Neighborhood Factors Associated with COVID-19 Cases in California

BACKGROUND

There is a need to assess neighborhood-level factors driving COVID-19 disparities across racial and ethnic groups.

OBJECTIVE

To use census tract-level data to investigate neighborhood-level factors contributing to racial and ethnic group-specific COVID-19 case rates in California.

DESIGN

Quasi-Poisson generalized linear models were used to identify neighborhood-level factors associated with COVID-19 cases. In separate sequential models for Hispanic, Black, and Asian, we characterized the associations between neighborhood factors on neighborhood COVID-19 cases. Subanalyses were conducted on neighborhoods with majority Hispanic, Black, and Asian residents to identify factors that might be unique to these neighborhoods. Geographically weighted regression using a quasi-Poisson model was conducted to identify regional differences.

MAIN MEASURES

All COVID-19 cases and tests reported through January 31, 2021, to the California Department of Public Health. Neighborhood-level data from census tracts were obtained from American Community Survey 5-year estimates (2015-2019), United States Census (2010), and United States Department of Housing and Urban Development.

KEY RESULTS

The neighborhood factors associated with COVID-19 case rate were racial and ethnic composition, age, limited English proficiency (LEP), income, household size, and population density. LEP had the largest influence on the positive association between proportion of Hispanic residents and COVID-19 cases (- 2.1% change). This was also true for proportion of Asian residents (- 1.8% change), but not for the proportion of Black residents (- 0.1% change). The influence of LEP was strongest in areas of the Bay Area, Los Angeles, and San Diego.

CONCLUSION

Neighborhood-level contextual drivers of COVID-19 burden differ across racial and ethnic groups.

Asian American Enclaves and Healthcare Accessibility: An Ecologic Study Across Five States

INTRODUCTION

Access to primary care has been a long-standing priority for improving population health. Asian Americans, who often settle in ethnic enclaves, have been found to underutilize health care. Understanding geographic primary care accessibility within Asian American enclaves can help to ensure the long-term health of this fast-growing population.

METHODS

U.S. Census data from five states (California, Florida, New Jersey, New York, and Texas) were used to develop and describe census-tract level measures of Asian American enclaves and social and built environment characteristics for years 2000 and 2010. The 2-step floating catchment area method was applied to National Provider Identifier data to develop a tract-level measure of geographic primary care accessibility. Analyses were conducted in 2022-2023, and associations between enclaves (versus nonenclaves) and geographic primary care accessibility were evaluated using multivariable Poisson regression with robust variance estimation, adjusting for potential area-level confounders.

RESULTS

Of 24,482 census tracts, 26.1% were classified as Asian American enclaves. Asian American enclaves were more likely to be metropolitan and have less poverty, lower crime, and lower proportions of uninsured individuals than nonenclaves. Asian American enclaves had higher primary care accessibility than nonenclaves (adjusted prevalence ratio=1.23, 95% CI=1.17, 1.29).

CONCLUSIONS

Asian American enclaves in five of the most diverse and populous states in the U.S. had fewer markers of disadvantage and greater geographic primary care accessibility. This study contributes to the growing body of research elucidating the constellation of social and built environment features within Asian American enclaves and provides evidence of health-promoting characteristics of these neighborhoods.

Neighborhood-level COVID vaccination and booster disparities: A population-level analysis across California

Objectives

To describe vaccine and booster uptake by neighborhood-level factors in California.

Methods

We examined trends in COVID-19 vaccination up to September 21, 2021, and boosters up to March 29, 2022 using data from the California Department of Public Health. Quasi-Poisson regression was used to model the association between neighborhood-level factors and fully vaccinated and boosted among ZIP codes. Sub-analyses on booster rates were compared among the 10 census regions.

Results

In a minimally adjusted model, a higher proportion of Black residents was associated with lower vaccination (HR = 0.97; 95%CI: 0.96-0.98). However, in a fully adjusted model, proportion of Black, Hispanic/Latinx, and Asian residents were associated with higher vaccination rates (HR = 1.02; 95%CI: 1.01-1.03 for all). The strongest predictor of low vaccine coverage was disability (HR = 0.89; 95%CI: 0.86-0.91). Similar trends persisted for booster doses. Factors associated with booster coverage varied by region.

Conclusions

Examining neighborhood-level factors associated with COVID-19 vaccination and booster rates uncovered significant variation within the large and geographically and demographically diverse state of California. Equity-based approaches to vaccination must ensure a robust consideration of multiple social determinants of health.

Neighborhood socioeconomic status and the effectiveness of colorectal cancer screening outreach with mailed fecal immunochemical tests within a safety net healthcare system in San Francisco, CA: A subgroup analysis of a randomized controlled trial

Neighborhood context shapes opportunities and barriers for residents to access healthcare and cancer screening. Neighborhood socioeconomic status (nSES) is associated with disparities in colorectal cancer (CRC) screening, but the extent to which the effectiveness of specific screening interventions vary by nSES has not been studied. The original trial conducted in San Francisco, CA from 2016 to 2017 randomly assigned patients eligible for CRC screening either to a multicomponent intervention including advanced notification, mailed fecal immunochemical test (FIT) kits and reminders or to a control group receiving usual care. For the nSES analysis addresses for 9699 patients were geocoded and stratified by city-wide nSES quintile (Q1 lowest, Q5 highest) using an established index at the census tract level. Compared to usual care, the outreach intervention improved FIT test completion at one year (58.7% vs 38.4%; OR 2.32 [2.14, 2.52]) but its effectiveness did not vary substantially by nSES quintile (adjusted OR Q1 2.64 [2.30, 3.04]; Q2 2.43 [2.04, 2.90]; Q3 2.31 [1.84, 2.89]; Q4 2.47 [1.86, 3.28]; Q5 2.64 [1.83, 3.81]; Wald test for interaction p = 0.87). The implementation of mailed FIT outreach has the potential to increase CRC screening completion without leading to disparities in screening related to nSES (ClinicalTrials.gov NCT02613260).

Improved survival in cervical cancer patients receiving care at National Cancer Institute-designated cancer centers

Background

Locally advanced cervical cancer (CC) remains lethal in the United States. We investigate the effect of receiving care at an National Cancer Institute–designated cancer center (NCICC) on survival.

Methods

Data for women diagnosed with CC from 2004 to 2016 who received radiation treatment were extracted from the California Cancer Registry (n = 4250). Cox proportional hazards regression models assessed whether (1) receiving care at NCICCs was associated with risk of CC‐specific death, (2) this association remained after multivariable adjustment for age, race/ethnicity, and insurance status, and (3) this association was explained by receipt of guideline‐concordant treatment.

Results

Median age was 50 years (interquartile range [IQR] 41–61 years), with median follow‐up of 2.7 years (IQR 1.3–6.0 years). One‐third of patients were seen at an NCICC, and 29% died of CC. The hazard of CC‐specific death was reduced by 20% for those receiving care at NCICCs compared with patients receiving care elsewhere (HR = .80; 95% CI, 0.70–0.90). Adjustment for guideline‐concordant treatment and other covariates minimally attenuated the association to 0.83 (95% CI, 0.74–0.95), suggesting that the survival advantage associated with care at NCICCs may not be due to receipt of guideline‐concordant treatment.

Conclusions

This study demonstrates survival benefit for patients receiving care at NCICCs compared with those receiving care elsewhere that is not explained by differences in guideline‐concordant care. Structural, organizational, or provider characteristics and differences in patients receiving care at centers with and without NCI designation could explain observed associations. Further understanding of these factors will promote equality across oncology care facilities and survival equity for patients with CC.

This study demonstrates survival benefit for patients receiving care for cervical cancer at National Cancer Institute–designated cancer centers that is not explained by receipt of guideline‐concordant treatment. Further understanding of these factors will promote equality across oncology care facilities resulting in survival equity for patients with cervical cancer.

Changes in Cancer Mortality by Race and Ethnicity Following the Implementation of the Affordable Care Act in California

Although Affordable Care Act (ACA) implementation has improved cancer outcomes, less is known about how much the improvement applies to different racial and ethnic populations. We examined changes in health insurance coverage and cancer-specific mortality rates by race/ethnicity pre- and post-ACA. We identified newly diagnosed breast (n = 117,738), colorectal (n = 38,334), and cervical cancer (n = 11,109) patients < 65 years in California 2007-2017. Hazard rate ratios (HRR) and 95% confidence intervals (CI) were calculated using multivariable Cox regression to estimate risk of cancer-specific death pre- (2007-2010) and post-ACA (2014-2017) and by race/ethnicity [American Indian/Alaska Natives (AIAN); Asian American; Hispanic; Native Hawaiian or Pacific Islander (NHPI); non-Hispanic Black (NHB); non-Hispanic white (NHW)]. Cancer-specific mortality from colorectal cancer was lower post-ACA among Hispanic (HRR = 0.82, 95% CI = 0.74 to 0.92), NHB (HRR = 0.69, 95% CI = 0.58 to 0.82), and NHW (HRR = 0.90; 95% CI = 0.84 to 0.97) but not Asian American (HRR = 0.95, 95% CI = 0.82 to 1.10) patients. We observed a lower risk of death from cervical cancer post-ACA among NHB women (HRR = 0.68, 95% CI = 0.47 to 0.99). No statistically significant differences in breast cancer-specific mortality were observed for any racial or ethnic group. Cancer-specific mortality decreased following ACA implementation for colorectal and cervical cancers for some racial and ethnic groups in California, suggesting Medicaid expansion is associated with reductions in health inequity.

Changes in cancer mortality by race and ethnicity following the Affordable Care Act implementation in California

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Background: Implementation of the Affordable Care Act (ACA) has resulted in improvements in cancer outcomes but the extent to which these apply to specific racial and ethnic populations is unknown. We examined changes in health insurance distributions pre- and post-ACA and assessed cancer-specific mortality rates by race and ethnicity. Methods: The population included 167,181 newly diagnosed breast (n = 117,738), colorectal (n = 38,334), and cervix cancer (n = 11,109) patients younger than 65 years and 141,026 patients 65 years or older in the California Cancer Registry. Hazard rate ratios (HRRs) and 95% confidence intervals (CIs) were calculated using multivariable Cox regression to estimate associations with risk of 5-year cancer-specific death for each cancer site pre- (2007-2010) and post-ACA (2014-2017), and by race and ethnicity (American Indian/Alaska Natives, AIAN; Asian Americans; Hispanics; Native Hawaiian/Pacific Islanders, NHPI; non-Hispanic Blacks, NHB; and non-Hispanic whites, NHW). Difference-in-difference analysis was conducted to compare changes over time between younger (< 65 years) and older (65 years and older) patients. Results: Cancer-specific mortality for patients age < 65 was significantly lower post- vs. pre-ACA for colorectal cancer among Hispanic (HRR = 0.83; 95% CI: 0.74-0.93), NHB (HRR = 0.69; 95% CI: 0.58-0.81), and NHW (HRR = 0.90 95% CI: 0.84-0.97) but not Asian American (HRR = 0.95; 95% CI: 0.82-1.10) patients. The HRR for younger NHB colorectal cancer patients was significantly lower than that for patients 65 years of and older (HRR = 1.09; 95% CI, 0.95-1.25, p-interaction < 0.0001). A significantly lower risk of dying from cervix cancer was observed in the post- vs. pre-ACA period among younger NHB women (HRR = 0.68; 95% CI: 0.47-0.99), but this was not significantly different than that for older women (HRR = 0.41; 95% CI, 0.16-1.01, p-interaction = 0.30). No significant differences in breast cancer-specific mortality were observed for any racial or ethnic group. Conclusions: Findings show decreases in cancer-specific mortality for colorectal and cervix cancers for some racial and ethnic groups following ACA implementation in California. These results shed light on ongoing discussions as additional states consider Medicaid expansion. Future studies should assess shifts between health insurance plans resulting from the economic impact of the 2019 novel coronavirus (COVID-19) pandemic.

