Association Between Sleep Apnea Treatment and Health Care Resource Use in Patients With Atrial Fibrillation

BACKGROUND

Obstructive sleep apnea (OSA) contributes to the generation, recurrence, and perpetuation of atrial fibrillation, and it is associated with worse outcomes. Little is known about the economic impact of OSA therapy in atrial fibrillation. This retrospective cohort study assessed the impact of positive airway pressure (PAP) therapy adherence on health care resource use and costs in patients with OSA and atrial fibrillation.

METHODS AND RESULTS

Insurance claims data for ≥1 year before sleep testing and 2 years after device setup were linked with objective PAP therapy use data. PAP adherence was defined from an extension of the US Medicare 90-day definition. Inverse probability of treatment weighting was used to create covariate-balanced PAP adherence groups to mitigate confounding. Of 5867 patients (32% women; mean age, 62.7 years), 41% were adherent, 38% were intermediate, and 21% were nonadherent. Mean±SD number of all-cause emergency department visits (0.61±1.21 versus 0.77±1.55 [P=0.023] versus 0.95±1.90 [P<0.001]), all-cause hospitalizations (0.19±0.69 versus 0.24±0.72 [P=0.002] versus 0.34±1.16 [P<0.001]), and cardiac-related hospitalizations (0.06±0.26 versus 0.09±0.41 [P=0.023] versus 0.10±0.44 [P=0.004]) were significantly lower in adherent versus intermediate and nonadherent patients, as were all-cause inpatient costs ($2200±$8054 versus $3274±$12 065 [P=0.002] versus $4483±$16 499 [P<0.001]). All-cause emergency department costs were significantly lower in adherent and intermediate versus nonadherent patients ($499±$1229 and $563±$1292 versus $691±$1652 [P<0.001 and P=0.002], respectively).

CONCLUSIONS

These data suggest clinical and economic benefits of PAP therapy in patients with concomitant OSA and atrial fibrillation. This supports the value of diagnosing and managing OSA and highlights the need for strategies to enhance PAP adherence in this population.

Performance of Claims-Based Algorithms for Adherence to Positive Airway Pressure Therapy in Commercially Insured Patients With OSA

BACKGROUND

Positive airway pressure (PAP) therapy is first-line therapy for OSA, but consistent use is required for it to be effective. Previous studies have used Medicare fee-for-service claims data (eg, device, equipment charges) as a proxy for PAP adherence to assess its effects. However, this approach has not been validated in a US commercially insured population, where coverage rules are not standardized.

RESEARCH QUESTION

In a commercially insured population in the United States, how well do claims-based algorithms for defining PAP adherence correspond with objective PAP device usage?

STUDY DESIGN AND METHODS

Deidentified administrative claims data of commercially insured patients (aged 18-64 years) with OSA were linked to objective PAP therapy usage data from cloud-connected devices. Adherence was defined based on device use (using an extension of Centers for Medicare & Medicaid Services 90-day compliance criteria) and from claims-based algorithms to compare usage metrics and identify potential misclassifications.

RESULTS

The final sample included 213,341 patients. Based on device usage, 48% were adherent in the first year. Based on claims, between 10% and 84% of patients were identified as adherent (accuracy, sensitivity, and specificity ranges: 53%-68%, 12%-95%, and 26%-92%, respectively). Relative to patients who were claims-adherent, patients who were device-adherent had consistently higher usage across all metrics (mean, 339.9 vs 260.0-290.0 days of use; 6.6 vs 5.1-5.6 d/wk; 6.4 vs 4.6-5.2 h/d). Consistent PAP users were frequently identified by claims-based algorithms as nonadherent, whereas many inconsistent users were classified by claims-based algorithms as adherent.

INTERPRETATION

In aggregate US commercial data with nonstandardized PAP coverage rules, concordance between existing claims-based definitions and objective PAP use was low. Caution is warranted when applying existing claims-based algorithms to commercial populations.

Healthcare resource utilisation and costs in patients with treated obstructive sleep apnea

Obstructive sleep apnea (OSA) is a highly prevalent yet underdiagnosed disease that creates a large economic burden on the United States healthcare system. In this retrospective study, we tested the hypothesis that adherence to positive airway pressure (PAP) therapy, the 'gold standard' treatment for OSA, is associated with reduced healthcare resource utilisation and costs. We linked de-identified payer-sourced medical claims and objective PAP usage data for patients newly diagnosed with OSA. Inverse probability of treatment weighting was used to create balanced groups of patients who were either adherent, intermediately adherent, or non-adherent to PAP therapy. From a sample of 179,542 patients (average age 52.5 years, 61% male), 37% were adherent, 40% intermediate, and 23% non-adherent. During the first year, PAP adherence was significantly associated with fewer emergency room visits (mean [SD] adherent: 0.39 [1.20] versus intermediate: 0.47 [1.30], p < 0.001; versus non-adherent: 0.54 [1.44], p < 0.001), all-cause hospitalisations (mean [SD] adherent: 0.09 [0.43] versus intermediate: 0.12 [0.51], p < 0.001; versus non-adherent: 0.13 [0.55], p < 0.001), and lower total costs (mean [SD] adherent $5874 [8045] versus intermediate $6523 [9759], p < 0.001; versus non-adherent $6355 [10,517], p < 0.001). Results were similar in the second year of PAP use. These results provide additional evidence from a large, diverse sample to support the diagnosis and treatment of OSA and encourage long-term adherence to PAP therapy.

