, such as providing resources and language services, to improve cancer screening utilization among uninsured, Medicaid, and patients with limited English proficiency in rural CHCs.

American Cancer Society's report on the status of cancer disparities in the United States, 2023

In 2021, the American Cancer Society published its first biennial report on the status of cancer disparities in the United States. In this second report, the authors provide updated data on racial, ethnic, socioeconomic (educational attainment as a marker), and geographic (metropolitan status) disparities in cancer occurrence and outcomes and contributing factors to these disparities in the country. The authors also review programs that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. There are substantial variations in risk factors, stage at diagnosis, receipt of care, survival, and mortality for many cancers by race/ethnicity, educational attainment, and metropolitan status. During 2016 through 2020, Black and American Indian/Alaska Native people continued to bear a disproportionately higher burden of cancer deaths, both overall and from major cancers. By educational attainment, overall cancer mortality rates were about 1.6-2.8 times higher in individuals with ≤12 years of education than in those with ≥16 years of education among Black and White men and women. These disparities by educational attainment within each race were considerably larger than the Black-White disparities in overall cancer mortality within each educational attainment, ranging from 1.03 to 1.5 times higher among Black people, suggesting a major role for socioeconomic status disparities in racial disparities in cancer mortality given the disproportionally larger representation of Black people in lower socioeconomic status groups. Of note, the largest Black-White disparities in overall cancer mortality were among those who had ≥16 years of education. By area of residence, mortality from all cancer and from leading causes of cancer death were substantially higher in nonmetropolitan areas than in large metropolitan areas. For colorectal cancer, for example, mortality rates in nonmetropolitan areas versus large metropolitan areas were 23% higher among males and 21% higher among females. By age group, the racial and geographic disparities in cancer mortality were greater among individuals younger than 65 years than among those aged 65 years and older. Many of the observed racial, socioeconomic, and geographic disparities in cancer mortality align with disparities in exposure to risk factors and access to cancer prevention, early detection, and treatment, which are largely rooted in fundamental inequities in social determinants of health. Equitable policies at all levels of government, broad interdisciplinary engagement to address these inequities, and equitable implementation of evidence-based interventions, such as increasing health insurance coverage, are needed to reduce cancer disparities.

Changes in cancer incidence rates by stage during the COVID-19 pandemic in the US

The coronavirus disease 2019 (COVID-19) pandemic led to health care disruptions and declines in cancer diagnoses in the United States. However, the impact of the pandemic on cancer incidence rates by stage at diagnosis and race and ethnicity is unknown. This cross-sectional study calculated delay- and age-adjusted incidence rates, stratified by stage at diagnosis and race and ethnicity, and rate ratios (RRs) comparing changes in year-over-year incidence rates (eg, 2020 vs 2019) from 2016 to 2020 for 22 cancer types based on data obtained from the Surveillance, Epidemiology, and End Results 22-registry database. From 2019 to 2020, the incidence of local-stage disease statistically significantly declined for 19 of the 22 cancer types, ranging from 4% (RR = 0.96; 95%CI, 0.93-0.98) for urinary bladder cancer to 18% for colorectal (RR = 0.82; 95%CI, 0.81-0.84) and laryngeal (RR = 0.82; 95%CI, 0.78-0.88) cancers, deviating from pre-COVID stable year-over-year changes. Incidence during the corresponding period also declined for 16 cancer types for regional-stage and six cancer types for distant-stage disease. By race and ethnicity, the decline in local-stage incidence for screening-detectable cancers was generally greater in historically marginalized populations. The decline in cancer incidence rates during the first year of the COVID-19 pandemic occurred mainly for local- and regional-stage diseases across racial and ethnic groups. Whether these declines will lead to increases in advanced-stage disease and mortality rates remain to be investigated with additional data years. Nevertheless, the findings reinforce the importance of strengthening the return to preventive care campaigns and outreach for detecting cancers at early and more treatable stages.

Mediators of Black-White inequities in cardiovascular mortality among survivors of 18 cancers in the USA

BACKGROUND

This study aims to quantify Black-White inequities in cardiovascular disease (CVD) mortality among US survivors of 18 adult-onset cancers and the extent to which these inequities are explained by differences in socio-economic and clinical factors.

METHODS

Survivors of cancers diagnosed at ages 20-64 years during 2007-16 were identified from 17 Surveillance, Epidemiology and End Results registries. Associations between race and CVD mortality were examined using proportional hazards models. Mediation analyses were performed to quantify the contributions of potential mediators, including socio-economic [health insurance, neighbourhood socio-economic status (nSES), rurality] and clinical (stage, surgery, chemotherapy, radiotherapy) factors.

RESULTS

Among 904 995 survivors, 10 701 CVD deaths occurred (median follow-up, 43 months). Black survivors were more likely than White survivors to die from CVD for all 18 cancers with hazard ratios ranging from 1.30 (95% CI = 1.15-1.47) for lung cancer to 4.04 for brain cancer (95% CI = 2.79-5.83). The total percentage mediations (indirect effects) ranged from 24.8% for brain (95% CI=-5.2-59.6%) to 99.8% for lung (95% CI = 61.0-167%) cancers. Neighbourhood SES was identified as the strongest mediator for 14 cancers with percentage mediations varying from 25.0% for kidney cancer (95% CI = 14.1-36.3%) to 63.5% for lung cancer (95% CI = 36.5-108.7%). Insurance ranked second for 12 cancers with percentage mediations ranging from 12.3% for leukaemia (95% CI = 0.7-46.7%) to 31.3% for thyroid cancer (95% CI = 10.4-82.7%).

CONCLUSIONS

Insurance and nSES explained substantial proportions of the excess CVD mortality among Black survivors. Mitigating the effects of unequal access to care and differing opportunities for healthy living among neighbourhoods could substantially reduce racial inequities in CVD mortality among cancer survivors.

Government Housing Assistance and Cancer Screening Among Adults With Low Income

INTRODUCTION

Access to affordable housing may support cancer control for adults with low income by alleviating financial barriers to preventive care. This study examines relationships between cancer screening and receipt of government housing assistance among adults with low income.

METHODS

Data are from the 2019 and 2021 National Health Interview Survey. Eligible respondents were classified as up-to-date or not with breast cancer (BC), cervical cancer (CVC) and colorectal cancer (CRC) screening guidelines. Multivariable logistic regression was used to model guideline-concordant screening by receipt of government housing assistance, overall and stratified by urban-rural status, race/ethnicity, and age. Analyses were performed in 2023.

RESULTS

Analyses for BC, CVC and CRC screening included 2,258, 3,132, and 3,233 respondents, respectively. There was no difference in CVC screening by housing assistance status, but screening for BC and CRC was higher among those who received assistance compared to those who did not (59.7% vs. 50.8%, p<0.01 for BC; 57.1% vs. 44.1%, p<0.01 for CRC). In models adjusted for sociodemographic characteristics, health status and insurance, these differences were not statistically significant for either BC or CRC screening. In stratified adjusted models, housing assistance was statistically significantly associated with increased BC screening in urban areas (aOR=1.35, 95% CI=1.00-1.82) and among Hispanic women (aOR=2.20, 95% CI=1.01-4.78) and women 45-54 years of age (aOR=2.10, 95% CI=1.17-3.75).

CONCLUSIONS

Policies that address housing affordability may enhance access to BC screening for some subgroups, including women in urban areas, Hispanic women, and younger women. More research on the mechanisms that link housing assistance to BC screening is needed.

Survival difference between secondary and de novo acute myeloid leukemia by age, antecedent cancer types, and chemotherapy receipt

BACKGROUND

This study compared the survival of persons with secondary acute myeloid leukemia (sAML) to those with de novo AML (dnAML) by age at AML diagnosis, chemotherapy receipt, and cancer type preceding sAML diagnosis.

METHODS

Data from Surveillance, Epidemiology, and End Results 17 Registries were used, which included 47,704 individuals diagnosed with AML between 2001 and 2018. Multivariable Cox proportional hazards regression was used to compare AML-specific survival between sAML and dnAML. Trends in 5-year age-standardized relative survival were examined via the Joinpoint survival model.

RESULTS

Overall, individuals with sAML had an 8% higher risk of dying from AML (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.05-1.11) compared to those with dnAML. Disparities widened with younger age at diagnosis, particularly in those who received chemotherapy for AML (HR, 1.14; 95% CI, 1.10-1.19). In persons aged 20-64 years and who received chemotherapy, HRs were greatest for those with antecedent myelodysplastic syndrome (HR, 2.04; 95% CI, 1.83-2.28), ovarian cancer (HR, 1.91; 95% CI, 1.19-3.08), head and neck cancer (HR, 1.55; 95% CI, 1.02-2.36), leukemia (HR, 1.45; 95% CI, 1.12-1.89), and non-Hodgkin lymphoma (HR, 1.42; 95% CI, 1.20-1.69). Among those aged ≥65 years and who received chemotherapy, HRs were highest for those with antecedent cervical cancer (HR, 2.42; 95% CI, 1.15-5.10) and myelodysplastic syndrome (HR, 1.28; 95% CI, 1.19-1.38). The 5-year relative survival improved 0.3% per year for sAML slower than 0.86% per year for dnAML. Consequently, the survival gap widened from 7.2% (95% CI, 5.4%-9.0%) during the period 2001-2003 to 14.3% (95% CI, 12.8%-15.8%) during the period 2012-2014.

CONCLUSIONS

Significant survival disparities exist between sAML and dnAML on the basis of age at diagnosis, chemotherapy receipt, and antecedent cancer, which highlights opportunities to improve outcomes among those diagnosed with sAML.