Health care utilization among women of reproductive age living in public housing: Associations across six public housing sites in San Francisco

Housing is a key social determinant of health and health care utilization. Although stigmatized due to poor quality, public housing may provide stability and affordability needed for individuals to engage in health care utilization behaviors. For low-income women of reproductive age (15-44 y), this has implications for long-term reproductive health trajectories. In a sample of 5,075 women, we used electronic health records (EHR) data from 2006 to 2011 to assess outpatient and emergency department (ED) visits across six public housing sites in San Francisco, CA. Non-publicly housed counterparts were selected from census tracts surrounding public housing sites. Multivariable regression models adjusted for age and insurance status estimated incidence rate ratios (IRR) for outpatient visits (count) and odds ratios (OR) for ED visit (any/none). We obtained race/ethnicity-specific associations overall and by public housing site. Analyses were completed in December 2020. Public housing was consistently associated with health care utilization among the combined Asian, Alaskan Native/Native American, Native Hawaiian/Pacific Islander, and Other (AANHPI/Other) group. Public housing residents had fewer outpatient visits (IRR: 0.86; 95% Confidence Interval [CI]: 0.81, 0.93) and higher odds of an ED visit (OR: 1.81; 95% CI: 1.32, 2.48). Black women had higher odds of an ED visits (OR: 1.32; 95% CI: 1.07, 1.63), but this was driven by one public housing site (site-specific OR: 2.34; 95% CI: 1.12, 4.88). Variations by race/ethnicity and public housing site are integral to understanding patterns of health care utilization among women of reproductive age to potentially improve women's long-term health trajectories.

Neighborhood Contexts and Breast Cancer Among Asian American Women

BACKGROUND

This study examines how neighborhood socioeconomic status (nSES) and ethnic composition are associated with breast cancer risk for Asian American women.

METHODS

We linked individual level data from a population-based case-control study of breast cancer among Asian American women with neighborhood level data in the Greater San Francisco Bay Area (cases: n = 118, controls: n = 390). Multivariable logistic regression models examined the association between nSES, ethnic composition, and odds of having breast cancer.

RESULTS

Asian American women living in neighborhoods with high nSES and high ethnic composition had the highest odds of breast cancer, compared to those living in neighborhoods with high nSES and low ethnic composition (OR = 0.34, 95% CI [0.16-0.75]) or in neighborhoods with low nSES and high ethnic composition (OR = 0.37, 95% CI [0.17-0.83]).

DISCUSSION

Neighborhood socioeconomic and ethnic contexts are associated with breast cancer for Asian American women. We discuss explanations and avenues for future research.

Home mortgage discrimination and incidence of triple-negative and Luminal A breast cancer among non-Hispanic Black and non-Hispanic White females in California, 2006-2015

Purpose

In the United States, Black females are burdened by more aggressive subtypes and increased mortality from breast cancer compared to non-Hispanic (NH) White females. Institutional racism may contribute to these inequities. We aimed to characterize the association between home mortgage discrimination, a novel measure of institutional racism, and incidence of Luminal A and triple-negative breast cancer (TNBC) subtypes among NH Black and NH White females in California metropolitan areas.

Methods

We merged data from the California Cancer Registry on females aged 20 + diagnosed with primary invasive breast cancer between 2006 and 2015 with a census tract-level index of home mortgage lending bias measuring the odds of mortgage loan denial for Black versus White applicants, generated from the 2007–2013 Home Mortgage Disclosure Act database. Poisson regression estimated cross-sectional associations of census tract-level racial bias in mortgage lending with race/ethnicity- and Luminal A and TNBC-specific incidence rate ratios, adjusting for neighborhood confounders.

Results

We identified n = 102,853 cases of Luminal A and n = 15,528 cases of TNBC over the study period. Compared to NH Whites, NH Black females had higher rates of TNBC, lower rates of Luminal A breast cancer, and lived in census tracts with less racial bias in home mortgage lending. There was no evidence of association between neighborhood racial bias in mortgage lending at the time of diagnosis and either subtype among either racial/ethnic group.

Conclusion

Future research should incorporate residential history data with measures of institutional racism to improve estimation and inform policy interventions.

Incidence of Lung Cancer Among Never-Smoking Asian American, Native Hawaiian, and Pacific Islander Females

BACKGROUND

Although lung cancer incidence rates according to smoking status, sex, and detailed race/ethnicity have not been available, it is estimated that more than half of Asian American, Native Hawaiian, and Pacific Islander (AANHPI) females with lung cancer have never smoked.

METHODS

We calculated age-adjusted incidence rates for lung cancer according to smoking status and detailed race/ethnicity among females, focusing on AANHPI ethnic groups, and assessed relative incidence across racial/ethnic groups. We used a large-scale dataset that integrates data from electronic health records from 2 large health-care systems-Sutter Health in Northern California and Kaiser Permanente Hawai'i-linked to state cancer registries for incident lung cancer diagnoses between 2000 and 2013. The study population included 1 222 694 females (n = 244 147 AANHPI), 3297 of which were diagnosed with lung cancer (n = 535 AANHPI).

RESULTS

Incidence of lung cancer among never-smoking AANHPI as an aggregate group was 17.1 per 100 000 (95% confidence interval [CI] = 14.9 to 19.4) but varied widely across ethnic groups. Never-smoking Chinese American females had the highest rate (22.8 per 100 000, 95% CI = 17.3 to 29.1). Except for Japanese American females, incidence among every never-smoking AANHPI female ethnic group was higher than that of never-smoking non-Hispanic White females, from 66% greater among Native Hawaiian females (incidence rate ratio = 1.66, 95% CI = 1.03 to 2.56) to more than 100% greater among Chinese American females (incidence rate ratio = 2.26, 95% CI = 1.67 to 3.02).

CONCLUSIONS

Our study revealed high rates of lung cancer among most never-smoking AANHPI female ethnic groups. Our approach illustrates the use of innovative data integration to dispel the myth that AANHPI females are at overall reduced risk of lung cancer and demonstrates the need to disaggregate this highly diverse population.

Abstract IA-21: Applying a data integrative and convergence epidemiology approach to study multilevel risk factors for cancer in distinct AANHPI populations

Background: For Asian American, Native Hawaiian and Pacific Islander (AANHPI) females, lung cancer is one of the most common cancers and the leading cause of cancer death. More than half of lung cancers among AANHPI females occur among never-smokers, but incidence rates of lung cancer according to smoking status have not been available. Purpose: With a large, integrated dataset of electronic health record data from two healthcare systems—Sutter Health in Northern California and Kaiser Permanente Hawai'i—linked to state cancer registry data on incident lung cancer diagnoses 2000-2013, we describe incidence of lung cancer according to smoking status among females across detailed race and ethnicity. Methods: We calculated age-adjusted incidence rates for lung cancer according to smoking status and detailed race and ethnicity among females, focusing on AANHPI ethnic groups, and assessed relative incidence across racial and ethnic groups. The study population included N=1,222,694 females (n=244,147 AANHPI), n=3,297 (n=535) of whom were diagnosed with lung cancer. We examined relative incidence across group defined by detailed race and ethnicity. We also provided incidence of lung cancer among AANHPI males who never smoked in a supplement. Results: Among AANHPI female groups, proportions of lung cancers among never-smokers ranged from 25% among Native Hawaiian to 80% among Chinese females. Incidence of lung cancer among never-smoking AANHPI females as an aggregate was 17.1 per 100,000 (95% CI: 14.9, 19.4), but rates varied widely across ethnic groups. Never-smoking Chinese females had the highest rate (22.8; 95% CI: 17.3, 29.1). Except for Japanese females, incidence among every never-smoking AANHPI female ethnic group was higher than that of all never-smoking females combined. Never-smoking AANHPI males also have higher incidence of lung cancer compared to other groups defined by race and ethnicity. Conclusions: The integrative data analysis approach offers great advantages over traditional cancer cohorts, but it does require substantial time and effort to assure data confidentiality, integrity, and transparency to provide robust results. However, with convergence epidemiology—in this case leveraging needed expertise in data science and analysis to answer an epidemiology question—it is also a valuable approach to study disparate cancer outcomes among small populations. Illustrating this, our study is the first to document high rates of lung cancer among never-smoking AANHPI ethnic groups, dispels the myth that AANHPI females are at overall reduced risk of lung cancer, and demonstrates the need to disaggregate this highly diverse population. Results should inform lung cancer prevention strategies among AANHPI populations.

Citation Format: MIndy C. DeRouen, Alison J. Canchola, Caroline A. Thompson, Anqi Jin, Sixiang Nie, Carmen Wong, Daphne Lichtensztajn, Laura Allen, Manali I. Patel, Yihe G. Daida, Harold S. Luft, Salma Shariff-Marco, Peggy Reynolds, Heather A. Wakelee, Su-Ying Liang, Beth E. Waitzfelder, Iona Cheng, Scarlett L. Gomez. Applying a data integrative and convergence epidemiology approach to study multilevel risk factors for cancer in distinct AANHPI populations [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr IA-21.

Evaluating the Impact of Social and Built Environments on Health-Related Quality of Life among Cancer Survivors

BACKGROUND

With almost 17 million U.S. cancer survivors, understanding multilevel factors impacting health-related quality of life (HRQOL) is critical to improving survivorship outcomes. Few studies have evaluated neighborhood impact on HRQOL among cancer survivors.

METHODS

We combined sociodemographic, clinical, and behavioral data from three registry-based studies in California. Using a three-level mixed linear regression model (participants nested within block groups and study/regions), we examined associations of both independent neighborhood attributes and neighborhood archetypes, which capture interactions inherent among neighborhood attributes, with two HRQOL outcomes, physical (PCS) and mental (MCS) composite scores.

RESULTS

For the 2,477 survivors, 46% were 70+ years, 52% were non-Hispanic White, and 53% had localized disease. In models minimally adjusted for age, stage, and cancer recurrence, HRQOL was associated with neighborhood socioeconomic status (nSES), racial/ethnic composition, population density, street connectivity, restaurant environment index, traffic density, urbanicity, crowding, rental properties, and non-single family units. In fully adjusted models, higher nSES remained associated with better PCS, and restaurant environment index, specifically more unhealthy restaurants, associated with worse MCS. In multivariable-adjusted models of neighborhood archetype, compared with upper middle-class suburb, Hispanic small town and inner city had lower PCS, and high status had higher MCS.