Blood inflammatory markers and mortality in the US population: A Health and Retirement Survey (HRS) analysis

A potential direct correlation between systemic inflammation and physiological aging has been suggested, along with whether there is a higher expression of inflammatory markers in otherwise healthy older adults. Cross-sectional data were extracted from the publicly available 2016 Health and Retirement Survey, a nationally representative survey of older adults in the United States. A subset of participants (n = 9934) consented to a blood draw at the time of recruitment and were measured for high sensitivity C-reactive protein (hs-CRP), Interleukin (IL-6, IL-10, IL-1RA), soluble tumor necrosis factor receptor (sTNFR-1) and transforming growth factor beta 1 (TGF-β1). We included 9,188 participants, representative of 83,939,225 nationally. After adjusting for sex and the number of comorbidities, there remained a significant positive correlation between age and ln (log adjusted) IL-6, and ln sTNFR-1, and a significant inverse correlation between age and ln IL-1RA, ln TGF-β1, and ln hs-CRP. Among the subset of participants who reported none of the available comorbidities (n = 971), there remained an independent correlation of age with ln IL-6 and ln sTNFR-1. After adjusting for age, sex, and number of reported comorbidities, there was a statistically significant correlation between increased ln IL-6, ln IL-10, ln sTNFR-1, and ln hs-CRP with death. This study highlights the existence of a correlation between serum biomarkers of inflammation and aging, not only in the whole population, but also in the smaller subset who reported no comorbidities, confirming the existence of a presence of low-grade inflammation in aging, even in healthy elders. We also highlight the existence of a correlation between inflammatory markers and overall mortality. Future studies should address a possible threshold of systemic inflammation where mortality significantly increases, as well as explore the effectiveness of anti-inflammatory treatments on morbidity and mortality in healthy aging subjects.

Effect of stage shift and immunotherapy treatment on lung cancer survival outcomes

OBJECTIVES

Non-small-cell lung cancer mortality has declined at a faster rate than incidence due to multiple factors, including changes in smoking behaviour, early detection which shifts diagnosis, and novel therapies. Limited resources require that we quantify the contribution of early detection versus novel therapies in improving lung cancer survival outcomes.

METHODS

Non-small-cell lung cancer patients from the Surveillance, Epidemiology, and End Results-Medicare data were queried and divided into: (i) stage IV diagnosed in 2015 (n = 3774) and (ii) stage I-III diagnosed in 2010-2012 (n = 15 817). Multivariable Cox-proportional hazards models were performed to assess the independent association of immunotherapy or diagnosis at stage I/II versus III with survival.

RESULTS

Patients treated with immunotherapy had significantly better survival than those who did not (HRadj: 0.49, 95% confidence interval: 0.43-0.56), as did those diagnosed at stage I/II versus stage III (HRadj: 0.36, 95% confidence interval: 0.35-0.37). Patients on immunotherapy had a 10.7-month longer survival than those who were not. Stage I/II patients had an average survival benefit of 34 months, compared to stage III. If 25%% of stage IV patients not on immunotherapy received it, there would be a gain of 22 292 person-years survival per 100 000 diagnoses. A switch of only 25% from stage III to stage I/II would correspond to 70 833 person-years survival per 100 000 diagnoses.

CONCLUSIONS

In this cohort study, earlier stage at diagnosis contributed to life expectancy by almost 3 years, while gains from immunotherapy would contribute ½ year of survival. Given the relative affordability of early detection, risk reduction through increased screening should be optimized.

Personal and clinical characteristics associated with immunotherapy effectiveness in stage IV non-small cell lung cancer

Background

Immunotherapy response rates in metastatic non-small cell lung cancer (NSCLC) are low and survival varies significantly. Factors like age, sex, race, and histology may modulate immunotherapy response. Existing analyses are limited to clinical trials, with limited generalizability, and meta-analyses where adjustment for potential confounders cannot be performed. Here, we conduct a cohort study with patient-level analysis to explore how personal and clinical characteristics moderate chemoimmunotherapy effectiveness in metastatic NSCLC.

Methods

Stage IV NSCLC patients diagnosed in 2015 were drawn from Surveillance Epidemiology, and End Results-Medicare linked data. Receipt of chemoimmunotherapy and overall survival (OS) were the primary predictor and outcome of interest respectively. Multivariable Cox-proportional hazards regression and propensity-score matching were performed to evaluate the effectiveness of immunotherapy addition to chemotherapy.

Results

From a total of 1,471 patients, 349 (24%) received chemoimmunotherapy and 1,122 (76%) received chemotherapy alone. Survival was significantly better among those treated with chemoimmunotherapy compared to those receiving chemotherapy alone [adjusted hazard ratio (HR_adj) =0.72, 95% confidence interval (CI): 0.63-0.83]. Males saw significantly better OS from chemoimmunotherapy (HR_adj =0.62, 95% CI: 0.51-0.75) than females (HR_adj =0.81, 95% CI: 0.65-1.01, P_interaction=0.0557). After propensity-score matching, the effect of chemoimmunotherapy was borderline significant according to sex (P_interaction =0.0414), but not age or histology.

Conclusions

Males may benefit more from chemoimmunotherapy, but there is limited evidence suggesting age, histology, race, and comorbidities contribute to differences in effectiveness. Future research should elucidate who responds best to chemoimmunotherapy, and further analyses of characteristics like race can inform how to tailor different treatment regimens to distinct patient subpopulations.

Trends in prostate cancer incidence among Black men in the Caribbean and the United States

BACKGROUND

Prostate cancer incidence is highest for Black men of the African diaspora in the United States and Caribbean. Recent changes in recommendations for prostate cancer screening have been shown to decrease overall prostate cancer incidence and increase the likelihood of late stage disease. However, it is unclear how trends in prostate cancer characteristics among high risk Black men differ by geographic region during the changes in screening recommendations.

METHODS

In this study, we used population-based prostate cancer registry data to describe age-adjusted prostate cancer incidence trends from 2008 to 2015 among Black men from six geographic regions. We obtained data on incident Black prostate cancer patients from six cancer registries (in the United States: Florida, Alabama, Pennsylvania, and New York; and in the Caribbean: Guadeloupe and Martinique). After age standardization, we used descriptive analyses to compare the demographics and tumor characteristics by cancer registry site. The Joinpoint regression program was used to compare the trends in incidence by site.