Changes in cancer-related mortality during the COVID-19 pandemic in the United States

Few studies have examined cancer-related mortality overall, never mind select cancer types, during the COVID-19 pandemic. Data on cancer-related mortality (any mention in death certificates, multiple causes of death approach) was extracted from the US Centers for Disease Control and Prevention WONDER database. Changes in trends for age-standardized mortality rates through 1999-2021 were assessed by Joinpoint analysis. In total, 1 379 643 cancer-related deaths were registered in 2020-2021, with cancer selected as the underlying cause in 88%. After 2 decades of decline, age-standardized cancer-related mortality increased from 2019 to 2021 for all cancers (annual percentage change = 1.6%, 95% confidence interval = 0.6% to 2.6%), especially for prostate cancer (annual percentage change = 5.1%, 95% confidence interval = 2.2% to 8.2%) and hematologic cancers (annual percentage change = 4.8%, 95% confidence interval = 3.1% to 6.6%). Sharp peaks in cancer-related deaths for many cancer sites were observed during pandemic waves in both 2020 and 2021, mostly attributed to COVID-19 as the underlying cause. Multiple causes of death analyses are warranted to fully assess the impact of the pandemic on cancer-related mortality.

Medicaid Expansion Under the Affordable Care Act and Early Mortality Following Lung Cancer Surgery

Importance

Medicaid expansion under the Patient Protection and Affordable Care Act is associated with gains in health insurance coverage, earlier stage diagnosis, and improved survival among patients with cancer.

Objective

To examine the association of Medicaid expansion with changes in early mortality among adults undergoing surgical resection of non-small cell lung cancer (NSCLC), a setting in which access to care is a major determinant of survival.

Design, Setting, and Participants

This cohort study used the National Cancer Database to identify 14 984 adults 45 to 64 years of age who underwent surgical resection of NSCLC between 2008 and 2019. Analysis was conducted between March 28, 2021, and September 1, 2023.

Exposure

State of residence Medicaid expansion status.

Main Outcomes and Measures

Descriptive statistics were used to compare study population characteristics by Medicaid expansion status of patients' state of residence. Difference-in-differences analyses were used to evaluate the association between Medicaid expansion and postoperative mortality before implementation of the ACA (2008-2013) vs after (2014-2019).

Results

Among 14 984 adults included, the mean (SD) age was 56.3 (5.1) years, 54.6% were women, and 62.1% lived in Medicaid expansion states. Both 30-day (from 0.97% to 0.26%) and 90-day (from 2.63% to 1.32%) postoperative mortality decreased from before the ACA to after among patients residing in Medicaid expansion states (both P < .001) but not in nonexpansion states (30-day mortality before the ACA, 0.75% vs after the ACA, 0.68%; P = .74; and 90-day mortality before the ACA, 2.43% vs after the ACA, 2.20%; P = .57), leading to a difference-in-differences of -0.64 percentage points (95% CI, -1.19 to -0.08; P = .03) for 30-day mortality and -1.08 percentage points (95% CI, -2.08 to -0.08; P = .03) for 90-day mortality. The difference-in-differences for in-hospital mortality was not significant (P = .34) between expansion states (1.41% before the ACA to 0.77% after the ACA; 0.63 percentage point decrease; P = .004) and nonexpansion states (1.49% before the ACA to 1.20% after the ACA; 0.30 percentage point decrease; P = .29).

Conclusions and Relevance

In this cohort study of patients with NSCLC, Medicaid expansion was associated with declines in 30- and 90-day postoperative mortality following hospital discharge. These findings suggest that Medicaid expansion may be an effective strategy for improving access to care and cancer outcomes in this population.

Cancer statistics, 2024

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population-based cancer occurrence and outcomes using incidence data collected by central cancer registries (through 2020) and mortality data collected by the National Center for Health Statistics (through 2021). In 2024, 2,001,140 new cancer cases and 611,720 cancer deaths are projected to occur in the United States. Cancer mortality continued to decline through 2021, averting over 4 million deaths since 1991 because of reductions in smoking, earlier detection for some cancers, and improved treatment options in both the adjuvant and metastatic settings. However, these gains are threatened by increasing incidence for 6 of the top 10 cancers. Incidence rates increased during 2015-2019 by 0.6%-1% annually for breast, pancreas, and uterine corpus cancers and by 2%-3% annually for prostate, liver (female), kidney, and human papillomavirus-associated oral cancers and for melanoma. Incidence rates also increased by 1%-2% annually for cervical (ages 30-44 years) and colorectal cancers (ages <55 years) in young adults. Colorectal cancer was the fourth-leading cause of cancer death in both men and women younger than 50 years in the late-1990s but is now first in men and second in women. Progress is also hampered by wide persistent cancer disparities; compared to White people, mortality rates are two-fold higher for prostate, stomach and uterine corpus cancers in Black people and for liver, stomach, and kidney cancers in Native American people. Continued national progress will require increased investment in cancer prevention and access to equitable treatment, especially among American Indian and Alaska Native and Black individuals.

Assessment of Changes in Cancer Treatment During the First Year of the COVID-19 Pandemic in the US

Importance

The COVID-19 pandemic led to disruptions in access to health care, including cancer care. The extent of changes in receipt of cancer treatment is unclear.

Objective

To evaluate changes in the absolute number, proportion, and cancer treatment modalities provided to patients with newly diagnosed cancer during 2020, the first year of the pandemic.

Design, Setting, and Participants

In this cohort study, adults aged 18 years and older diagnosed with any solid tumor between January 1, 2018, and December 31, 2020, were identified using the National Cancer Database. Data analysis was conducted from September 19, 2022, to July 28, 2023.

Exposure

First year of the COVID-19 pandemic.

Main Outcomes and Measures

The expected number of procedures for each treatment modality (surgery, radiotherapy, chemotherapy, immunotherapy, and hormonal therapy) in 2020 were calculated using historical data (January 1, 2018, to December 31, 2019) with the vector autoregressive method. The difference between expected and observed numbers was evaluated using a generalized estimating equation under assumptions of the Poisson distribution for count data. Changes in the proportion of different types of cancer treatments initiated in 2020 were evaluated using the additive outlier method.

Results

A total of 3 504 342 patients (1 214 918 in 2018, mean [SD] age, 64.6 [13.6] years; 1 235 584 in 2019, mean [SD] age, 64.8 [13.6] years; and 1 053 840 in 2020, mean [SD] age, 64.9 [13.6] years) were included. Compared with expected treatment from previous years' trends, there were approximately 98 000 fewer curative intent surgical procedures performed, 38 800 fewer chemotherapy regimens, 55 500 fewer radiotherapy regimens, 6800 fewer immunotherapy regimens, and 32 000 fewer hormonal therapies initiated in 2020. For most cancer sites and stages evaluated, there was no statistically significant change in the type of cancer treatment provided during the first year of the pandemic, the exception being a statistically significant decrease in the proportion of patients receiving breast-conserving surgery and radiotherapy with a simultaneous statistically significant increase in the proportion of patients undergoing mastectomy for treatment of stage I breast cancer during the first months of the pandemic.

Conclusions and Relevance

In this large national cohort study, a significant deficit was noted in the number of cancer treatments provided in the first year of the COVID-19 pandemic. Data indicated that this deficit in the number of cancer treatments provided was associated with decreases in the number of cancer diagnoses, not changes in treatment strategies.

Living alone and cancer mortality by race/ethnicity and socioeconomic status among US working-age adults

BACKGROUND

Previous studies have shown an association between living alone and cancer mortality; however, findings by sex and race/ethnicity have generally been inconsistent, and data by socioeconomic status are sparse. The association between living alone and cancer mortality by sex, race/ethnicity, and socioeconomic status in a nationally representative US cohort was examined.

METHODS

Pooled 1998-2019 data for adults aged 18-64 years at enrollment from the National Health Interview Survey linked to the National Death Index (N = 473,648) with up to 22 years of follow-up were used to calculate hazard ratios (HRs) for the association between living alone and cancer mortality.

RESULTS

Compared to adults living with others, adults living alone were at a higher risk of cancer death in the age-adjusted model (HR, 1.32; 95% CI, 1.25-1.39) and after additional adjustments for multiple sociodemographic characteristics and cancer risk factors (HR, 1.10; 95% CI, 1.04-1.16). Age-adjusted models stratified by sex, poverty level, and educational attainment showed similar associations between living alone and cancer mortality, but the association was stronger among non-Hispanic White adults (HR, 1.33; 95% CI, 1.25-1.42) than non-Hispanic Black adults (HR, 1.18; 95% CI, 1.05-1.32; p value for difference < .05) and did not exist in other racial/ethnic groups. These associations were attenuated but persisted in fully adjusted models among men (HR, 1.13; 95% CI, 1.05-1.23), women (HR, 1.09; 95% CI, 1.01-1.18), non-Hispanic White adults (HR, 1.13; 95% CI, 1.05-1.20), and adults with a college degree (HR, 1.22; 95% CI, 1.07-1.39).

CONCLUSIONS

In this nationally representative study in the United States, adults living alone were at a higher risk of cancer death in several sociodemographic groups.

Annual Report to the Nation on the Status of Cancer, part 2: Early assessment of the COVID-19 pandemic's impact on cancer diagnosis

BACKGROUND

With access to cancer care services limited because of coronavirus disease 2019 control measures, cancer diagnosis and treatment have been delayed. The authors explored changes in the counts of US incident cases by cancer type, age, sex, race, and disease stage in 2020.

METHODS

Data were extracted from selected US population-based cancer registries for diagnosis years 2015-2020 using first-submission data from the North American Association of Central Cancer Registries. After a quality assessment, the monthly numbers of newly diagnosed cancer cases were extracted for six cancer types: colorectal, female breast, lung, pancreas, prostate, and thyroid. The observed numbers of incident cancer cases in 2020 were compared with the estimated numbers by calculating observed-to-expected (O/E) ratios. The expected numbers of incident cases were extrapolated using Joinpoint trend models.

RESULTS

The authors report an O/E ratio <1.0 for major screening-eligible cancer sites, indicating fewer newly diagnosed cases than expected in 2020. The O/E ratios were lowest in April 2020. For every cancer site except pancreas, Asians/Pacific Islanders had the lowest O/E ratio of any race group. O/E ratios were lower for cases diagnosed at localized stages than for cases diagnosed at advanced stages.

CONCLUSIONS

The current analysis provides strong evidence for declines in cancer diagnoses, relative to the expected numbers, between March and May of 2020. The declines correlate with reductions in pathology reports and are greater for cases diagnosed at in situ and localized stage, triggering concerns about potential poor cancer outcomes in the coming years, especially in Asians/Pacific Islanders.