CONCLUSIONS

Among survivors, higher nSES was associated with better HRQOL; more unhealthy restaurants were associated with worse HQROL. As some neighborhood archetypes were associated with HRQOL, they provide an approach to capture how neighborhood attributes interact to impact HRQOL.

IMPACT

Elucidating the pathways through which neighborhood attributes influence HRQOL is important in improving survivorship outcomes.

Individual- and neighborhood-level socioeconomic status and risk of aggressive breast cancer subtypes in a pooled cohort of women from Kaiser Permanente Northern California

BACKGROUND

Low socioeconomic status (SES) has been associated with a higher risk of aggressive breast cancer (BC) subtypes, but few studies have examined the independent effects of both neighborhood-level socioeconomic status (nSES) and individual-level SES measures.

METHODS

This study included 5547 women from the Pathways and Life After Cancer Epidemiology cohorts who were diagnosed with invasive BC. Generalized estimating equation models were used to examine associations of nSES (a composite score based on income, poverty, education, occupation, employment, rent, and house value) and individual-level SES (income and education) with BC subtypes: luminal B (LumB), Her2-enriched (Her2-e), and triple-negative breast cancer (TNBC) relative to luminal A (LumA). Models controlled for age, race, nativity, stage, days from diagnosis to survey, and study cohort and simultaneously for nSES and individual-level SES.

RESULTS

In fully adjusted models, low nSES was significantly associated with the LumB (odds ratio for quartile 1 vs quartile 4 [ORQ1vQ4 ], 1.31; 95% confidence interval [CI], 1.11-1.54; P for trend = .005) and TNBC subtypes (ORQ1vQ4 , 1.32; 95% CI, 1.02-1.71; P for trend = .037) relative to LumA. Conversely, individual education was significantly associated with only the Her2-e subtype (odds ratio for high school degree or less vs postgraduate, 1.68; 95% CI, 1.03-2.75; P for trend = .030) relative to LumA. Individual income was not significantly associated with any BC subtype.

CONCLUSIONS

nSES and individual-level SES are independently associated with different BC subtypes; specifically, low nSES and individual-level education are independent predictors of more aggressive BC subtypes relative to LumA.

Integrating Electronic Health Record, Cancer Registry, and Geospatial Data to Study Lung Cancer in Asian American, Native Hawaiian, and Pacific Islander Ethnic Groups

BACKGROUND

A relatively high proportion of Asian American, Native Hawaiian, and Pacific Islander (AANHPI) females with lung cancer have never smoked. We used an integrative data approach to assemble a large-scale cohort to study lung cancer risk among AANHPIs by smoking status with attention to representation of specific AANHPI ethnic groups.

METHODS

We leveraged electronic health records (EHRs) from two healthcare systems-Sutter Health in northern California and Kaiser Permanente Hawai'i-that have high representation of AANHPI populations. We linked EHR data on lung cancer risk factors (i.e., smoking, lung diseases, infections, reproductive factors, and body size) to data on incident lung cancer diagnoses from statewide population-based cancer registries of California and Hawai'i for the period between 2000 and 2013. Geocoded address data were linked to data on neighborhood contextual factors and regional air pollutants.

RESULTS

The dataset comprises over 2.2 million adult females and males of any race/ethnicity. Over 250,000 are AANHPI females (19.6% of the female study population). Smoking status is available for over 95% of individuals. The dataset includes 7,274 lung cancer cases, including 613 cases among AANHPI females. Prevalence of never-smoking status varied greatly among AANHPI females with incident lung cancer, from 85.7% among Asian Indian to 14.4% among Native Hawaiian females.

CONCLUSION

We have developed a large, multilevel dataset particularly well-suited to conduct prospective studies of lung cancer risk among AANHPI females who never smoked.

IMPACT

The integrative data approach is an effective way to conduct cancer research assessing multilevel factors on cancer outcomes among small populations.

Integration of electronic pathology reporting with clinical trial matching for advanced prostate cancer

INTRODUCTION

Racial/ethnic diversity in prostate cancer (CaP) clinical trials (CTs) is essential to address CaP disparities. California Cancer Registry mandated electronic reporting (e-path) of structured data elements from pathologists diagnosing cancer thereby creating an opportunity to identify and approach patients rapidly. This study tested the utility of an online CT matching tool (called Trial Library) used in combination with e-path to improve matching of underrepresented CaP patients into CTs at time of diagnosis.

METHODS

This was a nonrandomized, single-arm feasibility study among patients with a new pathologic diagnosis of high-risk CaP (Gleason Score ≥8). Eligible patients were sent recruitment materials and enrolled patients were introduced to Trial Library.

RESULTS

A total of 419 case listings were assessed. Patients were excluded due to physician contraindication, not meeting baseline eligibility, or unable to be reached. Final participants (N = 52) completed a baseline survey. Among study participants, 77% were White, 10% were Black/Hispanic/Missing, and 14% were Asian. The majority of the study participants were over 65 years of age (81%) and Medicare insured (62%). Additionally, 81% of participants reported using the Internet to learn about CaP. The majority (62%) of participants reported that Trial Library increased their interest in CT participation.

CONCLUSIONS

The current study demonstrated that leveraging structured e-path data reporting to a population-based cancer registry to recruit men with high risk CaP to clinical research is feasible and acceptable. We observed that e-path may be linked with an online CT matching tool, Trial Library. Future studies will prioritize recruitment from reporting facilities that serve more racially/ethnically diverse patient populations.

Nativity, ethnic enclave residence, and breast cancer survival among Latinas: Variations between California and Texas

BACKGROUND

Among Latinas with breast cancer, residence in an ethnic enclave may be associated with survival. However, findings from prior studies are inconsistent.

METHODS

The authors conducted parallel analyses of California and Texas cancer registry data for adult (aged ≥18 years) Latinas who were diagnosed with invasive breast cancer from 1996 to 2005, with follow-up through 2014. Existing indices applied to tract-level 2000 US Census data were used to measure Latinx enclaves and neighborhood socioeconomic status (nSES). Multivariable Cox proportional hazard models were fit for all-cause and breast cancer-specific survival adjusted for year of diagnosis, patient age, nativity (with multiple imputation), tumor stage, histology, grade, size, and clustering by census tract.

RESULTS

Among 38,858 Latinas, the majority (61.3% in California and 70.5% in Texas) lived in enclaves. In fully adjusted models for both states, foreign-born women were found to be more likely to die of breast cancer and all causes when compared with US-born women. Living in enclaves and in neighborhoods with higher SES were found to be independently associated with improved survival from both causes. When combined into a 4-level variable, those in low nSES nonenclaves had worse survival for both causes compared with those living in low nSES enclaves and, in the all-cause but not breast cancer-specific models, those in high nSES neighborhoods, regardless of enclave status, had improved survival from all causes.

CONCLUSIONS

Applying the same methods across 2 states eliminated previously published inconsistent associations between enclave residence and breast cancer survival. Future studies should identify specific protective effects of enclave residence to inform interventions.

Abstract B039: The impact of social and built environments on quality of life among cancer survivors

Background: With over 16 million cancer survivors in the U.S., understanding factors that improve health-related quality of life (HRQOL) after cancer diagnosis is critical. Previous studies have identified demographic, clinical and behavioral factors that shape HRQOL among cancer patients and have observed poorer HRQOL among racial/ethnic minorities, individuals of low socioeconomic status (SES), or those with comorbidities. Few studies have considered the influence of neighborhood factors (census block group SES (nSES), census tract poverty, county segregation) on HRQOL. Thus, we proposed to assess racial/ethnic disparities in HRQOL and evaluate the extent to which these disparities are explained by neighborhood factors.

Methods: We pooled data on 2,500 diverse (i.e., multiethnic, varied SES, multiple cancer sites) cancer survivors from three population-based cancer survivorship studies in California and linked them to the California Neighborhoods Data System. Separately for the two continuous HRQOL outcomes (physical and mental composite scores, PCS and MCS, from SF36), using a 3-level model with participants nested within block groups, which are nested within study/region, we calculated least squares means and parameter estimates for each racial/ethnic group, with and without adjustment for covariates. Predisposing factors included age, gender, education, employment, income, health insurance status, marital status and significant clinical and tumor characteristics. Health behaviors included physical activity and body mass index.

Results: Among 2,477 cancer survivors, we observed racial/ethnic disparities in HRQOL, with African Americans reporting the lowest (worst) PCS (42.7), Latinos reporting the lowest MCS (48.4) and Asians/Pacific Islanders reporting the highest scores (PCS: 45.4; MCS: 51.1) in unadjusted models. In models adjusted for age and cancer recurrence (and stage for PCS), both PCS and MCS increased with higher nSES. Assessed separately, the following neighborhood factors were associated with decreased MCS after adjusting for nSES: higher population density, street connectivity (gamma), % renting, % non-single-family units, more parks, and restaurant index (more unhealthy). No other neighborhood factor was associated with PCS after adjusting for nSES. Compared to non-Hispanic (NH) Whites, African American disparities in PCS were fully attenuated after adjusting for nSES. Similarly adjusting for neighborhood factors fully attenuated Hispanic disparities in MCS. For PCS, adjusting for predisposing, nSES, and/or behavioral factors resulted in Hispanics having better HRQOL compared to NH Whites.

Conclusions: Among a diverse cohort of cancer survivors, neighborhood attributes were associated with HRQOL. Racial/ethnic disparities in HRQOL were attenuated with inclusion of neighborhood factors in the models. Elucidating the pathways through which these neighborhood attributes impact HRQOL will be important to improving survivorship outcomes.

Citation Format: Salma Shariff-Marco, Alison J. Canchola, Theresa H.M. Keegan, Alyssa Nickell, Ingrid Oakley-Girvan, Ann S. Hamilton, Scarlett L. Gomez. The impact of social and built environments on quality of life among cancer survivors [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B039.

Abstract PR07: Lung cancer incidence and risk factors in never-smoking Asian American, Native Hawaiian, and Pacific Islander women: A multilevel dataset of electronic health record, cancer registry, and environmental data

Background: For Asian American, Native Hawaiian, and Pacific Islander (AANHPI) females, lung cancer is one of the most common cancers and the leading cause of cancer death. More than half of AANHPI female lung cancers occur in never-smokers, and contributing risk factors among never-smokers remain largely unknown. Until now, there was no single sufficiently large data source to document lung cancer incidence rates by smoking status and sex among specific AANHPI ethnic groups, which is central to understanding and reducing the burden of this disease in this population. We assembled a large-scale cohort to quantify the burden of lung cancer by smoking status among single- and multiethnic AANHPI groups, with an emphasis on identifying the underlying factors driving lung cancer risk among never-smoking AANHPI females.