RESULTS

A total of 59,246 men were analyzed. We found the highest incidence rates (per 100,000) for prostate cancer in the Caribbean countries (181.99 in Martinique and 176.62 in Guadeloupe) and New York state (178.74). Incidence trends decreased significantly over time at all sites except Martinique, which also showed significantly increasing rates of late stage (III/IV) and Gleason score 7+ tumors.

CONCLUSIONS

We observed significant differences in prostate cancer incidence trends among Black men after major changes prostate screening recommendations. Future studies will examine the factors that differentially influence prostate cancer trends among the African diaspora.

Malignant pleural mesothelioma characteristics and outcomes: A SEER-Medicare analysis

BACKGROUND

Pleural mesothelioma is rare cancer linked to asbestos exposure. Previous research has indicated that female individuals have better survival than male individuals, but this has never been examined in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database.

MATERIALS AND METHODS

Malignant pleural mesothelioma cases diagnosed from 1992 to 2015 were queried from the linked SEER-Medicare database. Multivariable logistic regression was used to assess the clinical and demographic factors associated with sex. A multivariable Cox proportional hazards model and propensity matching methods were used to assess sex differences in overall survival (OS) while accounting for potential confounders.

RESULTS

Among 4201 patients included in the analysis, 3340 (79.5%) were males and 861 (20.5%) females. Females were significantly older, with more epithelial histology than males were, and had significantly better OS, adjusted for confounders (adjusted hazard ratio, 0.83, 95% confidence interval: 0.76-0.90). Other variables independently associated with improved survival included younger age at diagnosis, having a spouse/domestic partner, epithelial histology, lower comorbidity score, and receipt of surgery or chemotherapy.

CONCLUSIONS

The study describes sex differences in mesothelioma occurrence, treatment, and survival and is the first to examine SEER-Medicare. It provides directions for future research into potential therapeutic targets.

The Scan, the Needle, or the Knife? National Trends in Diagnosing Stage I Lung Cancer

OBJECTIVE

Indeterminate lung nodules have been increasingly discovered since the expansion of lung cancer screening programs. The diagnostic approach for suspicious nodules varies based on institutional resources and preferences. The aim of this study is to analyze factors associated with diagnostic modalities used for early-stage non-small cell lung cancer (NSCLC).

METHODS

The National Cancer Database was queried for all patients with stage I NSCLC from 2004 to 2015. Four diagnostic modalities were identified, including clinical radiography alone (CRA), bronchial cytology (BC), procedural biopsy (PB), and surgical biopsy (SB). A multivariable multinomial logistic regression was used to assess associations of patient demographics, cancer characteristics, and facility characteristics with these modalities.

RESULTS

Of 250,614 patients, 4,233 (1.7%) had CRA, 5,226 (2.1%) had BC, 147,621 (59.9%) had PB, and 93,534 (37.3%) had SB. Older patients were more likely to receive CRA (adjusted odds ratio [ORadj] = 5.3) and less likely to receive SB (ORadj = 0.73). Black patients were less likely to receive SB (ORadj = 0.83) and more likely to receive BC (ORadj = 1.31). Private insurance was associated with SB (ORadj = 1.11), whereas Medicaid was associated with BC (ORadj = 1.21). Patients more than 50 miles from the facility were more likely to undergo SB (ORadj = 1.25 vs PB; ORadj = 1.30 vs CRA; ORadj = 1.38 vs BC). Patients receiving SB had shorter days from diagnosis to treatment (23.0 vs 53.5 to 64.7 for other modalities, P < 0.001).

CONCLUSIONS

Diagnostic SB to confirm early-stage NSCLC was associated with younger age, greater travel distance, and shorter time to treatment in comparison with other modalities. Black race and non-private insurance were less likely to be associated with SB.

Methodological Considerations on COVID-19 Mortality in Cancer Patients: A Systematic Review and Meta-Analysis

Background

Patients with cancer are at risk for severe COVID-19. Previous studies examining mortality in cancer patients with COVID-19 have produced inconclusive results. Several published meta-analyses have aimed to estimate this association; however, because of methodological limitations in study selection and data aggregation, these studies do not reliably estimate the independent association between cancer and COVID-19 mortality. We conducted this systematic review and meta-analysis to determine whether cancer is an independent risk factor for COVID-19 mortality.

Methods

A literature search was performed in PubMed to identify studies that compared COVID-19 mortality in adult patients with and without cancer. Selection criteria included polymerase chain reaction–confirmed COVID-19, multivariate adjustment and/or matching for mortality risk estimates, and inclusion of hospitalized noncancer controls. Adjusted odds ratios and/or hazard ratios for mortality based on cancer status were extracted. Odds ratio and hazard ratio estimates were pooled using a random effects model.

Results

The analysis included 42 studies comprising 129 840 patients: 8612 cancer patients and 121 228 noncancer patients. Of these studies, 18 showed a null difference in survival between cancer and noncancer patients with COVID-19, and 24 studies showed statistically significantly worse survival in cancer patients with COVID-19. Meta-analysis revealed an increased risk of mortality in patients with cancer compared with noncancer patients with COVID-19 (odds ratio = 1.93, 95% confidence interval = 1.55 to 2.41; hazard ratio = 1.54, 95% confidence interval = 1.29 to 1.84).

Conclusion

We conclude that cancer is an independent risk factor for mortality in unvaccinated patients admitted for or diagnosed with COVID-19 during hospitalization.