PLAIN LANGUAGE SUMMARY

To help control the spread of coronavirus disease 2019 (COVID-19), health care organizations suspended nonessential medical procedures, including preventive cancer screening, during early 2020. Many individuals canceled or postponed cancer screening, potentially delaying cancer diagnosis. This study examines the impact of the COVID-19 pandemic on the number of newly diagnosed cancer cases in 2020 using first-submission, population-based cancer registry database. The monthly numbers of newly diagnosed cancer cases in 2020 were compared with the expected numbers based on past trends for six cancer sites. April 2020 had the sharpest decrease in cases compared with previous years, most likely because of the COVID-19 pandemic.

The association of initiating HPV vaccination at ages 9-10 years and up-to-date status among adolescents ages 13-17 years, 2016-2020

Recent guidelines from the American Cancer Society stress HPV vaccination series initiation at the youngest opportunity, i.e., age 9 years. There are limited data on the association between initiating HPV vaccination at ages 9-10 years and up-to-date (UTD) status. In this study, we compare nationally representative UTD HPV vaccination rates between adolescents who initiated the series younger (ages 9-10 years) vs. older (≥ age 11 years). Five years of pooled data (2016-2020) from National Immunization Survey-Teen were used to estimate the UTD HPV vaccination prevalence among younger vs. older initiating 13-17-year-olds. Adjusted logistic regression models estimated prevalence ratios (aPRs), differences (aDs), and difference in differences (aDDs) in prevalence of being UTD to assess the overall association of age at initiation with being UTD and differences in sociodemographic predictors of being UTD among younger vs. older initiators. UTD prevalence for younger initiators was 93% compared with 72% among older initiators (aPR: 1.27,95%CI: 1.24,1.31). Among older initiators, UTD prevalence was significantly different by sex, insurance status, and current age; no such differences were observed among younger initiators. Results indicate that younger initiation is associated with a 27% higher UTD prevalence, highlighting the importance of promoting younger initiation, particularly among those with health-care barriers.

Incidence and pattern of childhood cancer in Addis Ababa, Ethiopia (2012-2017)

BACKGROUND

Cancer is becoming a major public health problem globally and a leading cause of death in children in developed countries. However, little is known about the epidemiology of childhood cancer in Ethiopia. This study, therefore, assessed childhood cancer incidence patterns in Addis Ababa using the Addis Ababa city population-based cancer registry data from 2012 to 2017.

METHODS

Invasive cancer cases diagnosed in ages 0-14 years from 2012 to 2017 were obtained from the Addis Ababa City population-based Cancer Registry. Cases were grouped according to the International Classification of Childhood Cancer, 3rd edition (ICCC-3) based on morphology and primary anatomic site. Age-standardized incidence rates (ASR) were calculated by the direct method using the world standard population.

RESULTS

The overall average annual incidence rate during 2012-2017 in children was 84.6 cases per million, with rates higher in boys (98.97 per million) than in girls (69.7 per million). By age, incidence rates per million increased from 70.8 cases in ages 0-4 years to 88.4 cases in ages 5-9 years to 110.0 cases 10-14 years. Leukaemia was the most common childhood cancer in both boys (29.1%) and girls (26.8%), followed by lymphoma in boys (24.7%) and renal tumours (13.1%) in girls. The overall cancer incidence rate decreased from 87.02 per million in 2012 to 51.07 per million in 2017.

CONCLUSION

The burden of childhood cancer is considerably high in Addis Ababa. The observed distribution of childhood cancer in Addis Ababa differs from other African countries. This study highlights the need for further research and understanding of the variations in cancer patterns and risk factors across the region.

The Burden of Lung Cancer in Women Compared With Men in the US

This cross-sectional study examines the incidence rates of lung cancer in women compared with men from 2000 to 2019.

Educational Attainment and Cancer Incidence in a Large Nationwide Prospective Cohort

BACKGROUND

Educational attainment is a social determinant of health and frequently used as an indicator of socioeconomic status. Educational attainment is a predictor of cancer mortality, but associations with site-specific cancer incidence are variable. The aim of this study was to evaluate the association of educational attainment and site-specific cancer incidence adjusting for known risk factors in a large prospective cohort.

METHODS

Men and women enrolled in the American Cancer Society's Cancer Prevention Study-II Nutrition Cohort who were cancer free at baseline were included in this study (n = 148,965). Between 1992 and 2017, 22,810 men and 17,556 women were diagnosed with incident cancer. Cox proportional hazards regression models were used to estimate age- and multivariable-adjusted risk and 95% confidence intervals of total and site-specific cancer incidence in persons with lower versus higher educational attainment.

RESULTS

Educational attainment was inversely associated with age-adjusted cancer incidence among men but not women. For specific cancer sites, the multivariable-adjusted risk of cancer in the least versus most educated individuals remained significant for colon, rectum, and lung cancer among men and lung and breast cancer among women.

CONCLUSIONS

Educational attainment is associated with overall and site-specific cancer risk though adjusting for cancer risk factors attenuates the association for most cancer sites.

IMPACT

This study provides further evidence that educational attainment is an important social determinant of cancer but that its effects are driven by associated behavioral risk factors suggesting that targeting interventions toward those with lower educational attainment is an important policy consideration.

Guideline Concordance of Treatment and Outcomes Among Adult Non-Hodgkin Lymphoma Patients in Sub-Saharan Africa: A Multinational, Population-Based Cohort

BACKGROUND

Although non-Hodgkin lymphoma (NHL) is the 6th most common malignancy in Sub-Saharan Africa (SSA), little is known about its management and outcome. Herein, we examined treatment patterns and survival among NHL patients.

METHODS

We obtained a random sample of adult patients diagnosed between 2011 and 2015 from 11 population-based cancer registries in 10 SSA countries. Descriptive statistics for lymphoma-directed therapy (LDT) and degree of concordance with National Comprehensive Cancer Network (NCCN) guidelines were calculated, and survival rates were estimated.

FINDINGS

Of 516 patients included in the study, sub-classification was available for 42.1% (121 high-grade and 64 low-grade B-cell lymphoma, 15 T-cell lymphoma and 17 otherwise sub-classified NHL), whilst the remaining 57.9% were unclassified. Any LDT was identified for 195 of all patients (37.8%). NCCN guideline-recommended treatment was initiated in 21 patients. This corresponds to 4.1% of all 516 patients, and to 11.7% of 180 patients with sub-classified B-cell lymphoma and NCCN guidelines available. Deviations from guideline-recommended treatment were initiated in another 49 (9.5% of 516, 27.2% of 180). By registry, the proportion of all patients receiving guideline-concordant LDT ranged from 30.8% in Namibia to 0% in Maputo and Bamako. Concordance with treatment recommendations was not assessable in 75.1% of patients (records not traced (43.2%), traced but no sub-classification identified (27.8%), traced but no guidelines available (4.1%)). By registry, diagnostic work-up was in part importantly limited, thus impeding guideline evaluation significantly. Overall 1-year survival was 61.2% (95%CI 55.3%-67.1%). Poor ECOG performance status, advanced stage, less than 5 cycles and absence of chemo (immuno-) therapy were associated with unfavorable survival, while HIV status, age, and gender did not impact survival. In diffuse large B-cell lymphoma, initiation of guideline-concordant treatment was associated with favorable survival.

INTERPRETATION

This study shows that a majority of NHL patients in SSA are untreated or undertreated, resulting in unfavorable survival. Investments in enhanced diagnostic services, provision of chemo(immuno-)therapy and supportive care will likely improve outcomes in the region.

Cancer Screening in the United States During the Second Year of the COVID-19 Pandemic

PURPOSE

To examine whether cancer screening prevalence in the United States during 2021 has returned to prepandemic levels using nationally representative data.

METHODS

Information on receipt of age-eligible screening for breast (women age 50-74 years), cervical (women without a hysterectomy age 21-65 years), prostate (men age 55-69 years), and colorectal cancer (men and women age 50-75 years) according to the US Preventive Services Task Force recommendations was obtained from the 2019 and 2021 National Health Interview Survey. Past-year screening prevalence in 2019 and 2021 and adjusted prevalence ratios (aPRs), 2021 versus 2019, with their 95% CIs were calculated using complex survey logistic regression models.

RESULTS

Between 2019 and 2021, past-year screening in the United States decreased from 59.9% to 57.1% (aPR, 0.94; 95% CI, 0.91 to 0.97) for breast cancer, from 45.3% to 39.0% (aPR, 0.85; 95% CI, 0.82 to 0.89) for cervical cancer, and from 39.5% to 36.3% (aPR, 0.9; 95% CI, 0.84 to 0.97) for prostate cancer. Declines were most notable for non-Hispanic Asian persons. Colorectal cancer screening prevalence remained unchanged because an increase in past-year stool testing (from 7.0% to 10.3%; aPR, 1.44; 95% CI, 1.31 to 1.58) offset a decline in colonoscopy (from 15.5% to 13.8%; aPR, 0.88; 95% CI, 0.83 to 0.95). The increase in stool testing was most pronounced in non-Hispanic Black and Hispanic populations and in persons with low socioeconomic status.

CONCLUSION

Past-year screening prevalence for breast, cervical, and prostate cancer among age-eligible adults in the United States continued to be lower than prepandemic levels in the second year of the COVID-19 pandemic, reinforcing the importance of return to screening health system outreach and media campaigns. The large increase in stool testing emphasizes the role of home-based screening during health care system disruptions.

[Media: see text].

Treatment and Survival Among Patients With Colorectal Cancer in Sub-Saharan Africa: A Multicentric Population-Based Follow-Up Study

BACKGROUND

The burden of colorectal cancer (CRC) is increasing in Sub-Saharan Africa (SSA). However, little is known about CRC treatment and survival in the region.

METHODS

A random sample of 653 patients with CRC diagnosed from 2011 to 2015 was obtained from 11 population-based cancer registries in SSA. Information on clinical characteristics, treatment, and/or vital status was obtained from medical records in treating hospitals for 356 (54%) of the patients ("traced cohort"). Concordance of CRC treatment with NCCN Harmonized Guidelines for SSA was assessed. A Cox proportional hazards model was used to examine the association between survival and human development index (HDI).