Methods: Assembly of the cohort involved (1) harmonizing and pooling electronic health record (EHR) data on known and putative lung cancer risk factors from two large health systems (i.e., Northern California Sutter Health system and Kaiser Permanente Hawaii (KPH)), (2) linking EHR data from Sutter and KPH with tumor and diagnosis data from the California Cancer Registry and Hawaii Tumor Registry, respectively, (3) geocoding and linking the Sutter portion of the cohort to regional air pollutant data and data on specific neighborhood contextual factors from the California Neighborhoods Data System, and (4) developing neighborhood contextual variables to enhance the geocoded data for KPH cohort members. Incidence rates stratified by sex, detailed race/ethnicity, smoking status, and lung cancer histology have been calculated; as well as incidence rate ratios by race/ethnicity.

Results: The cohort comprises over 2.3 million individuals (250,000 AANHPI females) followed up to 15 years for incident lung cancer. It includes over 6,000 incident lung cancer cases, of which 558 are AANHPI females. Among AANHPI female groups, proportions of lung cancers among never-smokers range from 31% among Native Hawaiian to 88% among Chinese females. Incidence rates of never-smoking lung cancer are highest among Native Hawaiian females (AAIR, 28.7) and Asian females reporting multiple races/ethnicities (AAIR, 27.8).

Conclusions: We have assembled a large, integrated dataset well suited to study multilevel risk of lung cancer that will serve as a critical evidence base to inform screening, research, and public health priorities, especially among AANHPI females. Ongoing work will include longitudinal analyses of lung cancer risk among never-smoking AANHPI females, including absolute risk modeling, examining six exposure domains representing known and putative lung cancer risk factors.

This abstract is also being presented as Poster A104.

Citation Format: Mindy C. DeRouen, Caroline Thompson, Alison J. Canchola, Anqi Jin, Siaxing Nie, Jennifer Jain, Salma Shariff-Marco, Daphne Y. Lichetensztajn, Yihe Daida, Carmen Wong, Yuqing Li, Manali I. Patel, Heather A. Wakelee, Su-Ying Liang, Beth E. Waitzfelder, Iona Cheng, Scarlett L. Gomez. Lung cancer incidence and risk factors in never-smoking Asian American, Native Hawaiian, and Pacific Islander women: A multilevel dataset of electronic health record, cancer registry, and environmental data [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr PR07.

Abstract C061: Neighborhood racial context and race- and subtype-specific breast cancer incidence among non-Hispanic Black and non-Hispanic White women in California, 2006-2015

BACKGROUND: Determinants of racial inequities in risk of subtype-specific breast cancers are poorly understood. Features of the neighborhood context may contribute to racial inequities along the breast cancer continuum, however few have examined subtype-specific incidence. Therefore, this study aimed to characterize the association between the neighborhood racial context (housing discrimination and racial composition) and race- and subtype-specific breast cancer incidence among NH Black and NH White women in California. METHODS: We merged data from the California Cancer Registry on women aged 20+ diagnosed with primary breast cancer between 2006-2015 with neighborhood racial context at time of diagnosis: census tract % NH Black and a new racial bias index derived using 2007-2013 data from the Home Mortgage Disclosure Act. We used Poisson regression to estimate associations between neighborhood racial context and race- and Luminal A and TNBC (triple-negative breast cancer)-specific incidence rates, adjusting for neighborhood confounders. RESULTS: We identified n=104,716 cases of Luminal A and n=15,739 cases of TNBC over the study period. Among Black women, living in a high % Black census tract was associated with higher incidence of Luminal A (IRRadj=1.16 (1.08, 1.24)) and TNBC (IRRadj=1.17 (1.04, 1.32)) subtypes, relative to residence in low % Black tracts. No statistically significant association between neighborhood racial composition and either subtype was observed among NH Whites, nor between racial bias in mortgage lending and breast cancer among either racial group. CONCLUSION: Neighborhood racial composition may proxy cross-cutting social and environmental risk factors for breast cancer, regardless of subtype. These exposures may disproportionately burden Black versus White women with respect to breast cancer risk.

Citation Format: Eli K. Michaels, Kirsten M.M. Beyer, Yuhong Zhou, Alison J. Canchola, Salma Shariff-Marco, Scarlett L. Gomez. Neighborhood racial context and race- and subtype-specific breast cancer incidence among non-Hispanic Black and non-Hispanic White women in California, 2006-2015 [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C061.

Abstract IA37: Lung cancer incidence and risk factors in never-smoking Asian American, Native Hawaiian, and Pacific Islander women: The development of a multilevel integrated dataset of EHR, cancer registry, and environmental data

Background: For Asian American, Native Hawaiian, and Pacific Islander (AANHPI) females, lung cancer is one of the most common cancers and the leading cause of cancer death. More than half of AANHPI female lung cancers occur in never-smokers, and contributing risk factors among never-smokers remain largely unknown. Until now, there was no single sufficiently-large data source to document lung cancer incidence rates by smoking status and sex among specific AANHPI ethnic groups, which is central to understanding and reducing the burden of this disease in this population. We assembled a large-scale cohort to quantify the burden of lung cancer by smoking status among single- and multiethnic AANHPI groups, with an emphasis on identifying the underlying factors driving lung cancer risk among never-smoking AANHPI females.

Methods: Assembly of the cohort involved (1) harmonizing and pooling electronic health record (EHR) data on known and putative lung cancer risk factors from two large health systems (i.e., Northern California Sutter Health system and Kaiser Permanente Hawaii [KPH]); (2) linking EHR data from Sutter and KPH with tumor and diagnosis data from the California Cancer Registry and Hawaii Tumor Registry, respectively; (3) geocoding and linking the Sutter portion of the cohort to regional air pollutant data and data on specific neighborhood contextual factors from the California Neighborhoods Data System; and (4) developing neighborhood contextual variables to enhance the geocoded data for KPH cohort members. Incidence rates stratified by sex, detailed race/ethnicity, and smoking status were calculated.

Results: The cohort comprises 1.8 million individuals, including 750,000 females of whom 190,000 are AANHPI females, with up to 15 years' follow-up for incident lung cancer. It includes over 24,000 incident lung cancer cases, of which 10,595 are females and over 1,500 are single- and multiethnic AANHPI females. The cohort has high representation of Asian Indian, Chinese, Japanese, Filipino, Korean, and Pacific Islander never-smoking females in addition to multiple multiethnic AANHPI ethnic groups. Ongoing analyses, including overall and histologic cell-type specific incidence rates of lung cancer by sex, race/ethnicity, and smoking status will be presented.

Conclusions: We have assembled a large, integrated dataset well suited to study multilevel risk of lung cancer that will serve as a critical evidence base to inform screening, research, and public health priorities, especially among AANHPI females. Future work will include longitudinal analyses of lung cancer risk among never-smoking AANHPI females, including absolute risk modeling, examining six exposure domains representing putative lung cancer risk factors: second-hand smoke, previous lung diseases, infections, reproductive history and hormone exposure, body size, and neighborhood environmental factors, including measures of particulate matter, traffic density, neighborhood socioeconomic status, and ethnic enclave.

Citation Format: Mindy C. DeRouen, Salma Shariff-Marco, Daphne Lichtensztajn, Anqi Jin, Yihe G. Daida, Alison J. Canchola, Yuqing Li, Jennifer Jain, Laura Allen, Sixiang Nie, Carmen Wong, Robert Haile, Manali Patel, Peggy Reynolds, Heather Wakelee, Hal Luft, Caroline Thompson, Su-Ying Liang, Beth E. Waitzfelder, Iona Cheng, Scarlett L. Gomez. Lung cancer incidence and risk factors in never-smoking Asian American, Native Hawaiian, and Pacific Islander women: The development of a multilevel integrated dataset of EHR, cancer registry, and environmental data [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr IA37.

Abstract B133: Disparities in survival by sociodemographic factors among patients with young-onset colorectal cancer: A population-based study

Background: According to the Surveillance, Epidemiology, and End Results Program, the annual percent change in colorectal cancer (CRC) incidence increased by 3.6% from 2013 to 2016 in individuals less than 50 years of age. Data on survival after young onset CRC diagnosis, including differences by sociodemographic characteristics, are lacking. We assessed differences in CRC survival according to sociodemographic factors, including race/ethnicity, sex, health insurance type, and neighborhood socioeconomic status (nSES) in patients under the age of 50 years at CRC diagnosis. Methods: The study included male and female CRC cancer cases under 50 years old, diagnosed from 2000-2015 and followed through 2016 in the California Cancer Registry. Analysis included 21,128 patients and 6,269 CRC deaths. Multivariable Cox proportional hazards regression was used to generate hazard ratios (HR) and 95% confidence intervals (CI) for risk of CRC-specific mortality. Multivariable models were stratified by American Joint Committee on Cancer (AJCC) stage (to account for hazard non-proportionality), and adjusted for age at diagnosis, year of diagnosis, race, sex, tumor size, tumor subsite, tumor grade, marital status, insurance status type, NCI-designated cancer center, nSES, neighborhood percent NH black, urban/rural, and clustering by block group. Results: Compared to non-Hispanic Whites (NHW), risk of dying from CRC was higher in Blacks (HR=1.21; 95% CI, 1.09-1.34) but not in Hispanics (HR=0.98; 95% CI, 0.92-1.05) nor Asian/Pacific Islanders (API) (HR=1.03; 95% CI, 0.96-1.11). CRC mortality was lower in female compared to male patients (HR=0.87; 95% CI, 0.83-0.92). Higher CRC mortality was observed for patients on Medicaid (HR=1.41; 95% CI, 1.31-1.50) and those with no insurance HR=1.32; 95% CI, 1.15-1.52), as compared to privately insured patients. An increase in CRC mortality associated with lower nSES was observed (HR=1.39; 95% CI, 1.25-1.54 for lowest compared to highest statewide quintile; P-trend &lt;0.0001). Conclusion: Results corroborate recent reported disparities in young-onset CRC survival between Blacks and Whites. Our findings further point to higher mortality in patients who are not privately insured and those living in lower SES neighborhoods. Further studies that integrate biological and molecular factors are needed to advance our understanding of CRC mortality in younger patients.

Citation Format: Maria Elena Martinez, Scarlett Lin Gomez, Alison J Canchola, James D Murphy, Joshua Demb, Jesse N Nodora, Samir Gupta. Disparities in survival by sociodemographic factors among patients with young-onset colorectal cancer: A population-based study [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B133.

Egocentric social networks, lifestyle behaviors, and body size in the Asian Community Health Initiative (CHI) cohort

BACKGROUND

Social networks have been shown to influence lifestyle behaviors in non-Latinx white (NLW) populations. We examined their influence in Asian American, Native Hawaiian and Pacific Islander (AANHPI) women.

METHODS

We included 477 AANHPI women from the Asian Community Health Initiative Study who provided egocentric (degree, density, composition) and epidemiologic (size, types of ties) social network data and data on alcohol intake, physical activity, smoking, diet, and body size. We used logistic regression to evaluate associations of social network measures and dichotomous outcomes, and linear regression for continuous outcomes.

RESULTS

In multivariable-adjusted analyses, higher degree and/or proportion of friends were significantly related to higher Western diet, higher odds of any alcohol consumption, and lower odds of physical inactivity and body mass index (BMI)≥23 kg/m2. Additionally, a higher proportion of NLW in women's networks was related to lower Asian diet but also lower waist size. Community participation was related to higher Western diet and lower Asian diet. By contrast, degree and/or proportion of relatives were positively related to BMI, waist size and to a higher odds of BMI≥23 kg/m2 and of ever smoking 100 cigarettes. Being married was related to fewer alcoholic drinks per week and higher Asian diet. A higher density of relationships with frequent contact was also associated with higher Asian diet.