Global DNA methylation of WTC prostate cancer tissues show signature differences compared to non-exposed cases

There is increased incidence of prostate cancer (PC) among World Trade Center (WTC)-exposed responders and community members, with preliminary evidence suggestive of more aggressive disease. While previous research is supportive of differences in DNA methylation and gene expression as a consequence of WTC exposure, as measured in blood of healthy individuals, the epigenetics of WTC PC tissues has yet to be explored. Patients were recruited from the World Trade Center Health Program. Non-WTC PC samples were frequency matched on age, race/ethnicity and Gleason score. Bisulfite-treated DNA was extracted from tumor tissue blocks and used to assess global DNA methylation with the MethylationEPIC BeadChip. Differential and pathway enrichment analyses were conducted. RNA from the same tumor blocks was used for gene expression analysis to further support DNA methylation findings. Methylation data were generated for 28 samples (13 WTC and 15 non-WTC). Statistically significant differences in methylation were observed for 3,586 genes; on average WTC samples were statistically significantly more hypermethylated (P = 0.04131). Pathway enrichment analysis revealed hypermethylation in epithelial mesenchymal transition (EMT), hypoxia, mitotic spindle, TNFA signaling via NFKB, WNT signaling, and TGF beta signaling pathways in WTC compared to non-WTC samples. The androgen response, G2M and MYC target pathways were hypomethylated. These results correlated well with RNA gene expression. In conclusion, long-term epigenic changes associated with WTC dust exposure were observed in PC tissues. These occurred in genes of critical pathways, likely increasing prostate tumorigenesis potential. This warrants analysis of larger WTC groups and other cancer types.

Ecologic study of influenza vaccination uptake and COVID-19 death rate in New York City

BACKGROUND

The aim of this ecological study was to assess the area-level relationship between cumulative death rate for COVID-19 and historic influenza vaccination uptake in the New York City population.

METHODS

Predictors of COVID-19 death included self-reported influenza vaccination in 2017, as well as four CDC-defined risk factors of severe COVID-19 infection available at the ecological level, which were diabetes, asthma, BMI 30-100 (2 kg/m2) and hypertension, in addition to race and age (65 + years).

RESULTS

After adjusting for potential confounders, for every one-unit increase in influenza vaccination uptake for each zip code area, the rate of COVID-19 deaths decreased by 5.17 per 100,000 residents (p < 0.0001).

CONCLUSIONS

Zip codes with a higher prevalence of influenza vaccination had lower rates of COVID-19 mortality, inciting the need to further explore the relationship between influenza vaccination uptake and COVID-19 mortality at the individual level.

High-risk non-16 human papillomavirus genotypes in head and neck squamous cell carcinoma

e18052

Background: Oropharyngeal cancer patients with Human Papillomavirus (HPV)-associated disease have more favorable outcomes. HPV16 is the primary genotype in this population. Our knowledge of the impact of high-risk non-16 HPV (HRN16) subtypes on survival is limited. The objective of this study is to investigate the incidence, demographics, and survival outcomes of HRN16 genotypes in patients with HPV-positive head and neck squamous cell carcinoma (HNSCC). Methods: This is a retrospective chart review of patients diagnosed with HPV+ HNSCC from 2012-2021 at the Mount Sinai Health System. Genotyping was performed with polymerase chain reaction (PCR). Demographic, clinical and tumor data was extracted from electronic medical records.The primary outcomes are overall survival (OS) and event-free survival (EFS) for patients with non-metastatic disease at presentation, treated with curative-intent, with > 6 months follow-up.Survival analysis was performed by Kaplan-Meier method. Results: 733 patients had HPV+ HNSCC, and 109 (14.9%) are HRN16 subtypes. Mean age at diagnosis is 62.4 years. Most individuals are non-Hispanic white males, non-active smokers, social drinkers, and have good performance status (Table). A majority has non-metastatic oropharyngeal cancer treated with standard of care (SOC) definitive therapy. The predominate genotypes are HPV35 (39.4%, n = 41), HPV33 (27.9%, n = 29), and HPV18 (14.4%, n = 15). Survival analysis demonstrated no significant differences in OS (log-rank p = 0.90) and EFS (log-rank p = 0.19) among the different HRN16 subtypes. There was a trend for better EFS for HPV35. Conclusions: HRN16 genotype may not meaningfully impact patient outcomes in HNSCC. Larger multivariate analyses may identify specific site and genotype differences in survival comparedwith HPV16-assoicated disease and indicate if patients with selected HRN16 subtypes are candidates for treatment de-escalation.[Table: see text]

A national profile of health-focused caregiving activities prior to a new cancer diagnosis

BACKGROUND

Little is known about how unpaid family caregivers may already be engaged in caregiving activities prior to their care recipient's cancer diagnosis. We examined pre-cancer diagnosis caregiving patterns and their association with caregiving strain.

METHODS

We conducted a population-based analysis of 2011-2017 National Health and Aging Trends Study (NHATS) linked with the National Study of Caregiving (NSOC) and Medicare claims data. Latent class analysis was used to examine patterns of 16 health-focused caregiving tasks (e.g., tracking medications, making appointments) of family caregivers assisting adults ≥65 years prior to an incident cancer diagnosis. High caregiving strain was defined as a total score ≥ 85th percentile of 6 caregiving strain items (e.g., financial difficulty, no time for self). Association between caregiving patterns and strain were examined using multivariable logistic regression, adjusting for care recipient and caregiver characteristics.

RESULTS

An estimated 4.2 million caregivers cared for older adults prior to care recipients' new cancer diagnoses during 2011-2017. They engaged in a median of four health-focused caregiving activities. Nearly 1-in-5 (18.7%) pre-cancer caregivers had high caregiving strain. Caregivers were classified into 3 health-focused caregiving activity classes: Low-level (41.2%), Moderate-coordination (29.3%), and High-intensity (29.4%). Higher caregiving activity was associated with higher caregiving strain (adjusted odds ratio (aOR) = 3.85, 95% CI: 2.34-6.33). Caregivers in the High-intensity class had the highest caregiving strain (39.9%), and included more spouses (28.1% vs <18%).