RESULTS

Of the 356 traced patients with CRC, 51.7% were male, 52.8% were from countries with a low HDI, 55.1% had colon cancer, and 73.6% were diagnosed with nonmetastatic (M0) disease. Among the patients with M0 disease, however, only 3.1% received guideline-concordant treatment, 20.6% received treatment with minor deviations, 31.7% received treatment with major deviations, and 35.1% received no treatment. The risk of death in patients who received no cancer-directed therapy was 3.49 (95% CI, 1.83-6.66) times higher than in patients who received standard treatment or treatment with minor deviations. Similarly, the risk of death in patients from countries with a low HDI was 1.67 (95% CI, 1.07-2.62) times higher than in those from countries with a medium HDI. Overall survival at 1 and 3 years was 70.9% (95% CI, 65.5%-76.3%) and 45.3% (95% CI, 38.9%-51.7%), respectively.

CONCLUSIONS

Fewer than 1 in 20 patients diagnosed with potentially curable CRC received standard of care in SSA, reinforcing the need to improve healthcare infrastructure, including the oncology and surgical workforce.

Clinical presentation, treatment patterns, and outcomes of colorectal cancer patients at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia: A prospective cohort study

BACKGROUND

Colorectal cancer (CRC) is the third most common cause of cancer death in both genders worldwide.

AIMS

This study aimed to evaluate the outcomes and prognostic factors of CRC patients at Tikur Anbessa Specialized Hospital in Ethiopia.

METHODS AND RESULTS

A prospective cohort study was conducted on 209 patients from January 2020 to September 2022. Kaplan-Meier curves and bivariate and multivariate Cox regression analyses were used to analyze overall and progression-free survival, with a significance value of P < .05. Results showed an overall mortality rate was 67.46% (95% confidence interval [CI]: 61.0-74.0), while the 1-year overall survival (OS) rate was 63.16% (95% CI: 56.23-69.29), with a median follow-up duration of 20 months. The median OS and progression-free survival times were 17 and 11 months, respectively. Age above 40 years (hazard ratio [HR] = 1.53, 1.02-2.29, p < .040), lower educational level (high school and below) (HR = 2.20, 1.24-3.90, p < .007), poor performance status (HR = 1.60, 1.03-2.48, p < .035), Hgb ≤12.5 g/dL (HR = 1.55, 1.03-2.08, p < .035), T-4 disease (HR = 6.05, 2.28-16.02, p < .000), and metastases at diagnosis (HR = 8.53, 3.77-19.25, p < .000) were all associated with poorer survival.

CONCLUSION

These findings suggest that poor survival of CRC patients in Ethiopia is largely due to advanced stage of the disease and lack of timely treatment, and highlight the urgent need for improved access to cancer treatment in the region.

Association of Delay in Breast Cancer Diagnosis With Survival in Addis Ababa, Ethiopia: A Prospective Cohort Study

PURPOSE

There are limited data on the association between delay in breast cancer diagnosis after breast symptom recognition and survival, particularly in sub-Saharan Africa. The recently launched Global Breast Cancer Initiative by WHO includes measuring delay as the core indicator for quality of breast cancer care. Herein, we examined the association between delay in breast cancer diagnosis with overall survival among women in Addis Ababa, Ethiopia.

MATERIALS AND METHODS

A total of 439 women diagnosed with breast cancer from January 1, 2017, to June 30, 2018, in Addis Ababa were followed for survival to the end of 2019. Survival rates were estimated using the Kaplan-Meier method. The association between delay in diagnosis (>3 months after symptom recognition) and overall survival was computed using the multivariable Cox regression model after adjusting for demographic and clinical factors.

RESULTS

Nearly 70% (303/439) of women with breast cancer were delayed in diagnosis of their cancer. During a median follow-up period of 25.1 months, 2-year overall survival rate was 73.5% (95% CI, 68.0 to 78.2) in women with diagnosis delay compared with 79.1% (95% CI, 71.2 to 85.1) in those women without diagnosis delay. In the multivariable Cox regression model, the risk of death was 73% higher (hazard ratio, 1.73; 95% CI, 1.09 to 2.74) in women with diagnosis delay compared with those without diagnosis delay.

CONCLUSION

Delay in diagnostic confirmation of breast cancer after recognition of breast symptoms was negatively associated with overall survival in Addis Ababa, Ethiopia, underscoring the need to increase awareness about the importance of prompt presentation for clinical evaluation and referral for diagnostic confirmation to mitigate the undue high burden of the disease.

Progress in reducing cancer mortality in the United States by congressional district, 1996-2003 to 2012-2020

BACKGROUND

United States cancer death rates have been steadily declining since the early 1990s, but information on disparities in progress against cancer mortality across congressional districts is lacking. This study examined trends in cancer death rates, overall and for lung, colorectal, female breast, and prostate cancer by congressional district.

METHODS

County level cancer death counts and population data from the National Center for Health Statistics were used to estimate relative change in age-standardized cancer death rates from 1996-2003 to 2012-2020 by sex and congressional district.

RESULTS

From 1996-2003 to 2012-2020, overall cancer death rates declined in every congressional district, with most congressional districts showing a 20%-45% decline among males and a 10%-40% decline among females. In general, the smallest percent of relative declines were found in the Midwest and Appalachia, whereas the largest declines were found in the South along the East Coast and the southern border. As a result, the highest cancer death rates generally shifted from congressional districts across the South in 1996-2003 to districts in the Midwest and central divisions of the South (including Appalachia) in 2012-2020. Death rates for lung, colorectal, female breast, and prostate cancers also declined in almost all congressional districts, although with some variation in relative changes and geographical patterns.

CONCLUSIONS

Progress in reducing cancer death rates during the past 25 years considerably vary by congressional district, underscoring the need for strengthening existing and implementing new public health policies for broad and equitable application of proven interventions such as raising tax on tobacco and Medicaid expansion.

Implementation of Brachytherapy for Patients With Cervical Cancer in Ethiopia: A 3-Year Practice Report

PURPOSE

Although cervical cancer is the second most commonly diagnosed cancer in Ethiopia, brachytherapy (BT) was not a component in patient treatment until 2015. The purpose of this study was to identify the patterns of utilization as well as to describe the practice of BT in Ethiopia.

MATERIALS AND METHODS

A retrospective descriptive data analysis of 138 patients with cervical cancer treated with a curative potential using BT from 2015 to 2018 at Tikur Anbassa Specialized Hospital, which housed the only BT facility in Ethiopia during the study period.

RESULTS

During the first 3-year period of BT service commencement, each year n = 37, n = 36, and n = 65 patients with cervical cancer were treated, respectively, with curative intention treatment. The median age of these 138 patients was 50 years (range, 22-75). All the patients were in International Federation of Gynecology and Obstetrics stage Ib-IIIb group, and stage IIb (66.4%) was the predominant. Majority (79%) of the patients were treated primarily with radiotherapy (RT), while 21% received RT after surgery. More than half of these patients (62%) received a total RT dose of 82 Gy in equivalent dose in 2 Gy fractions (EQD2), while the rest received a dose ranging from 76 to 86 Gy. Concurrent cisplatin with RT was given only for 36% of the patients for undocumented reasons. The overall treatment time including both external-beam RT and BT was greater than 8 weeks in 21% of the patients.

CONCLUSION

The utilization of BT service increased gradually and BT enabled the delivery of a higher RT dose to patients with cervical cancer (mostly stage IIB). However, there was protracted treatment duration and low concurrent chemotherapy utilization.

Changes in E-Cigarette Use Among U.S. Adults, 2019-2021

INTRODUCTION

E-cigarette use increased between 2014 and 2018 among younger U.S. adults who had never smoked combustible cigarettes, potentially increasing nicotine addiction risk and progression to combustible tobacco products. It is unknown how prevalence changed after the E-cigarette, or vaping, product use-associated lung injury epidemic (late 2019) and COVID-19 pandemic (March 2020) by age group and combustible cigarette smoking status.

METHODS

Data from cross-sectional, nationally representative National Health Interview Surveys in 2019, 2020, and 2021 (analyzed in 2022) were used to estimate current E-cigarette use prevalence, adjusted prevalence difference between survey years, and population counts, by age group (younger, 18-29 years, n=11,700; middle age, 30-44 years, n=21,300, 45-59 years, n=21,308; older, ≥60 years, n=36,224) and cigarette smoking status (current, former, and never).

RESULTS

E-cigarette use prevalence increased among younger adults between 2019 and 2021 (8.8%-10.2%, adjusted prevalence difference=1.7% points, 95% CI=0.1, 3.3), primarily owing to an increase among those who never smoked cigarettes (4.9%-6.4%, adjusted prevalence difference=1.7% points, 95% CI=0.3, 3.1). People who never smoked cigarettes constituted 53% (2.68 million) of younger adults who used E-cigarettes in 2021, increasing by 0.71 million from 2019. Conversely, among middle age and older adults, the prevalence was similar in 2019 and 2021 irrespective of cigarette smoking status, and those who formerly smoked cigarettes constituted the largest proportion of people who used E-cigarettes in 2021 (age 30-44 years: 51.8%, 1.8 million; age 45-59 years: 51.6%, 0.85 million; age ≥60 years: 47.5%, 0.45 million).

CONCLUSIONS

Efforts must address the rise in E-cigarette use among younger adults who never smoked cigarettes. At the same time, assistance is needed to help those who switched to E-cigarettes to stop smoking to transition to non-use of all products.

Racial and Ethnic Disparities in Survival Among People With Second Primary Cancer in the US

Importance

Comprehensive data for racial and ethnic disparities after second primary cancers (SPCs) are lacking despite the growing burden of SPCs.

Objective

To quantify racial and ethnic disparities in survival among persons with SPCs.

Design, Setting, and Participants

This population-based, retrospective cohort study used data from 18 Surveillance, Epidemiology, and End Results registries in the US for persons diagnosed with the most common SPCs at age 20 years or older from January 1, 2000, to December 31, 2013 (with follow-up through December 31, 2018). Data were analyzed between January and April 2023.

Exposure

Race and ethnicity (Hispanic, non-Hispanic Asian or Pacific Islander, non-Hispanic Black, and non-Hispanic White).