CONCLUSIONS

AANHPI women with larger proportions of friends and NLWs in their networks had more Western health behaviors and smaller body size. Norms for health behaviors and body size may be influenced by the size, composition, and structure of social networks, relevant to chronic disease prevention.

Changes in Colorectal Cancer 5-Year Survival Disparities in California, 1997-2014

BACKGROUND

Colorectal cancer incidence and mortality have declined with increased screening and scientific advances in treatment. However, improvement in colorectal cancer outcomes has not been equal for all groups and disparities have persisted over time.

METHODS

Data from the California Cancer Registry were used to estimate changes in 5-year colorectal cancer-specific survival over three diagnostic time periods: 1997-2002, 2003-2008, and 2009-2014. Analyses included all patients in California with colorectal cancer as a first primary malignancy. Multivariable Cox proportional hazard regression models were used to evaluate the effect of race/ethnicity, insurance status, and neighborhood socioeconomic status (nSES) on 5-year colorectal cancer-specific survival.

RESULTS

On the basis of a population-based sample of 197,060 colorectal cancer cases, racial/ethnic survival disparities decreased over time among non-Hispanic Blacks (NHB) compared with non-Hispanic Whites (NHW), after adjusting for demographic, clinical, and treatment characteristics. For cases diagnosed 1997-2002, colorectal cancer-specific hazard rates were higher for NHB [HR, 1.12; 95% confidence interval (CI), 1.06-1.19] and lower for Asians/Pacific Islanders (HR, 0.92; 95% CI, 0.87-0.96) and Hispanics (HR, 0.94; 95% CI, 0.90-0.99) compared with NHW. In 2009-2014, colorectal cancer-specific HR for NHB was not significantly different to the rate observed for NHW (HR, 1.03; 95% CI, 0.97-1.10). There were no changes in disparities in nSES, but increasing disparities by health insurance status.

CONCLUSIONS

We found a decrease in survival disparities over time by race/ethnicity, but a persistence of disparities by neighborhood socioeconomic status and health insurance status.

IMPACT

Further investigation into the drivers for these disparities can help direct policy and practice toward health equity for all groups.

Urinary cadmium and timing of menarche and pubertal development in girls

BACKGROUND

Cadmium (Cd) is a developmental toxicant that is released into the environment during industrial processes. Previous animal studies suggest that Cd may impact the onset of puberty.

OBJECTIVES

To determine whether Cd exposure, measured as urinary Cd concentration, was associated with ages at menarche and pubertal development.

METHODS

A cohort of 211 girls, ages 10-13 years at baseline, was followed for up to two years. Girls completed an interview and self-assessment of Tanner stages of breast development and pubic hair growth. They were followed monthly until menarche. Urinary Cd concentrations were measured in overnight urine specimens. Multivariable Cox regression was used to evaluate the association between urinary Cd and age at menarche and cumulative logit regression was used to evaluate the associations between urinary Cd and breast development and pubic hair growth.

RESULTS

The baseline geometric mean creatinine-adjusted Cd concentration was 0.22 μg/g creatinine (geometric standard deviation = 1.6) and decreased with increasing age (p-trend = 0.04). Cd levels were higher among Asian than White girls or girls of other/mixed race/ethnicity (p = 0.04). In multivariable analyses, girls with urinary Cd ≥ 0.4 μg/L were less likely to have attained menarche than girls with urinary Cd < 0.2 μg/L (hazard ratio = 0.42; 95% confidence interval, 0.23-0.78). Urinary Cd was negatively associated with pubic hair growth (p-trend = 0.01) but not with breast development (p-trend = 0.72) at baseline.

CONCLUSIONS

These findings suggest that a higher Cd body burden may delay some aspects of pubertal development among girls.

Age-related differences in breast cancer mortality according to race/ethnicity, insurance, and socioeconomic status

BACKGROUND

We assessed breast cancer mortality in older versus younger women according to race/ethnicity, neighborhood socioeconomic status (nSES), and health insurance status.

METHODS

The study included female breast cancer cases 18 years of age and older, diagnosed between 2005 and 2015 in the California Cancer Registry. Multivariable Cox proportional hazards modeling was used to generate hazard ratios (HR) of breast cancer specific deaths and 95% confidence intervals (CI) for older (60+ years) versus younger (< 60 years) patients separately by race/ethnicity, nSES, and health insurance status.

RESULTS

Risk of dying from breast cancer was higher in older than younger patients after multivariable adjustment, which varied in magnitude by race/ethnicity (P-interaction< 0.0001). Comparing older to younger patients, higher mortality differences were shown for non-Hispanic White (HR = 1.43; 95% CI, 1.36-1.51) and Hispanic women (HR = 1.37; 95% CI, 1.26-1.50) and lower differences for non-Hispanic Blacks (HR = 1.17; 95% CI, 1.04-1.31) and Asians/Pacific Islanders (HR = 1.15; 95% CI, 1.02-1.31). HRs comparing older to younger patients varied by insurance status (P-interaction< 0.0001), with largest mortality differences observed for privately insured women (HR = 1.51; 95% CI, 1.43-1.59) and lowest in Medicaid/military/other public insurance (HR = 1.18; 95% CI, 1.10-1.26). No age differences were shown for uninsured women. HRs comparing older to younger patients were similar across nSES strata.

CONCLUSION

Our results provide evidence for the continued disparity in Black-White breast cancer mortality, which is magnified in younger women. Moreover, insurance status continues to play a role in breast cancer mortality, with uninsured women having the highest risk for breast cancer death, regardless of age.

Association of change in the neighborhood obesogenic environment with colorectal cancer risk: The Multiethnic Cohort Study

Background

Neighborhood environment has been associated with health behaviors. Despite the evidence of the influence of neighborhood social and physical factors on cancer risk, no research has evaluated whether changes in the neighborhood obesogenic environment, either by physical moves to different neighborhoods or experiencing neighborhood redevelopment or neglect, affect cancer risk.

Methods

The association of change in neighborhood environment attributes (socioeconomic status, population density, restaurant and retail food environments, numbers of recreational facilities and businesses, commute patterns, traffic density, and street connectivity) with colorectal cancer (CRC) risk was examined among 95,472 Los Angeles, CA, Multiethnic Cohort participants, including 2295 invasive CRC cases diagnosed between 1993 and 2010 using Cox proportional hazards regression, adjusting for age, race/ethnicity, other risk factors including BMI and physical activity, and baseline levels of neighborhood attributes. Stratified analyses were conducted by racial/ethnic group and moving status.

Results

40% of participants moved (changed physical residence) during follow-up. Across all races/ethnicities, upward change in population density was statistically significantly associated with higher CRC risk among male and female non-movers (HR: 1.35 and 1.41, respectively). The same association was also observed separately among female African American and Japanese American non-movers, male Latino non-movers, female African American and male White movers. Downward change in population density was significantly related to higher CRC risk among female non-movers (HR: 1.33). Downward change in traffic density was associated with lower CRC risk among male non-movers but with higher CRC risk among female movers (HR: 0.66 and 1.43, respectively). Downward changes in street connectivity or the number of recreational facilities were associated with higher CRC risk (HR: 1.34 and 1.54, respectively). Upward change in the number of recreational facilities was associated with lower CRC risk among female non-movers (HR: 0.70). Changes in the other neighborhood attributes did not exhibit significant associations with CRC risk within more than one racial/ethnic group.

Conclusion

Changes over time in neighborhood attributes have an effect on the risk of colorectal cancer, which is separate from the baseline levels of the same attributes and individual-level risk factors, and differs between sexes, movers and non-movers and across racial/ethnic groups.

•

A person's neighborhood environment can change due to physical moves or neighborhood redevelopment.

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Association of change in neighborhood environment with colorectal cancer risk was examined.

•

The California part of the Multiethnic Cohort was used for the analysis.

•

Upward change in population density was associated with higher colorectal cancer risk among non-movers.

Magnitude of reduction in risk of second contralateral breast cancer with bilateral mastectomy in patients with breast cancer: Data from California, 1998 through 2015

BACKGROUND

Increasingly, patients with breast cancer undergo bilateral mastectomy (BLM). To the authors' knowledge, the magnitude of benefit is unknown.

METHODS

The authors used data from the Surveillance, Epidemiology, and End Results (SEER) program regarding all women diagnosed with American Joint Committee on Cancer stage 0 to stage III unilateral breast cancer in California from 1998 through 2015 and treated with BLM versus breast-conserving therapy including surgery and radiotherapy (BCT) or unilateral mastectomy (ULM). The authors measured relative risks of second contralateral breast cancer (CBC) and breast cancer death using Fine and Gray multivariable regression modeling adjusted for the competing risk of death and death from another cause, respectively, and potential confounding factors. Absolute excess risk of CBC was measured as the observed minus expected number of breast cancers in the general population divided by 10,000 person-years at risk.

RESULTS

Among 245,418 patients with a median follow-up of 6.7 years, 7784 patients (3.2%) developed CBC. Relative risks were lower after BLM (hazard ratio [HR], 0.10; 95% CI, 0.07-0.14) and higher after ULM (HR, 1.07; 95% CI, 1.02-1.13) versus BCT. Absolute excess risks were higher after BCT and ULM (5.0 and 13.6 more cases, respectively) compared with BLM (28.6 fewer cases). BLM reduced risk more among older women (38.0 fewer cases for women aged ≥50 years vs 17.9 fewer cases among women aged <50 years) but provided similar risk reduction across categories of tumor grade and tumor hormone receptor status. Compared with BCT, the risk of breast cancer death was equivalent after BLM (HR, 1.03; 95% CI, 0.96-1.11) and higher after ULM (HR, 1.21; 95% CI, 1.17-1.25).

CONCLUSIONS

BLM may reduce second breast cancer risk by 34 to 43 cases per 10,000 person-years compared with other surgical procedures, but is not associated with a lower risk of death. Second breast cancers are rare, and their reduction should be weighed against the harms associated with BLM.

Trends in Cancer Survival by Health Insurance Status in California From 1997 to 2014

Importance

There have been substantial improvements in the early detection, treatment, and survival from cancer in the United States, but it is not clear to what extent patients with different types of health insurance have benefitted from these advancements.

Objective

To examine trends in cancer survival by health insurance status from January 1997 to December 2014.

Design, Setting, and Participants

California Cancer Registry (a statewide cancer surveillance system) data were used to estimate population-based survival by health insurance status in 3 calendar periods: January 1997 to December 2002, January 2003 to December 2008, and January 2009 to December 2014 with follow-up through 2014. Overall, 1 149 891 patients diagnosed with breast, prostate, colorectal, or lung cancer, or melanoma in California were included in the study.

Main Outcomes and Measures

Five-year all-cause and cancer-specific survival probabilities by insurance category and calendar period for each cancer site and sex; hazard ratios (HRs) and 95% CIs for each insurance category (none, Medicare, other public) compared with private insurance in each calendar period.