CONCLUSION

One-third of U.S. caregivers who help older adults prior to their cancer diagnoses are already highly strained and engaged in high-level health-focused caregiving tasks. Oncology clinicians should assess the capacity and strain of family caregivers who may already be supporting patients with new cancer diagnoses and refer caregivers to additional supportive care services.

Disparities in clinical and demographic characteristics among Asian/Pacific Islander and Non-Hispanic White newly diagnosed lung cancer patients

PURPOSE

Racial disparities persist among lung cancer patients but have not been adequately studied among Asian/Pacific Islander (API) subgroups, which are heterogeneous. This study compared clinical and demographic characteristics at diagnosis of API subgroups and NHW patients.

METHODS

NHW and API adults diagnosed with lung cancer were identified from the Surveillance, Epidemiology, and End Results database (1990-2015). API was divided into eight subgroups: Chinese, Japanese, Filipino, Hawaiian/Pacific Islander, Korean, Vietnamese, Asian Indian/Pakistani, and Other. Multivariable multinomial logistic regression models were used to assess adjusted associations of clinical and demographic factors with API/subgroups.

RESULTS

There were 522,702 (92.6%) NHW and 41,479 (7.4%) API lung cancer patients. API were less likely to be diagnosed at the age of ≥ 80 years (OR_adj 0.53, 95% CI 0.48-0.58 for ≥ 80 vs. ≤ 39 years) than NHW. However, Japanese patients were more often diagnosed at ≥ 80 years compared to other ethnic subgroups. API were less often female (OR_adj 0.85, 95% CI 0.83-0.86), and unmarried (OR_adj 0.71, 95% CI 0.68-0.74); however, among API, Japanese, Hawaiian/Pacific Islander, Korean, and Vietnamese were more often unmarried, compared to Chinese patients. API were more frequently diagnosed at stage IV, compared to stage I (OR_adj 1.31, 95% CI 1.27-1.35). API had significantly less squamous cell carcinoma (OR_adj 0.54, 95% CI 0.52-0.56, compared to adenocarcinoma); among API, Japanese, Filipino, Hawaiian/Pacific Islander, Korean, Asian Indian/Pakistani, and Other were more likely than Chinese patients to present with squamous cell histology (range: OR_adj[Other] 1.24, 95% CI 1.09-1.41; OR_adj[Hawaiian/Pacific Islander] 2.47, 95% CI 2.22-2.75).

CONCLUSION

At diagnosis, there are significant differences in demographic and clinical characteristics between NHW, API, and API subgroups. Treating API patients as a single population may overlook biological, environmental, and behavioral differences that might be beneficial in designing prevention strategies and treatment.

Trends for In- and Outpatient Thyroid Cancer Surgery in Older Adults in New York State, 2007-2017

BACKGROUND

In view of the 2013 American Thyroid Association consensus statement on outpatient thyroidectomy, the present study assessed the trends and factors associated with thyroid cancer surgery setting in older adults, using the New York Statewide Planning and Research Cooperative System database.

MATERIALS AND METHODS

There were 14,495 patients with surgically treated thyroid cancer in New York State between 2007 and 2017. Trends were plotted over time and stratified by surgery type. Significance of the trend was assessed using the Mann-Kendall test. Multivariable logistic regression was used to assess independent associations with surgical setting.

RESULTS

The overall outpatient surgery rate significantly increased over time (correlation coefficient 0.82; P < 0.001), for both total thyroidectomy (P < 0.001) and lobectomy (P < 0.001). Factors associated with increased odds of inpatient surgery were medium- and high-volume hospitalization (adjusted odds ratio [OR_adj] 2.12, 95% confidence interval [CI] 1.93-2.32; OR_adj 1.69, 95% CI 1.55-1.85, respectively) versus low volume, undergoing total thyroidectomy (OR_adj 1.75, 95% CI 1.61-1.90), as well as having Medicare insurance (OR_adj 1.13, 95% CI 1.02-1.24) versus private insurance.

CONCLUSIONS

The present study shows that outpatient thyroidectomy is increasingly favored over inpatient thyroidectomy over time in an older patient population. A clear changepoint following 2011 preceded the publication of the American Thyroid Association statement on outpatient thyroidectomy in 2013 and was likely associated with multiple publications reporting safety of outpatient thyroid surgery and clear economic benefits.

OUP accepted manuscript

Background

Although immunotherapy can increase survival in non-small cell lung cancer (NSCLC), response rates are low. It is unclear which characteristics contribute to variability in immunotherapy efficacy and survival. Research is needed to identify reasons for heterogeneity in response rates to better tailor treatments.

Methods

Web of Science, Ovid EMBASE, and MEDLINE were queried from 2013 to January 2021, and all studies reporting overall or progression-free survival for patients treated with immunotherapy for NSCLC of at least stage IIIB were screened.

Results

Included were 18 randomized controlled trials (RCTs; 6534 immunotherapy RCTs; 11 192 nonimmunotherapy RCTs) and 16 observational studies (n = 9073 immunotherapy patients). Among RCTs, there was improved survival with the addition of immunotherapy in patients aged younger than 65 years in 10 of 17 studies; smokers in 8 of 15 studies; and males in 10 of 17 studies and 6 of 17 females. Only 5 studies reported outcomes by race. Among observational studies, younger patients (aged younger than 60, younger than 65, or younger than 70 years in most studies) had better survival than older patients (aged 60 years and older, 65 years and older, or 70 years and older) in 4 of 13 studies, ever-smokers in 7 of 13, and females in 2 of 14. Three studies reported race with mixed results.