Main Outcomes and Measures

The main outcomes were 5-year relative survival and cause-specific survival. Cause-specific hazard ratios (HRs) were calculated for death from cancer or cardiovascular disease (CVD) in each racial and ethnic minority population compared with the White population overall and stratified by SPC type, with adjustment for sex, year and age at SPC diagnosis, and prior cancer type and stage (baseline model) and additionally for county attributes (household income, urbanicity), SPC characteristics (stage, subtype), and treatment.

Results

Among 230 370 persons with SPCs (58.4% male), 4.5% were Asian or Pacific Islander, 9.6% were Black, 6.4% were Hispanic, and 79.5% were White. A total of 109 757 cancer-related deaths (47.6%) and 18 283 CVD-related deaths (7.9%) occurred during a median follow-up of 54 months (IQR, 12-93 months). In baseline models, compared with the White population, the risk of cancer-related death overall was higher in the Black (HR, 1.21; 95% CI, 1.18-1.23) and Hispanic (HR, 1.10; 95% CI, 1.07-1.13) populations but lower in the Asian or Pacific Islander population (HR, 0.93; 95% CI, 0.90-0.96). When stratified by 13 SPC types, the risk of cancer-related death was higher for 10 SPCs in the Black population, with the highest HR for uterine cancer (HR, 1.87; 95% CI, 1.63-2.15), and for 7 SPCs in the Hispanic population, most notably for melanoma (HR, 1.46; 95% CI, 1.21-1.76). For CVD-related death, the overall HR was higher in the Black population (HR, 1.41; 95% CI, 1.34-1.49), with elevated risks evident for 11 SPCs, but lower in the Asian or Pacific Islander (HR, 0.75; 95% CI, 0.69-0.81) and Hispanic (HR, 0.90; 95% CI, 0.84-0.96) populations than in the White population. After further adjustments for county attributes and SPC characteristics and treatment, HRs were reduced for cancer-related death and for CVD-related death and associations in the same direction remained.

Conclusions and Relevance

In this cohort study of SPC survivors, the Black population had the highest risk of both death from cancer and death from CVD, and the Hispanic population had a higher risk of death from cancer than the White population. Attenuations in HRs after adjustment for potentially modifiable factors highlight opportunities to reduce survival disparities among persons with multiple primary cancers.

Changes in cancer diagnoses and stage distribution during the first year of the COVID-19 pandemic in the USA: a cross-sectional nationwide assessment

BACKGROUND

The emergence of COVID-19 disrupted health care, with consequences for cancer diagnoses and outcomes, especially for early stage diagnoses, which generally have favourable prognoses. We aimed to examine nationwide changes in adult cancer diagnoses and stage distribution during the first year of the COVID-19 pandemic by cancer type and key sociodemographic factors in the USA.

METHODS

In this cross-sectional study, adults (aged ≥18 years) newly diagnosed with a first primary malignant cancer between Jan 1, 2018, and Dec 31, 2020, were identified from the US National Cancer Database. We included individuals across 50 US states and the District of Columbia who were treated in hospitals that were Commission on Cancer-accredited during the study period. Individuals whose cancer stage was 0 (except for bladder cancer), occult, or without an applicable American Joint Committee on Cancer staging scheme were excluded. Our primary outcomes were the change in the number and the change in the stage distribution of new cancer diagnoses between 2019 (Jan 1 to Dec 31) and 2020 (Jan 1 to Dec 31). Monthly counts and stage distributions were calculated for all cancers combined and for major cancer types. We also calculated annual change in stage distribution from 2019 to 2020 and adjusted odds ratios (aORs) using multivariable logistic regression, adjusted for age group, sex, race and ethnicity, health insurance status, comorbidity score, US state, zip code-level social deprivation index, and county-level age-adjusted COVID-19 mortality in 2020. Separate models were stratified by sociodemographic and clinical factors.

FINDINGS

We identified 2 404 050 adults who were newly diagnosed with cancer during the study period (830 528 in 2018, 849 290 in 2019, and 724 232 in 2020). Mean age was 63·5 years (SD 13·5) and 1 287 049 (53·5%) individuals were women, 1 117 001 (46·5%) were men, and 1 814 082 (75·5%) were non-Hispanic White. The monthly number of new cancer diagnoses (all stages) decreased substantially after the start of the COVID-19 pandemic in March, 2020, although monthly counts returned to near pre-pandemic levels by the end of 2020. The decrease in diagnoses was largest for stage I disease, leading to lower odds of being diagnosed with stage I disease in 2020 than in 2019 (aOR 0·946 [95% CI 0·939-0·952] for stage I vs stage II-IV); whereas, the odds of being diagnosed with stage IV disease were higher in 2020 than in 2019 (1·074 [1·066-1·083] for stage IV vs stage I-III). This pattern was observed in most cancer types and sociodemographic groups, although was most prominent among Hispanic individuals (0·922 [0·899-0·946] for stage I; 1·110 [1·077-1·144] for stage IV), Asian American and Pacific Islander individuals (0·924 [0·892-0·956] for stage I; 1·096 [1·052-1·142] for stage IV), uninsured individuals (0·917 [0·875-0·961] for stage I; 1·102 [1·055-1·152] for stage IV), Medicare-insured adults younger than 65 years (0·909 [0·882-0·937] for stage I; 1·105 [1·068-1·144] for stage IV), and individuals living in the most socioeconomically deprived areas (0·931 [0·917-0·946] for stage I; 1·106 [1·087-1·125] for stage IV).

INTERPRETATION

Substantial cancer underdiagnosis and decreases in the proportion of early stage diagnoses occurred during 2020 in the USA, particularly among medically underserved individuals. Monitoring the long-term effects of the pandemic on morbidity, survival, and mortality is warranted.

FUNDING

None.

Recent Mortality Patterns and Time Trends for the Major Cancers in 47 Countries Worldwide

BACKGROUND

Most prior studies have reported cancer mortality trends across countries for specific cancer types. Herein, we examine recent patterns and trends in cancer mortality rates for the eight common forms of cancer in 47 countries across five continents (except Africa) based on the World Health Organization mortality database.

METHODS

Rates were age-standardized to the 1966 Segi-Doll world population, and trends in the age-standardized rates for the most recent 10 years of data were examined using Joinpoint regression.

RESULTS

Cancer-specific mortality rates vary substantially across countries, with rates of infection-related (cervix and stomach) and tobacco-related cancers (lung and esophagus) varying by 10-fold. Recent mortality rates for all major cancers decreased in most of the studied countries except lung cancer in females and liver cancer in males, where increasing rates were observed in most countries. Rates decreased or stabilized in all countries for lung cancer in men and stomach cancer in both sexes.

CONCLUSIONS

The findings reinforce the importance of implementing and strengthening resource-stratified and targeted cancer prevention and control programs in all parts of the world to further reduce or halt the rising cancer burden.

IMPACT

The results may inform cancer prevention and treatment strategies and in so doing, reduce the marked global cancer disparities observed today.

Medicaid Expansion Associated With Increase In Palliative Care For People With Advanced-Stage Cancers

Clinical guidelines have endorsed early palliative care for patients with advanced malignancies, but receipt remains low in the US. This study examined the association between Medicaid expansion under the Affordable Care Act and receipt of palliative care among patients newly diagnosed with advanced-stage cancers. Using the National Cancer Database, we found that the percentage of eligible patients who received palliative care as part of first-course treatment increased from 17.0 percent preexpansion to 18.9 percent postexpansion in Medicaid expansion states and from 15.7 percent to 16.7 percent, respectively, in nonexpansion states, resulting in a net increase of 1.3 percentage points in expansion states in adjusted analyses. Increases in receipt of palliative care associated with Medicaid expansion were largest for patients with advanced pancreatic, colorectal, lung, and oral cavity and pharynx cancers and non-Hodgkin lymphoma. Our findings suggest that increasing Medicaid coverage facilitates access to guideline-based palliative care for advanced cancer, and they provide additional evidence of benefit in cancer care from states' expansion of income eligibility for Medicaid.

Disparities and Trends in Genitourinary Cancer Incidence and Mortality in the USA

BACKGROUND

Previous studies have reported on incidence and mortality patterns for individual genitourinary cancers in the USA. However, these studies addressed individual cancer types rather than genitourinary cancers overall.

OBJECTIVE

To comprehensively examine disparities and trends in the incidence and mortality for the four major genitourinary cancers (bladder, kidney, prostate, and testis) in the USA.

DESIGN, SETTING, AND PARTICIPANTS

We obtained incidence data from the National Cancer Institute 22-registry Surveillance, Epidemiology and End Results (SEER) database and the US Cancer Statistics database (Centers for Disease Control and Prevention) and mortality data from the National Center for Health Statistics to examine cross-sectional and temporal trends in incidence and death rates stratified by sex, race/ethnicity, and county.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Age-adjusted incidence and death rates were calculated using SEER*Stat software. Temporal trends were analyzed using Joinpoint regression for a two-sided significance level of p < 0.05.

RESULTS AND LIMITATIONS

Incidence and mortality rates for bladder and kidney cancers were two to four times higher for men than for women. Among non-Hispanic White individuals, the highest incidence rates were found in the Northeast for bladder cancer and in Appalachia for kidney cancer, whereas the highest death rates for prostate cancer were found in the West. Incidence rates increased for cancers of the kidney and testis and for advanced-stage prostate cancer in almost all racial/ethnic populations and for bladder cancer in the American Indian/Alaska Native population. Death rates increased for testicular cancer in the Hispanic population and stabilized for prostate cancer among White and Asian American/Pacific Islander men after a steady decline since the early 1990s. Study limitations include misclassification of race/ethnicity on medical records and death certificates.

CONCLUSIONS

We found persistent sociodemographic disparities and unfavorable trends in incidence or mortality for all four major genitourinary cancers. Future studies should elucidate the reasons for these patterns.

PATIENT SUMMARY

In the USA, rates of cancer cases are increasing for kidney, testis, and advanced-stage prostate cancers in the overall population, and for bladder cancer in the American Indian/Alaska Native population. Differences in the rates by sex and race/ethnicity remain.