Results

According to data from 1 149 891 patients diagnosed with breast, prostate, colorectal, or lung cancer, or melanoma gathered from the California Cancer Registry, improvements in survival were almost exclusively limited to patients with private or Medicare insurance. For patients with other public or no insurance, survival was largely unchanged or declined. Relative to privately insured patients, cancer-specific mortality was higher in uninsured patients for all cancers except prostate, and disparities were largest from 2009 to 2014 for breast (HR, 1.72; 95% CI, 1.45-2.03), lung (men: HR, 1.18; 95% CI, 1.06-1.31 and women: HR, 1.32; 95% CI, 1.15-1.50), and colorectal cancer (women: HR, 1.30; 95% CI, 1.05-1.62). Mortality was also higher for patients with other public insurance for all cancers except lung, and disparities were largest from 2009 to 2014 for breast (HR, 1.25; 95% CI, 1.17-1.34), prostate (HR, 1.17; 95% CI, 1.04-1.31), and colorectal cancer (men: HR, 1.16; 95% CI, 1.08-1.23 and women: HR, 1.11; 95% CI, 1.03-1.20).

Conclusions and Relevance

After accounting for patient and clinical characteristics, survival disparities for men with prostate cancer and women with lung or colorectal cancer increased significantly over time, reflecting a lack of improvement in survival for patients with other public or no insurance. To mitigate these growing disparities, all patients with cancer need access to health insurance that covers all the necessary elements of health care, from prevention and early detection to timely treatment according to clinical guidelines.

Race/Ethnicity and Accuracy of Self-Reported Female First-Degree Family History of Breast and Other Cancers in the Northern California Breast Cancer Family Registry

BACKGROUND

Few studies have evaluated accuracy of self-reported family history of breast and other cancers in racial/ethnic minorities.

METHODS

We assessed the accuracy of cancer family history reports by women with breast cancer (probands) from the Northern California Breast Cancer Family Registry compared with 2 reference standards: personal cancer history reports by female first-degree relatives and California Cancer Registry records.

RESULTS

Probands reported breast cancer in first-degree relatives with high accuracy, but accuracy was lower for other cancers. Sensitivity (percentage correctly identifying relatives with cancer) was 93% [95% confidence interval (CI), 89.5-95.4] when compared with the relatives' self-report of breast cancer as the reference standard and varied little by proband race/ethnicity and other demographic factors, except for marginally lower sensitivity for Hispanic white probands (87.3%; 95% CI, 78.0-93.1; P = 0.07) than non-Hispanic white probands (95.1%; 95% CI, 88.9-98.0). Accuracy was also high when compared with cancer registry records as the reference standard, with a sensitivity of 95.5% (95% CI, 93.4-96.9) for breast cancer, but lower sensitivity for Hispanic white probands (91.2%; 95% CI, 84.4-95.2; P = 0.05) and probands with low English language proficiency (80%; 95% CI, 52.8-93.5; P < 0.01).

CONCLUSIONS

Non-Hispanic white, African American, and Asian American probands reported first-degree breast cancer family history with high accuracy, although sensitivity was lower for Hispanic white probands and those with low English language proficiency.

IMPACT

Self-reported family history of breast cancer in first-degree relatives is highly accurate and can be used as a reliable standard when other validation methods are not available.

Higher Breast Cancer Risk Among Immigrant Asian American Women Than Among US-Born Asian American Women

INTRODUCTION

Given rising rates of breast cancer in parts of Asia, immigrant Asian American women in the United States may have higher rates of breast cancer than previously anticipated. This study examined breast cancer risk among Asian American women by nativity and percentage of life lived in the United States, accounting for established breast cancer risk factors.

METHODS

We analyzed a breast cancer case-control data set of Asian American women living in the San Francisco Bay Area; this data set included 132 cases of women with breast cancer selected from a Surveillance, Epidemiology, and End Results cancer registry and 438 Asian American women without diagnosed breast cancer matched to cases by age and country of origin. We used logistic regression to compare 3 Asian American groups: US-born, immigrants who lived 50% or more of their life in the United States, and immigrants who lived less than 50% of their life in the United States.

RESULTS

In the minimally adjusted and fully adjusted models, both groups of immigrant Asian American women had higher risk of breast cancer than US-born Asian American women. In the fully adjusted model, compared with US-born Asian American women, immigrant Asian American women who lived more than 50% of their life in United States were on average 3 times as likely (odds ratio = 3.00; 95% confidence interval, 1.56-5.75) and immigrants who lived less than 50% of their life in United States were on average 2.46 times as likely (odds ratio = 2.46; 95% confidence interval, 1.21-4.99) to have breast cancer. We found no difference in fully adjusted odds ratios of having breast cancer between the 2 immigrant groups.

CONCLUSION

This study provides preliminary evidence that breast cancer risk among immigrant Asian American women may be higher than among their US-born counterparts.

Breast Cancer Mortality in Older and Younger Patients in California

BACKGROUND

Breast cancer in younger patients is reported to be more aggressive and associated with lower survival; however, factors associated with age-specific mortality differences have not been adequately assessed.

METHODS

We used data from the population-based California Cancer Registry for 38,509 younger (18-49 years) and 121,573 older (50 years and older) women diagnosed with stage I to III breast cancer, 2005-2014. Multivariable Cox regression models were used to estimate breast cancer-specific mortality rate ratios (MRR) and 95% confidence intervals (CI), stratified by tumor subtype, guideline treatment, and care at an NCI-designated cancer center (NCICC).

RESULTS

Older breast cancer patients at diagnosis experienced 17% higher disease-specific mortality than younger patients, after multivariable adjustment (MRR = 1.17; 95% CI, 1.11-1.23). Higher MRRs (95% CI) were observed for older versus younger patients with hormone receptor (HR)⁺/HER2^- (1.24; 1.14-1.35) and HR⁺/HER2⁺ (1.38; 1.17-1.62), but not for HR^-/HER2⁺ (HR = 0.94; 0.79-1.12) nor triple-negative breast cancers (1.01; 0.92-1.11). The higher mortality in older versus younger patients was diminished among patients who received guideline-concordant treatment (MRR = 1.06; 95% CI, 0.99-1.14) and reversed among those seen at an NCICC (MRR = 0.86; 95% CI, 0.73-1.01).

CONCLUSIONS

Although younger women tend to be diagnosed with more aggressive breast cancers, adjusting for these aggressive features results in older patients having higher mortality than younger patients, with variations by age, tumor subtype, receipt of guideline treatment, and being cared for at an NCICC.

IMPACT

Higher breast cancer mortality in older compared with younger women could partly be addressed by ensuring optimal treatment and comprehensive patient-centered care.

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

Purpose Racial/ethnic disparities in cancer survival in the United States are well documented, but the underlying causes are not well understood. We quantified the contribution of tumor, treatment, hospital, sociodemographic, and neighborhood factors to racial/ethnic survival disparities in California. Materials and Methods California Cancer Registry data were used to estimate population-based cancer-specific survival for patients diagnosed with breast, prostate, colorectal, or lung cancer between 2000 and 2013 for each racial/ethnic group (non-Hispanic black, Hispanic, Asian American and Pacific Islander, and separately each for Chinese, Japanese, and Filipino) compared with non-Hispanic whites. The percentage contribution of factors to overall racial/ethnic survival disparities was estimated from a sequence of multivariable Cox proportional hazards models. Results In baseline models, black patients had the lowest survival for all cancer sites, and Asian American and Pacific Islander patients had the highest, compared with whites. Mediation analyses suggested that stage at diagnosis had the greatest influence on overall racial/ethnic survival disparities accounting for 24% of disparities in breast cancer, 24% in prostate cancer, and 16% to 30% in colorectal cancer. Neighborhood socioeconomic status was an important factor in all cancers, but only for black and Hispanic patients. The influence of marital status on racial/ethnic disparities was stronger in men than in women. Adjustment for all covariables explained approximately half of the overall survival disparities in breast, prostate, and colorectal cancer, but it explained only 15% to 40% of disparities in lung cancer. Conclusion Overall reductions in racial/ethnic survival disparities were driven largely by reductions for black compared with white patients. Stage at diagnosis had the largest effect on racial/ethnic survival disparities, but earlier detection would not entirely eliminate them. The influences of neighborhood socioeconomic status and marital status suggest that social determinants, support mechanisms, and access to health care are important contributing factors.

Association between the neighborhood obesogenic environment and colorectal cancer risk in the Multiethnic Cohort

BACKGROUND

Information on the role of the neighborhood environment and colorectal cancer risk is limited. We investigated the association between a comprehensive suite of possible obesogenic neighborhood attributes (socioeconomic status, population density, restaurant and retail food environments, numbers of recreational facilities and businesses, commute patterns, traffic density, and street connectivity) and colorectal cancer risk in the Multiethnic Cohort Study.

METHODS

Among 81,197 eligible participants living in California (35,397 males and 45,800 females), 1973 incident cases (981 males and 992 females) of invasive colorectal cancer were identified between 1993 and 2010. Separately for males and females, multivariable Cox regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for colorectal cancer risk overall and by racial/ethnic group (African American, Japanese American, Latino, white).

RESULTS

In males, higher traffic density was associated with an increased risk of colorectal cancer (HR=1.29, 95% CI: 1.03-1.61, p=0.03, for quintile 5 vs. quintile 1; p-trend=0.06). While this association may be due to chance, this pattern was seen (albeit non-statistically significant) in all racial/ethnic groups except whites. There were no other significant associations between other neighborhood obesogenic attributes and colorectal cancer risk.

CONCLUSION

Findings from our large racial/ethnically diverse cohort suggest neighborhood obesogenic characteristics are not strongly associated with the risk of colorectal cancer.

Evaluating disease prediction models using a cohort whose covariate distribution differs from that of the target population

Personal predictive models for disease development play important roles in chronic disease prevention. The performance of these models is evaluated by applying them to the baseline covariates of participants in external cohort studies, with model predictions compared to subjects' subsequent disease incidence. However, the covariate distribution among participants in a validation cohort may differ from that of the population for which the model will be used. Since estimates of predictive model performance depend on the distribution of covariates among the subjects to which it is applied, such differences can cause misleading estimates of model performance in the target population. We propose a method for addressing this problem by weighting the cohort subjects to make their covariate distribution better match that of the target population. Simulations show that the method provides accurate estimates of model performance in the target population, while un-weighted estimates may not. We illustrate the method by applying it to evaluate an ovarian cancer prediction model targeted to US women, using cohort data from participants in the California Teachers Study. The methods can be implemented using open-source code for public use as the R-package RMAP (Risk Model Assessment Package) available at http://stanford.edu/~ggong/rmap/ .

Regular and low-dose aspirin, other non-steroidal anti-inflammatory medications and prospective risk of HER2-defined breast cancer: the California Teachers Study

BACKGROUND

Regular users of aspirin may have reduced risk of breast cancer. Few studies have addressed whether risk reduction pertains to specific breast cancer subtypes defined jointly by hormone receptor (estrogen and progesterone receptor) and human epidermal growth factor receptor 2 (HER2) expression. This study assessed the prospective risk of breast cancer (overall and by subtype) according to use of aspirin and other non-steroidal anti-inflammatory medications (NSAIDs) in a cohort of female public school professionals in California.