Conclusion

Although evidence is mixed, younger patients, smokers, and males may derive more benefit from immunotherapy. Evidence on racial differences is limited. Physicians should be mindful of personal characteristics when formulating treatment plans. Further research is needed to understand underlying mechanisms and to identify the best immunotherapy candidates and alternative treatments for those unlikely to benefit.

Age-Related Differences in Clinical and Psychosocial Predictors of Unmet Needs in Bladder Cancer Survivors

Understanding of unmet needs and their predictors among bladder cancer (BC) survivors is critical to optimize health care planning for patients. This study compares between younger (<65 Years) and older (≥65 Years) BC patients across seven domains of unmet needs (e.g., informational, psychological, supportive care, daily living, communication, logistic, and sexuality needs) and their demographic, clinical, and psychosocial predictors. BC survivors (N=159; 47% women) were recruited from the Bladder Cancer Advocacy Network and completed a questionnaire that included the needs assessment survey (BCNAS-32), hospital anxiety and depression scale (HADS), coping (BRIEF COPE), social provisions scale (SPS), and self-efficacy beliefs (GSE) scale. Although no significant group differences in all reported needs emerged, both groups reported more communication (IQR = 50 (62.5) and less sexuality needs (IQR =13 (52.1). Older patients reported higher depression and anxiety (IQR = 32 (11.5); N = 68) than younger patients (IQR = 28 (11.0); p < .01; N = 88). Multivariable analyses stratified by age showed significant effects of gender among older patients with women experiencing more psychological, care, communication, and sexuality needs than men. Multivariable analyses also showed age-related differences (p < .05) in the predictors of needs controlling for covariates (e.g., gender). Among older patients both higher depression and anxiety and lower self-efficacy beliefs were associated with more psychological, care, and communication needs. Among younger patients, higher depression and anxiety were associated with more psychological, logistic, daily living, and communication needs. Results emphasize the importance of tailoring care planning for patients based on age.

Association of Stage Shift and Population Mortality Among Patients With Non-Small Cell Lung Cancer

IMPORTANCE

Early detection by computed tomography and a more attention-oriented approach to incidentally identified pulmonary nodules in the last decade has led to population stage shift for non-small cell lung cancer (NSCLC). This stage shift could substantially confound the evaluation of newer therapeutics and mortality outcomes.

OBJECTIVE

To investigate the association of stage shift with population mortality among patients with NSCLC.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was performed from October 2020 to June 2021 and used data from the Surveillance, Epidemiology, and End Results (SEER) registries to assess all patients from 2006 to 2016 with NSCLC.

MAIN OUTCOMES AND MEASURES

Incidence-based mortality was evaluated by year-of-death. To assess shifts in diagnostic characteristics, clinical stage and histology distributions were examined by year using χ2 tests. Trends were assessed using the average annual percentage change (AAPC), calculated with JoinPoint software. Kaplan-Meier survival analysis assessed overall survival according to stage and compared those missing any stage with those with a reported stage.

RESULTS

The final sample contained 312 382 patients; 166 657 (53.4%) were male, 38 201 (12.2%) were Black, and 249 062 (79.7%) were White; the median (IQR) age was 68 (60-76) years; 163 086 (52.2%) had adenocarcinoma histology. Incidence-based mortality within 5 years of diagnosis decreased from 2006 to 2016 (AAPC, -3.7; 95% CI, -4.1 to -3.4). When assessing stage shift, there was significant association between year-of-diagnosis and clinical stage, with stage I/II diagnosis increasing from 26.5% to 31.2% (AAPC, 1.5; 95% CI, 0.5 to 2.5); and stage III/IV diagnosis decreasing significantly from 70.8% to 66.1% (AAPC, -0.6; 95% CI, -1.0 to -0.2). Missing staging information was not associated with year-of-diagnosis (AAPC, -1.6; 95% CI, -7.4 to 4.5). Year-of-diagnosis was significantly associated with tumor histology (χ2 = 8990.0; P < .001). There was a significant increase in adenocarcinomas: 42.9% in 2006 to 59.0% in 2016 (AAPC, 3.4; 95% CI, 2.9 to 3.9). Median (IQR) survival for stage I/II was 57 months (18 months to not reached); stage III/IV was 7 (2-19) months; and missing stage was 10 (2-28) months. When compared with those with known stage, those without stage information had significantly worse survival than those with stage I/II, with survival between those with stage III and stage IV (log-rank χ2 = 87 125.0; P < .001).

CONCLUSIONS AND RELEVANCE

This cohort study found an association between decreased mortality and a corresponding diagnostic shift from later to earlier stage. These findings suggest that studies investigating the effect of treatment on lung cancer must take into account stage shift and the confounding association with survival and mortality outcome.

Assessing influenza vaccination success to inform COVID-19 vaccination campaign

Given recent downward trends in daily rates of COVID‐19 vaccinations, it is important to reassess strategies to reach those most vulnerable. The success and efficacy of vaccination campaigns for other respiratory illnesses, such as influenza, may help inform messaging around COVID‐19 vaccinations. This cross‐sectional study examines the individual‐level factors associated with, and the spatial distribution of, predictors of COVID‐19 severity, and uptake of influenza and hepatitis B (as a negative control) vaccines across NYC. Data were obtained from the 2018 Community Health Survey (CHS), including self‐reported influenza and hepatitis B vaccine uptake, diabetes, asthma, hypertension, body mass index (BMI), age, race/ethnicity, educational attainment, borough, and United Hospital Fund (UHF) neighborhood of residence. A CDC‐defined COVID‐19 severity risk score was created with variables available in the CHS, including diabetes, asthma, hypertension, BMI ≥ 30 kg/m², and age ≥65 years old. After adjustment, there was a significant positive association between COVID‐19 severity risk score and influenza vaccine uptake (1: OR_adj = 1.49, 95% CI 1.28–1.73; 2: OR_adj = 1.99; 95% CI: 1.65–2.41; 3+: OR_adj = 2.89; 95% CI: 2.32–3.60, compared to 0). Hepatitis B vaccine uptake was significantly inversely associated with COVID‐19 severity risk score (1: OR_adj = 0.67; 95% CI: 0.57–0.79; 2: OR_adj = 0.54; 95% CI: 0.44–0.66; 3+: OR_adj = 0.45; 95% CI: 0.36–0.56, compared to 0). The influenza vaccination campaign template is effective at reaching those most at risk for serious COVID‐19 and, if implemented, may help reach the most vulnerable that have not yet been vaccinated against COVID‐19.