The Association Between Census Tract Healthy Food Accessibility and Life Expectancy in the United States

Accessibility of healthy food is an important predictor for several health outcomes, but its association with life expectancy is unclear. We evaluated the association between U.S. Department of Agriculture's Food Research Atlas measures of healthy food accessibility and life expectancy at birth across contiguous U.S. census tracts using spatial modeling analysis. Both income and healthy food accessibility were associated with life expectancy at birth, as indicated by shorter life expectancy in low-income census tracts when comparing tracts with similar healthy food accessibility level, and in low-access tracts when comparing tracts with similar income level. Compared to high-income/high-access census tracts, life expectancy at birth was lower in high-income/low-access (- 0.33 years; 95% confidence interval - 0.42, - 0.28), low-income/high-access (- 1.45 years; - 1.52, - 1.38), and low-income/low-access (- 2.29 years; - 2.38, - 2.21) tracts after adjusting for socio-demographic characteristics and incorporating vehicle availability. Effective interventions to increase healthy food accessibility may improve life expectancy.

Regional Variation in the Tumor Microenvironment, Immune Escape and Prognostic Factors in Breast Cancer in Sub-Saharan Africa

The low overall survival rates of patients with breast cancer in sub-Saharan Africa (SSA) are driven by regionally differing tumor biology, advanced tumor stages at diagnosis, and limited access to therapy. However, it is not known whether regional differences in the composition of the tumor microenvironment (TME) exist and affect patients' prognosis. In this international, multicentre cohort study, 1,237 formalin-fixed, paraffin-embedded breast cancer samples, including samples of the "African Breast Cancer-Disparities in Outcomes (ABC-DO) Study," were analyzed. The immune cell phenotypes, their spatial distribution in the TME, and immune escape mechanisms of breast cancer samples from SSA and Germany (n = 117) were investigated using histomorphology, conventional and multiplex IHC, and RNA expression analysis. The data revealed no regional differences in the number of tumor-infiltrating lymphocytes (TIL) in the 1,237 SSA breast cancer samples, while the distribution of TILs in different breast cancer IHC subtypes showed regional diversity, particularly when compared with German samples. Higher TIL densities were associated with better survival in the SSA cohort (n = 400), but regional differences concerning the predictive value of TILs existed. High numbers of CD163+ macrophages and CD3+CD8+ T cells accompanied by reduced cytotoxicity, altered IL10 and IFNγ levels and downregulation of MHC class I components were predominantly detected in breast cancer samples from Western SSA. Features of nonimmunogenic breast cancer phenotypes were associated with reduced patient survival (n = 131). We therefore conclude that regional diversity in the distribution of breast cancer subtypes, TME composition, and immune escape mechanisms should be considered for therapy decisions in SSA and the design of personalized therapies. See related Spotlight by Bergin et al., p. 705.

Declining trend in cigarette smoking among U.S. adults over 2008-2018: A decomposition analysis

The United States (U.S.) witnessed considerable reduction in cigarette smoking prevalence in the recent past. While the correlates of smoking prevalence and related disparities among U.S. adults are well documented, there is limited information on how this success was shared among different population sub-groups. Based on data from the National Health Interview Surveys, 2008 and 2018, representative of non-institutionalized U.S. adults (18 years and above), we applied the threefold Kitawaga-Oaxaca-Blinder linear decomposition analysis. We decomposed the trends in cigarette smoking prevalence, smoking initiation, and successful cessation into changes in population characteristics holding smoking propensities constant (compositional change), changes in smoking propensities by population characteristics holding population composition constant (structural change), and the unmeasured macro-level changes affecting smoking behavior in different population sub-groups at differential rates (residual change) to quantify the shares of population sub-groups by sex, age, race/ethnicity, education, marital status, employment status, health insurance coverage, family income, and region of residence in the overall change in smoking rates. The analysis shows that decreases in smoking propensities regardless of the changes in population composition accounted for 66.4% of the reduction in smoking prevalence and 88.7% of the reduction in smoking initiation. The major reductions in smoking propensity were among Medicaid recipients and young adults (ages 18-24 years). The 25-44-year-olds experienced moderate increase in successful smoking cessation, while the overall successful smoking cessation rate remained steady. Taken together, consistent reduction in smoking among U.S. adults by all major population characteristics, accompanied by disproportionately larger reduction in smoking propensities among the population sub-groups with initially higher smoking propensity compared to the national average, characterized the decline in overall cigarette smoking. Strengthening proven tobacco control measures with targeted interventions to reduce smoking propensities among underserved populations is key to continued success in reducing smoking overall and remedying inequities in smoking and population health.

Association of nicotine replacement therapy product sales with menthol cigarette sales restriction in Massachusetts

BACKGROUND

Massachusetts was the first to implement a state-wide menthol cigarette sales restriction in the USA. Following its implementation in June 2020, evidence showed declines in cigarette sales in Massachusetts; however, changes in nicotine replacement therapy (NRT) product sales are unknown.

METHODS

This cohort study analysed NRT products sold by US-based retailers available in 26 states from the Nielsen Retail Scanner Data. Outcomes were state-level 4-week aggregate sales of gum, lozenge and patch NRT products converted into pieces per 1000 adults (aged ≥18 years) who smoke cigarettes based on smoking rates from the Behavioral Risk Factor Surveillance System and corresponding population from the US Census Bureau. We used a difference-in-differences method to compare changes in NRT product sales in Massachusetts before (1 January 2017 to 13 June 2020) and after (14 June 2020 to 4 December 2021) the policy with sales in 25 states.

RESULTS

The analysis included 1664 observations for each NRT product, with 1170 from before and 494 from after the policy change. The 4-week NRT product sales per 1000 adults who smoke cigarettes in Massachusetts compared with the comparison states increased for gums by 643.11 (95% CI 365.33 to 920.89; p<0.001) pieces or 12.9% and for lozenges by 436.97 (95% CI 292.88 to 581.06; p<0.001) pieces or 17.9% but no statistically significant change in patches after implementing the policy.

CONCLUSION

The increases in sales of gum and lozenge NRT products in Massachusetts after implementing the policy suggest that a nationwide ban on menthol cigarettes can increase NRT product use; therefore, interventions are needed to strengthen cessation support for adults who smoke cigarettes but intend to quit.

Updated Review of Major Cancer Risk Factors and Screening Test Use in the United States, with a Focus on Changes During the COVID-19 Pandemic

We present national and state representative prevalence estimates of modifiable cancer risk factors, preventive behaviors and services, and screening, with a focus on changes during the COVID-19 pandemic. Between 2019 and 2021, current smoking, physical inactivity, and heavy alcohol consumption declined, and human papillomavirus vaccination and stool testing for colorectal cancer screening uptake increased. In contrast, obesity prevalence increased, while fruit consumption and cervical cancer screening declined during the same timeframe. Favorable and unfavorable trends were evident during the 2nd year of the COVID-19 pandemic that must be monitored as more years of consistent data are collected. Yet disparities by racial/ethnic and socioeconomic status persisted, highlighting the continued need for interventions to address suboptimal levels among these population subgroups.

State Variation in Racial and Ethnic Disparities in Incidence of Triple-Negative Breast Cancer Among US Women

Importance

There are few data on state variation in racial and ethnic disparities in incidence of triple-negative breast cancer (TNBC) in the US, limiting the ability to inform state-level health policy developments toward breast cancer equity.

Objective

To quantify between and within racial and ethnic disparities in TNBC incidence rates (IRs) among US women across states.

Design, Setting, and Participants

This cohort study using population-based cancer registry data included data for all women with TNBC diagnosed from January 1, 2015, to December 31, 2019, identified in the US Cancer Statistics Public Use Research Database. Data were analyzed from July through November 2022.

Exposures

State and race and ethnicity (Hispanic, non-Hispanic American Indian or Alaska Native, non-Hispanic Asian or Pacific Islander, non-Hispanic Black, or non-Hispanic White) abstracted from medical records.

Main Outcomes and Measures

The main outcomes were diagnosis of TNBC, age-standardized IR per 100 000 women, state-specific incidence rate ratios (IRRs) using the rate among White women in each state as a reference for between-population disparities, and state-specific IRRs using the race and ethnicity-specific national rate as a reference for within-population disparities.

Results

The study included data for 133 579 women; 768 (0.6%) were American Indian or Alaska Native; 4969 (3.7%), Asian or Pacific Islander; 28 710 (21.5%), Black; 12 937 (9.7%), Hispanic; and 86 195 (64.5%), White. The TNBC IR was highest among Black women (25.2 per 100 000 women), followed by White (12.9 per 100 000 women), American Indian or Alaska Native (11.2 per 100 000 women), Hispanic (11.1 per 100 000 women), and Asian or Pacific Islander (9.0 per 100 000 women) women. Racial and ethnic group-specific and state-specific rates substantially varied, ranging from less than 7 per 100 000 women among Asian or Pacific Islander women in Oregon and Pennsylvania to greater than 29 per 100 000 women among Black women in Delaware, Missouri, Louisiana, and Mississippi. Compared with White women, IRRs were statistically significantly higher in 38 of 38 states among Black women, ranging from 1.38 (95% CI, 1.10-1.70; IR, 17.4 per 100 000 women) in Colorado to 2.32 (95% CI, 1.90-2.81; IR, 32.0 per 100 000 women) in Delaware; lower in 22 of 22 states among Asian or Pacific Islander women, varying from 0.50 (95% CI, 0.34-0.70; IR, 5.7 per 100 000 women) in Oregon to 0.82 (95% CI, 0.75-0.90; IR, 10.5 per 100 000 women) in New York; and did not differ among Hispanic and American Indian or Alaska Native women in 22 of 35 states and 5 of 8 states, respectively. State variations within each racial and ethnic population were smaller but still substantial. For example, among White women, compared with the national rate, IRRs varied from 0.72 (95% CI, 0.66-0.78; IR, 9.2 per 100 000 women) in Utah to 1.18 (95% CI, 1.11-1.25; IR, 15.2 per 100 000 women) in Iowa, 1.15 (95% CI, 1.07-1.24; IR, 14.8 per 100 000 women) in Mississippi, and 1.15 (95% CI, 1.07-1.24; IR, 14.8 per 100 000 women) in West Virginia.