METHODS

In 1995 - 1996, participants in the California Teachers Study completed a baseline questionnaire on family history of cancer and other conditions, use of NSAIDs, menstrual and reproductive history, self-reported weight and height, living environment, diet, alcohol use, and physical activity. In 2005-2006, 57,164 participants provided some updated information, including use of NSAIDs and 1457 of these participants developed invasive breast cancer before January 2013. Multivariable Cox proportional hazards regression models provided hazard rate ratios (HRR) for the association between NSAID use and risk of invasive breast cancer as well as hormone receptor- and HER2-defined subtypes.

RESULTS

Developing breast cancer was associated inversely with taking three or more tablets of low-dose aspirin per week (23% of participants). Among women reporting this exposure, the HRR was 0.84 (95% confidence interval (CI) 0.72-0.98) compared to those not taking NSAIDs and this was particularly evident in women with the hormone receptor-positive/HER2-negative subtype (HRR = 0.80, 95% CI 0.66-0.96). Use of three or more tablets of "other" NSAIDs was marginally associated with lower risk of breast cancer (HRR = 0.79, 95% CI 0.62-1.00). Other associations with NSAIDs were generally null.

CONCLUSION

Our observation of reduced risk of breast cancer, among participants who took three or more tablets of low-dose aspirin weekly, is consistent with other reports looking at aspirin without differentiation by dose. This is the first report to suggest that the reduction in risk occurs for low-dose aspirin and not for regular-dose aspirin and only among women with the hormone receptor-positive/HER2-negative subtype. This preliminary study builds on previous knowledge and further supports the need for formal cancer chemoprevention studies of low-dose aspirin.

Variation in risk and outcomes of Epstein-Barr virus-associated breast cancer by epidemiologic characteristics and virus detection strategies: an exploratory study

PURPOSE

A relationship of Epstein-Barr virus (EBV) and breast cancer etiology and outcome may have clinical utility and potential to enhance understanding of tumor biology. Research to date has yielded variable results, likely reflecting differing virus detection assays and unaddressed epidemiologic heterogeneity across studies.

METHODS

Applying our novel, five-target assay detection strategy in an exploratory study, we examined demographic, clinical, and tumor characteristics, and overall survival, associated with EBV positivity in breast adenocarcinomas from 59 non-Hispanic white and 68 Hispanic women sampled by age (<50, 50+) and stage (localized, regional/remote) and examined associations based on single assay targets.

RESULTS

EBV was localized only to lymphocytes. Nevertheless, viral prevalence, although low, varied across patient subgroups. Adjusted odds ratios (OR) for EBV positivity were lower for younger Hispanic than white women (p _interaction = 0.05), and marginally higher for larger [OR (95% confidence intervals) 1.03 (1.00-1.05) per mm increase] and right-sided [2.8 (0.97-7.8)] tumors. In whites, ORs were marginally higher for larger tumors [1.04 (1.00-1.07)] and marginally lower for age 50+ [0.24 (0.06-1.03)]; in Hispanics, ORs were higher for ER negative [5.6 (1.1-30.5)], and marginally higher for right-sided, tumors [5.8 (0.94-36.2)]. Survival was suggestively poorer for EBV-positive than EBV-negative tumors in older women with localized disease. EBV associations differed across single assay targets, indicating variation in prior findings likely due to assay performance.

CONCLUSIONS

The differing EBV associations by age and race/ethnicity suggest a non-random role of EBV in breast cancer and support further study using multi-target assays, relevant epidemiologic design, and a larger study sample.

Recent declines in cancer incidence: related to the Great Recession?

PURPOSE

In recent years, cancer case counts in the U.S. underwent a large, rapid decline-an unexpected change given population growth for older persons at highest cancer risk. As these declines coincided with the Great Recession, we examined whether they were related to economic conditions.

METHODS

Using California Cancer Registry data from California's 30 most populous counties, we analyzed trends in cancer incidence during pre-recession (1996-2007) and recession/recovery (2008-2012) periods for all cancers combined and the ten most common sites. We evaluated the recession's association with rates using a multifactorial index that measured recession impact, and modeled associations between case counts and county-level unemployment rates using Poisson regression.

RESULTS

Yearly cancer incidence rate declines were greater during the recession/recovery (3.3% among males, 1.4% among females) than before (0.7 and 0.5%, respectively), particularly for prostate, lung, and colorectal cancers. Lower case counts, especially for prostate and liver cancer among males and breast cancer, melanoma, and ovarian cancer among females, were associated with higher unemployment rates, irrespective of time period, but independent of secular effects. The associations for melanoma translated up to a 3.6% decrease in cases with each 1% increase in unemployment. Incidence declines were not greater in counties with higher recession impact index.

CONCLUSIONS

Although recent declines in incidence of certain cancers are not differentially impacted by economic conditions related to the Great Recession relative to pre-recession conditions, the large recent absolute declines in the case counts of some cancer may be attributable to the large declines in unemployment in the recessionary period. This may occur through decreased engagement in preventive health behaviors, particularly for clinically less urgent cancers. Continued monitoring of trends is important to detect any rises in incidence rates as deferred diagnoses come to clinical attention.

Lifetime body size and estrogen-receptor-positive breast cancer risk in the California Teachers Study cohort

BACKGROUND

Obesity is a public health epidemic and an important breast cancer risk factor. The relationship between interrelated body measurements is complex and most studies fail to account for this complexity. We identified key aspects of body size which jointly, over the life-course (since adolescence), are associated with estrogen-receptor-positive (ER+) breast cancer risk.

METHODS

Among 109,862 women participating in the California Teachers Study cohort, 3844 were diagnosed with invasive ER+ breast cancer between 1997-1998 and December 2011. Based on validated self-reported height and weight at age 18, baseline, and 10-year follow up and waist circumference at 2-year and 10-year follow up, we identified 16 a priori body-size phenotypes. Multivariable Cox proportional hazards models provided estimates of hazard rate ratios (HR) and 95% confidence intervals (CI).

RESULTS

Premenopausal breast cancer was influenced by adolescent, but not adult, body size (HR = 0.51, 95% CI 0.31-0.86 for body mass index (BMI; kg/m2) ≥25 vs <20 at age 18). Among postmenopausal women currently using hormone therapy, only those with the greatest body size had increased breast cancer risk (HR = 1.36, 95% CI 1.13-1.64 for height ≥67 inches and adult BMI ≥25 vs height <67). Among postmenopausal women not currently using hormone therapy, the relationship between body size and risk was complex, with the largest effects of adiposity among short women. Among short women, those with gluteal adiposity (HR = 2.70, 95% CI 1.77-4.10) and those who continued to gain weight throughout adulthood (HR = 2.57, 95% CI 1.60-4.12) were at greatest risk, whereas those who had been overweight/obese since adolescence were not at increased risk (HR = 1.33, 95% CI 0.84-2.10). Height was associated with a small increased risk, with borderline statistical significance.

CONCLUSIONS

Considering absolute body mass in adolescence and at two points in adulthood, dynamic changes in adiposity over time, and body fat distribution, we identified obesity phenotypes associated with ER+ breast cancer risk. Our approach more clearly identifies specific risk groups than do analyses that evaluate similar measures separately. These findings may aid in improving risk prediction models and developing targeted interventions, and may clarify inconsistent findings across studies.

Body size over the life-course and the risk of endometrial cancer: the California Teachers Study

PURPOSE

Obesity is a public health epidemic and a major risk factor for endometrial cancer. Here, we identify key aspects of body size which jointly, over the life-course (since adolescence), are associated with endometrial cancer risk.

METHODS

Among 88,142 participants in the California Teachers Study, 887 were diagnosed with invasive type 1 endometrial cancer between 1997-1998 and 2012. Multivariable Cox proportional hazards models provided estimates of hazard rate ratios (HR) and 95% confidence intervals (CI) for endometrial cancer associated with life-course body size phenotypes, which incorporated validated measures.

RESULTS

Among women currently using hormone therapy, endometrial cancer risk was only associated with height (HR 1.78, 95% CI 1.32-2.40 for ≥67 vs. <67 inches). Among women not using hormone therapy, tall women who were overweight/obese in adolescence (HR 4.33, 95% CI 2.51-7.46) or who became overweight/obese as adults (HR 4.74, 95% CI 2.70-8.32) were at greatest risk.

CONCLUSIONS

Considering absolute body mass, changes in adiposity over time, and body fat distribution together, instead of each measure alone, we identified lifetime obesity phenotypes associated with endometrial cancer risk. These results more clearly define specific risk groups, and may explain inconsistent findings across studies, improve risk prediction models, and aid in developing targeted interventions for endometrial cancer.

Equivalent survival after nipple-sparing compared to non-nipple-sparing mastectomy: data from California, 1988-2013

PURPOSE

Nipple-sparing mastectomy, which may improve cosmesis, body image, and sexual function in comparison to non-nipple-sparing mastectomy, is increasingly used to treat early-stage breast cancer; however, long-term survival data are lacking. We evaluated survival after nipple-sparing mastectomy versus non-nipple-sparing mastectomy in a population-based cancer registry.

METHODS

We conducted an observational study using the California Cancer Registry, considering all stage 0-III breast cancers diagnosed in California from 1988 to 2013. We compared breast cancer-specific and overall survival time after nipple-sparing versus non-nipple-sparing mastectomy, using multivariable analysis.

RESULTS

Among 157,592 stage 0-III female breast cancer patients treated with unilateral mastectomy from 1988-2013, 993 (0.6 %) were reported as having nipple-sparing and 156,599 (99.4 %) non-nipple-sparing mastectomies; median follow-up was 7.9 years. The proportion of mastectomies that were nipple-sparing increased over time (1988, 0.2 %; 2013, 5.1 %) and with neighborhood socioeconomic status, and decreased with age and stage. On multivariable analysis, nipple-sparing mastectomy was associated with a lower risk of breast cancer-specific mortality compared to non-nipple-sparing mastectomy [hazard ratio (HR) 0.71, 95 % confidence interval (CI) 0.51-0.98]. However, when restricting to diagnoses 1996 or later and adjusting for a larger set of covariates, risk was attenuated (HR 0.86, 95 % CI 0.52-1.42).

CONCLUSIONS

Among California breast cancer patients diagnosed from 1988-2013, nipple-sparing mastectomy was not associated with worse survival than non-nipple-sparing mastectomy. These results may inform the decisions of patients and doctors deliberating between these surgical approaches for breast cancer treatment.

Differences in marital status and mortality by race/ethnicity and nativity among California cancer patients

BACKGROUND

It has been observed that married cancer patients have lower mortality rates than unmarried patients, but data for different racial/ethnic groups are scarce. The authors examined the risk of overall mortality associated with marital status across racial/ethnic groups and sex in data from the California Cancer Registry.