Analyzing disparities in COVID-19 testing trends according to risk for COVID-19 severity across New York City

BACKGROUND

Given the interplay between race and comorbidities on COVID-19 morbidity and mortality, it is vital that testing be performed in areas of greatest need, where more severe cases are expected. The goal of this analysis is to evaluate COVID-19 testing data in NYC relative to risk factors for COVID-19 disease severity and demographic characteristics of NYC neighborhoods.

METHODS

COVID-19 testing and the racial/ethnic composition of NYC Zip Code Tabulation Areas (ZCTA) were obtained from the NYC Coronavirus data repository and the American Community Survey, respectively. The prevalence of neighborhood-level risk factors for COVID-19 severity according to the Centers for Disease Control and Prevention criteria for risk of severe illness and complications from COVID-19 were used to create a ZCTA-level risk index. Poisson regressions were performed to study the ratio of total tests relative to the total ZCTA population and the proportion of positive tests relative to the total tests performed over time.

RESULTS

From March 2nd-April 6th, the total tests/population (%) was positively associated with the proportion of white residents (IRR_adj: 1.0003, 95% CI: 1.0003-1.0004) and the COVID risk index (IRR_adj: 1.038, 95% CI: 1.029-1.046). The risk index (IRR_adj: 1.017, 95% CI: 0.939-1.101) was not associated with total tests performed from April 6th-May 12th, and inversely associated from May 12th-July 6th (IRR_adj: 0.862, 95% CI: 0.814-0.913). From March 2nd-April 6th the COVID risk index was not statistically associated (IRR_adj: 1.010, 95% CI: 0.987-1.034) with positive tests/total tests. From April 6th-May 12th, the COVID risk index was positively associated (IRR_adj: 1.031, 95% CI: 1.002-1.060), while from May 12th-July 6th, the risk index was inversely associated (IRR_adj: 1.135, 95% CI: 1.042-1.237) with positivity.

CONCLUSIONS

Testing in NYC has suffered from the lack of availability in high-risk populations, and was initially limited as a diagnostic tool for those with severe symptoms, which were mostly concentrated in areas where vulnerable residents live. Subsequent time periods of testing were not targeted in areas according to COVID-19 disease risk, as these areas still experience more positive tests.

A Neighborhood Analysis of Time Trends in COVID-19 Infection in NYC

To understand how observed COVID-19 diagnostic testing disparities across New York City (NYC) have impacted infection rates and COVID-19 spread, we examined neighborhood-level factors associated with, and the spatial distribution of, antibody test and infection rates, and compared changes over time by NYC ZIP code tabulation area (ZCTA). Data were obtained from 2019 American Community Survey 5-year estimates to create an SES index by ZCTA. Other predictors obtained from 2018 census data were the proportions of white residents, Hispanic residents and residents ≥ 65 years old. Multivariable Poisson regressions were performed to assess the rate of change for antibody testing and positivity, and to assess the independent associations with SES, race and age. Results: There was a significant association between the rate of antibody tests and SES quartiles (Q1: β_adj = 0.04, Q2: β_adj = 0.03 and Q3: β_adj = - 0.03, compared to Q4), and the proportion of residents who are white (β_adj = 0.004, p < .0001), Hispanic   (β_adj = 0.001, p < .0001), and ≥ 65 years (β_adj = 0.01, p < .0001). Total number of positive antibody tests was significantly inversely associated with SES quartile (Q1: β_adj = 0.50, Q2: β_adj = 0.48 and Q3: β_adj = 0.29, compared to Q4), and proportion of white residents (β = - 0.001, p < .0001) and ≥ 65 years (β = - 0.02, p < .0001), and significantly positively associated with proportion of Hispanic residents (β = 0.003, p < .0001). There are disparities in antibody testing and positivity, reflecting disproportionate impacts and undercounts of COVID-19 infection across NYC ZCTAs. Future public health response should increase testing in these vulnerable areas to diminish infection spread.

Trends of hospitalizations among patients with both cancer and dementia diagnoses in New York 2007-2017

BACKGROUND

Cancer and dementia have often been studied in isolation. We aimed to examine the spatiotemporal trend of inpatient admissions with both cancer and dementia diagnoses.

METHODS

Using state-wide inpatient claims data, we identified all hospital admissions for patients aged ≥50 years with both cancer and dementia diagnoses in New York State, 2007-2017. We examined the spatiotemporal trend of the admission using a novel Bayesian hierarchical model adjusting for socioeconomic factor, as measured by Yost index.

RESULTS

Admissions with the presence of both cancer and dementia diagnoses represented 8.5% of all admissions with a cancer diagnosis, and the proportion increased from 7.1% in 2007 to 9.7% in 2017. The median admission rate was 3.5 (interquartile range: 2.2-5.2) hospitalizations per 1000 population aged ≥50 years, which increased from 2.9 in 2007 to 3.7 in 2017. The admission rate peaked first in 2010 followed by a smaller peak in 2014, before stabilizing at a level higher than the pre-2010 period. Taking into account the spatiotemporal heterogeneity, we found that hospitalizations among those with both cancer and dementia diagnoses were associated with a higher socioeconomic status (the posterior median relative risk for Yost index = 1.046 (95% credible interval: 1.033-1.058)).