Conclusions and Relevance

In this cohort study, there were substantial state variations in racial and ethnic disparities in TNBC incidence, with Black women in Delaware, Missouri, Louisiana, and Mississippi having the highest rates among all states and racial and ethnic populations. The findings suggest that more research is needed to identify factors contributing to the substantial geographic variations in racial and ethnic disparities in TNBC incidence to develop effective preventive measures and that social determinants of health contribute to the geographic disparities in TNBC risk.

Association of the COVID-19 Pandemic and Changes in Patterns of Cancer-Related Mortality in the United States

PURPOSE

This study examined changes in patterns of cancer-related deaths during the first year of the coronavirus disease 2019 pandemic in the United States.

METHODS

We identified cancer-related deaths, defined as deaths attributable to cancer as the primary cause (underlying cause) or deaths with cancer documented as one of the multiple contributing factors (contributing cause) from the Multiple Cause of Death database (2015-2020). We compared age-standardized cancer-related annual and monthly mortality rates for January-December 2020 (first pandemic year) to January-December 2015-2019 (prepandemic) overall and stratified by sex, race/ethnicity, urban rural residence, and place of death.

RESULTS

We found that the death rate (per 100,000 person-years) with cancer as the underlying cause was lower in 2020 compared with 2019 (144.1 v 146.2), continuing the past trend observed in 2015-2019. By contrast, the death rate with cancer as a contributing cause was higher in 2020 than in 2019 (164.1 v 162.0), reversing the continuously decreasing trend from 2015 to 2019. We projected 19,703 more deaths with cancer as a contributing cause than expected on the basis of historical trends. Mirroring pandemic peaks, the monthly death rates with cancer as a contributing cause first increased in April 2020 (rate ratio [RR], 1.03; 95% CI, 1.02 to 1.04), subsequently declined in May and June 2020, and then increased again each month from July through December 2020 compared with 2019, with the highest RR in December (RR, 1.07; 95% CI, 1.06 to 1.08).

CONCLUSION

Death rates with cancer as the underlying cause continued to decrease in 2020 despite the increase in death rates with cancer as a contributing cause in 2020. Ongoing monitoring of long-term cancer-related mortality trends is warranted to assess effects of delays in cancer diagnosis and receipt of care during the pandemic.

Abstract 4379: Survival among adults diagnosed with secondary acute myeloid leukemia

Background: The burden of second primary cancers including secondary acute myeloid leukemia (sAML) is increasing in the United States; however, limited data exist regarding survival among individuals with sAML. This study aims to examine survival differences between sAML and AML arising de novo (dnAML) in relation to antecedent cancer types and the receipt of prior cancer treatment.

Methods: Individuals aged ≥20 years and diagnosed with sAML or dnAML between 2001 and 2018 and followed for vital status through 2019 were identified from Surveillance, Epidemiology, and End Results 17 database, covering 27% of the US population. The differences in AML-specific survival between individuals with sAML and dnAML were examined using multivariable Cox proportional hazards regression. Trends in five-year age-standardized relative survival from 2001-2014 were assessed using Joinpoint survival model for sAML and dnAML, separately.

Results: A total of 7,306 individuals diagnosed with sAML and 40,398 individuals with dnAML were included. During a median follow-up of 6 months, 78% of individuals with sAML died from AML compared to 71% of those with dnAML. In multivariable models, the risk of AML-specific mortality was 8% higher in individuals diagnosed with sAML than in those diagnosed with dnAML (hazard ratio [HR]=1.08, 95%CI=1.05-1.11), with the elevated risk more pronounced among those with younger ages at diagnosis (HR20-54 years=1.60, 95%CI=1.46-1.75 versus HR65+ years=0.99, 95%CI=0.96-1.03; Pinteraction&lt;0.0001) and those who received chemotherapy (HRchemotherapy yes=1.14, 95%CI=1.10-1.19 versus HRchemotherapy no/unknown=0.95, 95%CI=0.90-0.99; Pinteraction=0.0004). Subgroup analysis by antecedent cancer types showed that HRs substantially varied ranging from 0.74 (95%CI=0.57-0.95) for individuals with a history of thyroid cancer to 1.78 (95%CI=1.04-3.07) for those with a history of soft tissue sarcomas. Further subgroup analysis by the receipt of chemotherapy for antecedent cancers showed that the elevated risk was generally restricted to individuals with a history of chemotherapy receipt with some variations by cancer types. Five-year relative survival significantly increased from 2001 to 2014 for both sAML and dnAML; though the increase was slower for sAML (annual percent change [APC]=0.30%, 95% CI 0.20-0.40) compared with dnAML (APC=0.77%, 95%CI=0.69-0.84). Likewise, five-year survival for the most contemporary period (2010-2018) was substantially lower for sAML (9.8%, 95%CI=9.3-10.3) than for dnAML (22.8%, 95%CI=22.3-23.2).

Conclusion: Individuals with sAML had in general worse AML cause-specific survival compared with their dnAML counterparts, with the differences most pronounced among those diagnosed at younger ages and who received chemotherapy. The findings may inform targeted treatment and survivorship recommendations for cancer survivors who develop sAML.

Citation Format: Ephrem Sedeta, Ahmedin Jemal, Lauren Nisotel, Hyuna Sung. Survival among adults diagnosed with secondary acute myeloid leukemia. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4379.

Abstract 1927: Differential effects of social isolation on cancer mortality by race/ethnicity and socioeconomic status among working age adults in the United States

Background Social isolation or living alone can negatively affect mental health, sleep quality, eating behavior, immunity, proinflammatory response to stress, and receipt of care in cancer patients (e.g., assistance with nutrition and mobility, emotional and informational support), which may increase the risk of death from cancer. Previous studies, however, have shown inconsistent findings on the association between social isolation and cancer mortality. To address the literature gap, we examined this association among working-age adults stratified by sociodemographic characteristics using a nationally representative cohort with long-term mortality follow-up.

Method We used the pooled 1998-2019 data for adults aged 18-64 years at enrollment from the National Health Interview Survey (NHIS) linked to National Death Index (N=473,648) with up to 22 years of follow-up. Cox proportional hazards regression was used to model survival time as a function of social isolation, measured by “living alone”, and sociodemographic, behavioral, and health characteristics. We estimated differential effects of social isolation on cancer mortality by age, sex, race/ethnicity, poverty level, and education, overall and for select common cancers (lung, colorectal, and female breast) with &gt;100 deaths in the public use NHIS-linked mortality database, 1998-2004.

Results The cancer mortality risk was 32% higher (hazard ratio [HR]=1.32; 95%CI:1.25,1.39) in adults living alone, controlling for age, and 16% higher (HR=1.16; 95%CI:1.10,1.23) in adults living alone, controlling for demographic and socioeconomic characteristics, when compared to adults living with others. The association between living alone and cancer mortality persisted after additional adjustments for health-risk behaviors and health status (HR=1.10, 95%CI:1.04,1.16). Stratified models generally showed similar associations between social isolation and cancer mortality risk across categories of sex, poverty, and education in age-adjusted models. However, the association was stronger among non-Hispanic (NH) White than NH Black adults and did not exist in other racial/ethnic groups. The associations were attenuated after additional adjustments but persisted in fully adjusted models among males, females, NH White people, and adults with a college degree. In the age-adjusted models, social isolation was associated with a higher risk of death from lung (HR=1.45; 95%CI:1.81,2.45) and colorectal (HR=1.65; 95%CI:2.58,1.56), but not from female breast cancer.

Conclusions In this nationally representative study in the United States, adults living alone were at a higher risk of cancer death compared to adults living with others. These findings underscore the significance of addressing social isolation in the general population and among cancer survivors.

Citation Format: Hyunjung Lee, Gopal K. Singh, Ahmedin Jemal, Farhad Islami. Differential effects of social isolation on cancer mortality by race/ethnicity and socioeconomic status among working age adults in the United States [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1927.

Association of Comprehensive Menthol Flavor Ban With Current Cigarette Smoking in Massachusetts From 2017 to 2021

This cross-sectional study compares self-reported smoking by adults before vs after prohibition of menthol-flavored cigarettes.

Cancer statistics for American Indian and Alaska Native individuals, 2022: Including increasing disparities in early onset colorectal cancer

American Indian and Alaska Native (AIAN) individuals are diverse culturally and geographically but share a high prevalence of chronic illness, largely because of obstacles to high-quality health care. The authors comprehensively examined cancer incidence and mortality among non-Hispanic AIAN individuals, compared with non-Hispanic White individuals for context, using population-based data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries. Overall cancer rates among AIAN individuals were 2% higher than among White individuals for incidence (2014 through 2018, confined to Purchased/Referred Care Delivery Area counties to reduce racial misclassification) but 18% higher for mortality (2015 through 2019). However, disparities varied widely by cancer type and geographic region. For example, breast and prostate cancer mortality rates are 8% and 31% higher, respectively, in AIAN individuals than in White individuals despite lower incidence and the availability of early detection tests for these cancers. The burden among AIAN individuals is highest for infection-related cancers (liver, stomach, and cervix), for kidney cancer, and for colorectal cancer among indigenous Alaskans (91.3 vs. 35.5 cases per 100,000 for White Alaskans), who have the highest rates in the world. Steep increases for early onset colorectal cancer, from 18.8 cases per 100,000 Native Alaskans aged 20-49 years during 1998 through 2002 to 34.8 cases per 100,000 during 2014 through 2018, exacerbated this disparity. Death rates for infection-related cancers (liver, stomach, and cervix), as well as kidney cancer, were approximately two-fold higher among AIAN individuals compared with White individuals. These findings highlight the need for more effective strategies to reduce the prevalence of chronic oncogenic infections and improve access to high-quality cancer screening and treatment for AIAN individuals. Mitigating the disparate burden will require expanded financial support of tribal health care as well as increased collaboration and engagement with this marginalized population.