METHODS

California Cancer Registry data for all first primary invasive cancers diagnosed from 2000 through 2009 for the 10 most common sites of cancer-related death for non-Hispanic whites (NHWs), blacks, Asians/Pacific Islanders (APIs), and Hispanics were used to estimate multivariable hazard ratios (HRs) and 95% confidence intervals (CIs) for marital status in relation to overall mortality by race/ethnicity and sex. The study cohort included 393,470 male and 389,697 female cancer patients and 204,007 and 182,600 deaths from all causes, respectively, through December 31, 2012.

RESULTS

All-cause mortality was higher in unmarried patients than in married patients, but there was significant variation by race/ethnicity. Adjusted HRs (95% CIs) ranged from 1.24 (95% CI, 1.23-1.26) in NHWs to 1.11 (95% CI, 1.07-1.15) in APIs among males and from 1.17 (95% CI, 1.15-1.18) in NHWs to 1.07 (95% CI, 1.04-1.11) in APIs among females. All-cause mortality associated with unmarried status compared with married status was higher in US-born API and Hispanic men and women relative to their foreign-born counterparts.

CONCLUSIONS

For patients who have the cancers that contribute most to mortality, being unmarried is associated with worse overall survival compared with being married, with up to 24% higher mortality among NHW males but only 6% higher mortality among foreign-born Hispanic and API females. Future research should pursue the identification of factors underlying these associations to inform targeted interventions for unmarried cancer patients. Cancer 2016;122:1570-8. © 2016 American Cancer Society.

Effects of marital status and economic resources on survival after cancer: A population-based study

BACKGROUND

Although married cancer patients have more favorable survival than unmarried patients, reasons underlying this association are not fully understood. The authors evaluated the role of economic resources, including health insurance status and neighborhood socioeconomic status (nSES), in a large California cohort.

METHODS

From the California Cancer Registry, we identified 783,167 cancer patients (386,607 deaths) who were diagnosed during 2000 through 2009 with a first primary, invasive cancer of the 10 most common sites of cancer-related death for each sex and were followed through 2012. Age-stratified and stage-stratified Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for all-cause mortality associated with marital status, adjusted for cancer site, race/ethnicity, and treatment.

RESULTS

Compared with married patients, unmarried patients had an elevated risk of mortality that was higher among males (HR, 1.27; 95% CI, 1.26-1.29) than among females (HR, 1.19; 95% CI, 1.18-1.20; Pinteraction < .001). Adjustment for insurance status and nSES reduced the marital status HRs to 1.22 for males and 1.15 for females. There was some evidence of synergistic effects of marital status, insurance, and nSES, with relatively higher risks observed for unmarried status among those who were under-insured and living in high nSES areas compared with those who were under-insured and living in low nSES areas (Pinteraction = 6.8 × 10(-9) among males and 8.2 × 10(-8) among females).

CONCLUSIONS

The worse survival of unmarried than married cancer patients appears to be minimally explained by differences in economic resources. Cancer 2016;122:1618-25. © 2016 American Cancer Society.

Parity and Oral Contraceptive Use in Relation to Ovarian Cancer Risk in Older Women

BACKGROUND

Several studies have suggested that the ovarian cancer risk reductions associated with parity and oral contraceptive use are weaker in postmenopausal than premenopausal women, yet little is known about the persistence of these reductions as women age. This question gains importance with the increasing numbers of older women in the population.

METHODS

We addressed the question using data from three large U.S. cohort studies involving 310,290 white women aged 50+ years at recruitment, of whom 1,815 developed subsequent incident invasive epithelial ovarian cancer. We used Cox regression, stratified by cohort, to examine age-related trends in the HRs per full-term pregnancy and per year of oral contraceptive use.

RESULTS

The parity-associated risk reductions waned with age (Ptrend < 0.001 in HR with increasing age), particularly among women aged 75 years or more, for whom we observed no association with parity. However, we observed no such attenuation in the oral contraceptive-associated risk reductions (P = 0.79 for trend in HR with increasing age).

CONCLUSION

These findings suggest that prior oral contraceptive use is important for ovarian cancer risk assessment among women of all ages, while the benefits of parity wane as women age.

IMPACT

This information, if duplicated in other studies, will be useful to preventive counseling and risk prediction, particularly for women at increased ovarian cancer risk due to a personal history of breast cancer or a family history of ovarian cancer. Cancer Epidemiol Biomarkers Prev; 25(7); 1059-63. ©2016 AACR.

Dietary patterns and endometrial cancer risk in the California Teachers Study cohort

PURPOSE

Information on the role of dietary patterns and endometrial cancer risk is limited. We investigated whether dietary patterns are associated with endometrial cancer risk among women in the California Teachers Study cohort.

METHODS

Among 75,093 eligible women, 937 developed invasive endometrial cancer between 1995 and 2011. Multivariate Cox regression was performed to estimate relative risks (RR) and 95% confidence intervals (CI) associated with five dietary patterns identified by principal components factor analysis: "plant-based," "high protein/high fat," "high carbohydrates," "ethnic," and "salad and wine."

RESULTS

These dietary patterns were not associated with endometrial cancer risk overall (RR = 0.91, 95% CI: 0.72, 1.15 for the highest vs. lowest quintile of the "plant-based" dietary pattern) or by menopausal status and hormone therapy use.

CONCLUSIONS

Dietary patterns do not seem to be associated with endometrial cancer risk.

Abstract MP85: Mediterranean Diet and Incidence of Stroke in the California Teachers Study

Introduction: A Mediterranean diet (MeDi) has been associated with a reduced incidence of cardiovascular and neurodegenerative diseases, and overall mortality, in several prospective studies. There is limited data, however, regarding the relationship between MeDi and stroke, and in particular, stroke subtypes. We hypothesized that MeDi would be associated with reduced total, ischemic, and hemorrhagic stroke incidence.

Methods: The California Teachers Study comprises 133,478 women who enrolled in 1995 and have been continuously followed. Using linked California state hospitalization data and national death records from 1996-2011, incident strokes were identified and validated. Socio-demographic and medical risk factor data were collected from the baseline questionnaire. Diet was assessed using a food-frequency questionnaire in 113,547 women. The Mediterranean diet emphasizes plant-based foods, mono-unsaturated fats, fish and moderate alcohol intake. We used the MeDi adherence score, a nine point scale, which has been used and validated in prior studies. A higher score on the 0-9 scale represents increased adherence. Multivariable Cox proportional-hazard models adjusted for socio-demographic factors including age, ethnicity, socioeconomic status, moderate-to-strenuous physical activity, total calorie intake, body mass index, cigarette smoking, menopausal and hormonal status and vascular risk factors were used to assess the association (hazard ratios and 95% confidence intervals, HR 95% CI) between MeDi score and risk of stroke and stroke subtypes.

Results: A total of 104,268 participants were eligible for the analysis (mean age 52 ± 13.9 years, 87.4% white, 4.6% Hispanic, 3.2% Asian and 2.1% black). The MeDi score distribution was: 0-2 (16.1%), 3 (18.2%), 4 (21.4%), 5 (20.1%), and 6-9 (24.3%). During follow-up, 3165 stroke events occurred (2270 ischemic ; 895 hemorrhagic). In the multivariable model, compared to those in the lowest MeDi score quintile (score 0-2), those in the fourth quintile (score 5: HR 0.86, 95% CI 0.75-0.98) and highest quintile (score 6 - 9: HR 0.83, 95% CI 0.73-0.95) were at lower risk of stroke (p for trend 0.009). For ischemic stroke, those in the third (HR 0.84, 95% CI 0.72-0.97), fourth (0.85, 95% CI 0.73-0.98), and highest quintile (HR 0.82, 95% CI 0.70-0.95) were all at reduced risk (p for trend 0.02). There was no association with hemorrhagic stroke.

Discussion:

Adherence to the Mediterranean diet is associated with decreased risk of total and ischemic stroke incidence among the participants of the California Teachers Study.

Dietary patterns and breast cancer risk in the California Teachers Study cohort

BACKGROUND

Evidence that diet is associated with breast cancer risk is inconsistent. Most studies have examined risks associated with specific foods and nutrients, rather than measures of overall diet.

OBJECTIVE

This study aimed to evaluate dietary patterns and their relation to breast cancer risk in a large cohort of women.

DESIGN

Data from 91,779 women in the California Teachers Study cohort were analyzed, including data from 4140 women with a diagnosis of invasive breast cancer made between 1995 and 2009. Five predominant dietary patterns were identified by using principal components factor analysis: a plant-based diet, high in fruit and vegetables; a high-protein, high-fat diet, high in meats, eggs, fried foods, and high-fat condiments; a high-carbohydrate diet, high in convenience foods, pasta, and bread products; an ethnic diet, high in legumes, soy-based foods, rice, and dark-green leafy vegetables; and a salad and wine diet, high in lettuce, fish, wine, low-fat salad dressing, and coffee and tea.

RESULTS

The plant-based pattern was associated with a reduction in breast cancer risk (RR: 0.85; 95% CI: 0.76, 0.95 for the highest compared with the lowest consumption quintile; P-trend = 0.003); risk reduction was greater for estrogen receptor-negative progesterone receptor-negative (ER-PR-) tumors (RR: 0.66; 95% CI: 0.48, 0.91; P-trend = 0.03). The salad and wine pattern was associated with an increased risk of estrogen receptor-positive progesterone receptor-positive tumors (RR: 1.29; 95% CI: 1.12, 1.49); this effect was only slightly attenuated after adjustment for alcohol consumption.

CONCLUSION

The finding that greater consumption of a plant-based dietary pattern is associated with a reduced breast cancer risk, particularly for ER-PR- tumors, offers a potential avenue for prevention.

Determinants and within-person variability of urinary cadmium concentrations among women in northern California

BACKGROUND

Cadmium (Cd) is a toxic metal associated with increased morbidity and mortality. Urinary Cd (U-Cd) concentration is considered a biomarker of long-term exposure.

OBJECTIVES

Our objectives were to evaluate the within-person correlation among repeat samples and to identify predictors of U-Cd concentrations.

METHODS

U-Cd concentrations (micrograms per liter) were measured in 24-hr urine samples collected from 296 women enrolled in the California Teachers Study in 2000 and a second 24-hr sample collected 3-9 months later from 141 of the participants. Lifestyle and sociodemographic characteristics were obtained via questionnaires. The Total Diet Study database was used to quantify dietary cadmium intake based on a food frequency questionnaire. We estimated environmental cadmium emissions near participants' residences using a geographic information system.

RESULTS

The geometric mean U-Cd concentration was 0.27 µg/L and the range was 0.1-3.6 µg/L. The intraclass correlation among repeat samples from an individual was 0.50. The use of a single 24-hr urine specimen to characterize Cd exposure in a case-control study would result in an observed odds ratio of 1.4 for a true odds ratio of 2.0. U-Cd concentration increased with creatinine, age, and lifetime pack-years of smoking among ever smokers or lifetime intensity-years of passive smoking among nonsmokers, whereas it decreased with greater alcohol consumption and number of previous pregnancies. These factors explained 42-44% of the variability in U-Cd concentrations.

CONCLUSION

U-Cd levels varied with several individual characteristics, and a single measurement of U-Cd in a 24-hr sample did not accurately reflect medium- to long-term body burden.