Colorectal cancer statistics, 2023

Colorectal cancer (CRC) is the second most common cause of cancer death in the United States. Every 3 years, the American Cancer Society provides an update of CRC statistics based on incidence from population-based cancer registries and mortality from the National Center for Health Statistics. In 2023, approximately 153,020 individuals will be diagnosed with CRC and 52,550 will die from the disease, including 19,550 cases and 3750 deaths in individuals younger than 50 years. The decline in CRC incidence slowed from 3%-4% annually during the 2000s to 1% annually during 2011-2019, driven partly by an increase in individuals younger than 55 years of 1%-2% annually since the mid-1990s. Consequently, the proportion of cases among those younger than 55 years increased from 11% in 1995 to 20% in 2019. Incidence since circa 2010 increased in those younger than 65 years for regional-stage disease by about 2%-3% annually and for distant-stage disease by 0.5%-3% annually, reversing the overall shift to earlier stage diagnosis that occurred during 1995 through 2005. For example, 60% of all new cases were advanced in 2019 versus 52% in the mid-2000s and 57% in 1995, before widespread screening. There is also a shift to left-sided tumors, with the proportion of rectal cancer increasing from 27% in 1995 to 31% in 2019. CRC mortality declined by 2% annually from 2011-2020 overall but increased by 0.5%-3% annually in individuals younger than 50 years and in Native Americans younger than 65 years. In summary, despite continued overall declines, CRC is rapidly shifting to diagnosis at a younger age, at a more advanced stage, and in the left colon/rectum. Progress against CRC could be accelerated by uncovering the etiology of rising incidence in generations born since 1950 and increasing access to high-quality screening and treatment among all populations, especially Native Americans.

Abstract P4-03-24: State variation in racial and ethnic disparities in triple-negative breast cancer rates: NPCR-SEER incidence data, 2015-2019

Background: Triple-negative breast cancer (TNBC) (i.e., estrogen receptor-negative, progesterone receptor-negative, and human epidermal growth factor receptor type 2-negative) is an aggressive subtype of breast cancer, more frequently diagnosed among non-Hispanic Black women than other racial/ethnic groups in the United States. TNBC risk also varies by location, but limited data exist for state-level variation in the racial/ethnic disparities in TNBC risk. Methods: Data for TNBC diagnosed at all ages during 2015-2019 were obtained from the National Program of Cancer Registries and Surveillance, Epidemiology & End Results for racial/ethnic groups classified as non-Hispanic American Indian/Alaska Native (AIAN), non-Hispanic Asian or Pacific Islander (API), non-Hispanic Black (Black), Hispanic, or non-Hispanic White (White). State-specific incidence rates were available for 8, 23, and 36 states for AIAN, API, and Hispanic women, respectively, and 38 states and Washington, D.C. for Black women and 50 states and Washington, D.C. (hereafter referred to collectively as “states”) for White women. State-specific rates were compared within and between racial/ethnic groups using incidence rate ratios (IRR). Results: Nationally, the age-standardized incidence rate of TNBC was the highest among Black women (25.1 per 100,000), followed by White (12.9 per 100,000), AIAN (11.1 per 100,000), Hispanic (11.1 per 100,000), and API (9.0 per 100,000) women. The highest state-specific rates were found among Black women in Delaware, Missouri, and Louisiana (&gt;30 per 100,000) and the lowest rates were among API women in Oregon and Pennsylvania (&lt; 7 per 100,000). State variations within a population were relatively larger among AIAN (2.8-fold) and Hispanic (2.3-fold) women, and smaller among White women (1.65-fold). Compared with White women, Black women had a higher rate of TNBC in all 39/39 states with the greatest IRRs in Delaware (2.31, 95%CI=1.90-2.81), Missouri (2.28, 95%CI=2.08-2.50), and Louisiana (2.20, 95%CI=2.02-2.38) and the lowest IRRs in Minnesota (1.38, 95%CI=1.12-1.68) and Colorado (1.38, 95%CI=1.12-1.68). In contrast, API women had a lower rate than White women in 22/23 states, except for Nevada, with the lowest IRR in Oregon (0.50, 95%CI=0.34-0.70) and the highest IRR in New York (0.82, 95%CI=0.75-0.90). The rate among Hispanic compared with White women did not differ statistically significantly in 23/36 states but was lower in 12/36 states, with the lowest IRR in Ohio (0.57, 95%CI=0.43-0.74), and higher in Massachusetts (1.21, 95%CI=1.04-1.39). The rate among AIAN compared with White women did not differ in 5/8 states but was lower in Arizona (0.53, 95%CI=0.38-0.73) and North Carolina (0.68, 95%CI=0.46-0.96), and higher in Oklahoma (1.30, 95%CI=1.09-1.54). Conclusions: State variations in TNBC incidence rates both within and between populations are substantial, signifying the important role of potentially modifiable risk factors in determining the risk of TNBC by state and race/ethnicity. This finding highlights the need for more research to identify factors contributing to these variations to develop more effective preventive measures. Meanwhile, to mitigate the impact of the disproportionate burden of TNBC across states and racial/ethnic groups, universal access to screening modalities and timely, guideline-concordant treatments is essential.

Citation Format: Hyuna Sung, Daniel Wiese, Ismail Jatoi, Ahmedin Jemal. State variation in racial and ethnic disparities in triple-negative breast cancer rates: NPCR-SEER incidence data, 2015-2019 [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-03-24.

Suicide Risk Among Individuals Diagnosed With Cancer in the US, 2000-2016

Importance

Individuals diagnosed with cancer have elevated suicide risks compared with the general population. National estimates of suicide risks among individuals with cancer are lacking in the US, and knowledge about risk factors is limited.

Objective

To provide contemporary estimates of suicide risks associated with cancer and to identify sociodemographic and clinical factors associated with suicide risks among individuals diagnosed with cancer.

Design, Setting, and Participants

A population-based cohort of individuals diagnosed with cancer from January 1, 2000, to December 31, 2016, from 43 states in the US were followed up through December 31, 2016. Standardized mortality ratios (SMRs) were calculated adjusting for attained age at death, sex, and race and ethnicity groups to compare suicide risks in the cancer cohort vs the general US population. Cox proportional hazards regression models were fitted to identify cancer-specific risk factors of suicide among the cancer cohort. Analyses were conducted from October 27, 2020, to May 13, 2022.

Main Outcomes and Measures

The main outcomes were risk of suicide death compared with the general population, measured by the standardized mortality ratio; and risk of suicide death associated with sociodemographic and clinical factors among individuals with cancer.

Exposure

Diagnosis of cancer.

Results

Among a total of 16 771 397 individuals with cancer, 8 536 814 (50.9%) were 65 years or older at cancer diagnosis, 8 645 631 (51.5%) were male, 13 149 273 (78.4%) were non-Hispanic White, and 20 792 (0.1%) died from suicide. The overall SMR for suicide was 1.26 (95% CI, 1.24-1.28), with a decreasing trend (from an SMR of 1.67 [95% CI, 1.47-1.88] in 2000 to 1.16 [95% CI, 1.11-1.21] in 2016). Compared with the general population, elevated suicide risks were observed in the cancer cohort across all sociodemographic groups, with particularly high SMRs among Hispanic individuals (SMR, 1.48; 95% CI, 1.38-1.58), Medicaid-insured individuals (SMR, 1.72; 95% CI, 1.61-1.84), Medicare-insured individuals 64 years or younger (SMR, 1.94; 95% CI, 1.80-2.07), or uninsured individuals (SMR, 1.66; 95% CI, 1.53-1.80). Moreover, the highest SMR was observed in the first 6 months after the cancer diagnosis (SMR, 7.19; 95% CI, 6.97-7.41). Among individuals diagnosed with cancer, relatively higher suicide risks (ie, hazard ratios) were observed for cancer types with a poor prognosis and high symptom burden in the first 2 years after diagnosis, including cancers of oral cavity and pharynx, esophagus, stomach, brain and other nervous system, pancreas, and lung. After 2 years, individuals with cancers subject to long-term quality-of-life impairments, such as oral cavity and pharynx, leukemia, female breast, uterine, and bladder, had higher suicide risks.

Conclusions and Relevance

In this cohort study of individuals with cancer, elevated suicide risks remained despite a decreasing trend during the past 2 decades. Suicide risks varied by sociodemographic and clinical factors. Timely symptom management and targeted psychosocial interventions are warranted for suicide prevention in individuals diagnosed with cancer.

Mortality by Education Before and During the COVID-19 Pandemic, U.S., 2017-2020

INTRODUCTION

Mortality disparities by SES, including education, have steadily increased in the U.S. over the past decades. This study examined whether these disparities overall and for 7 major causes of death were exacerbated in 2020, coincident with the emergence of the COVID-19 pandemic.

METHODS

Using data on 7,123,254 U.S. deaths from 2017 to 2020, age-standardized death rates and mortality rate differences per 100,000 population and rate ratios comparing least with most educated were calculated by sex and race/ethnicity.

RESULTS

All-cause death rates were approximately 2 times higher among adults with least than among those with most education. Disparities in all-cause mortality by educational attainment slightly increased from 2017 (rate ratio=1.97; 95% CI=1.95, 1.98; rate difference=739.9) to 2019 (rate ratio=2.04; 95% CI=2.03, 2.06; rate difference=761.3) and then greatly increased in 2020 overall (rate ratio=2.32; 95% CI=2.30, 2.33; rate difference=1,042.9) and when excluding COVID-19 deaths (rate ratio=2.27; 95% CI=2.25, 2.28; rate difference=912.3). Similar patterns occurred across race/ethnicity and sex, although Hispanic individuals had the greatest relative increase in disparities for all-cause mortality from 2019 (rate ratio=1.47; 95% CI=1.43, 1.51; rate difference=282.4) to 2020 overall (rate ratio=2.00; 95% CI=1.94, 2.06; rate difference=652.3) and when excluding COVID-19 deaths (rate ratio=1.84; 95% CI=1.79, 1.90; rate difference=458.7). Disparities in cause-specific mortality by education were generally stable from 2017 to 2019, followed by a considerable increase from 2019 to 2020 for heart disease, cancer, cerebrovascular disease, and unintentional injury. Among these causes of death, the relative increase in rate ratio from 2019 to 2020 was greatest for unintentional injury (24.8%; from 3.41 [95% CI=3.23, 3.60] to 4.26 [95% CI=3.99, 4.53]).

CONCLUSIONS

Mortality disparities by education widened in the U.S. in 2020, during the COVID-19 pandemic. Further research is warranted to understand the reasons for these widened disparities.