CONCLUSIONS

Hospitalizations of patients with both cancer and dementia increased over time. Cancer care providers and healthcare systems should be prepared to provide prevention and management strategies and engage in complex medical decision-making for this increasingly common patient population comprised of individuals with cancer and dementia.

Changes in E-Cigarette Perceptions Over Time: A National Youth Tobacco Survey Analysis

INTRODUCTION

This multiyear, cross-sectional study explores the changes over time in how U.S. middle- and high-school students perceive the harm and addiction risk of E-cigarettes.

METHODS

This study analyzed 83,779 participants in the National Youth Tobacco Survey from 2015 to 2019. Associations of survey year with perceived harm and addiction risk of E-cigarettes were assessed using multivariable multinomial logistic regression models, adjusted for sociodemographic characteristics.

RESULTS

Smoking decreased over the 5 years (-1.85 percentage points, p=0.07); vaping increased (9.03 percentage points, p<0.01). Perceived harm of both combustible cigarettes and E-cigarettes increased with time. Male, older, and non-White students perceived less harm from smoking or vaping. Perceptions of the addictiveness of E-cigarettes increased over time: 26.31% of students considered E-cigarettes to be more addictive than combustible cigarettes in 2019, compared with 7.26% in 2016. Female and non-White students were more likely to think that E-cigarettes were at least as addictive as combustible cigarettes but also reported less knowledge about them.

CONCLUSIONS

The perceptions of both harm and addictiveness of E-cigarettes have increased over time, independent of current use. Perceptions vary on the basis of age, sex, race/ethnicity, and current use. Efforts should be made to further educate adolescents about E-cigarettes and to regulate their sale and advertisement. Efforts to reduce the uptake of combustible cigarettes among adolescents have been successful and should be duplicated for E-cigarettes.

Mild anemia as a single independent predictor of mortality in patients with COVID-19

The coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has led to an unprecedented international health crisis. COVID-19 clinical presentations cover a wide range from asymptomatic to severe illness and death. Given the limited therapeutic resources and unexpected clinical features of the disease, readily accessible predictive biomarkers are urgently needed to improve patient care and management. We asked the degree to which anemia may influence the outcome of patients with COVID-19. To this end, we identified 3777 patients who were positively diagnosed with COVID-19 between March 1 and April 1 2020 in New York City. We evaluated 2,562 patients with available red blood cell, hemoglobin, and related laboratory values. Multivariable cox proportional hazards regression showed that anemia was a significant independent predictor of mortality (hazard ratio (HR): 1.26, 95% Confidence Interval [CI]: 1.06-1.51), independent of age, sex, and comorbidities. There was a direct correlation between the degree of anemia and the risk of mortality when hemoglobin was treated as a continuous variable (HRadj 1.05; [CI]: 1.01-1.09). The hemoglobin level that was maximally predictive of mortality, was 11.5 g/dL in males and 11.8 g/dL in females. These findings identify a routinely measured biomarker that is predictive of disease outcomes and will aid in refining clinical care algorithms and optimize resource allocation. Mechanisms of impacts of anemia on COVID-19 outcome are likely to be multiple in nature and require further investigation.

A risk index for COVID-19 severity is associated with COVID-19 mortality in New York City

BACKGROUND

New York City (NYC) was the epicenter of the COVID-19 pandemic, and is home to underserved populations with higher prevalence of chronic conditions that put them in danger of more serious infection. Little is known about how the presence of chronic risk factors correlates with mortality at the population level. Here we determine the relationship between these factors and COVD-19 mortality in NYC.

METHODS

A cross-sectional study of mortality data obtained from the NYC Coronavirus data repository (03/02/2020-07/06/2020) and the prevalence of neighborhood-level risk factors for COVID-19 severity was performed. A risk index was created based on the CDC criteria for risk of severe illness and complications from COVID-19, and stepwise linear regression was implemented to predict the COVID-19 mortality rate across NYC zip code tabulation areas (ZCTAs) utilizing the risk index, median age, socioeconomic status index, and the racial and Hispanic composition at the ZCTA-level as predictors.

RESULTS

The COVID-19 death rate per 100,000 persons significantly decreased with the increasing proportion of white residents (βadj = - 0.91, SE = 0.31, p = 0.0037), while the increasing proportion of Hispanic residents (βadj = 0.90, SE = 0.38, p = 0.0200), median age (βadj = 3.45, SE = 1.74, p = 0.0489), and COVID-19 severity risk index (βadj = 5.84, SE = 0.82, p <  0.001) were statistically significantly positively associated with death rates.

CONCLUSIONS

Disparities in COVID-19 mortality exist across NYC and these vulnerable areas require increased attention, including repeated and widespread testing, to minimize the threat of serious illness and mortality.

Serum cotinine levels and nicotine addiction potential of e-cigarettes: an NHANES analysis

This study aims to compare serum cotinine levels in e-cigarette and combustible cigarette smokers, in an attempt to quantify the potential chronic nicotine addiction risk that e-cigarettes pose. We analyzed 428 participants in 2015-2016 NHANES: 379 (87.03%) smoked combustible cigarettes alone and 49 (12.97%) smoked e-cigarettes. Serum cotinine levels were measured by isotope-dilution high-performance liquid chromatography/atmospheric pressure chemical ionization tandem mass spectrometric method with a detection limit of 0.015 ng/ml. Electronic cigarette smokers were younger than combustible cigarette smokers (mean age 36.79 versus 42.69 years, P = 0.03), more likely to be male (64.93% versus 48.32%, P = 0.09) and significantly less likely to live with other smokers (50.17% versus 90.07%, P < 0.01). Serum cotinine levels increased linearly with self-reported days of smoking in both electronic cigarette and combustible cigarette smokers, after accounting for living with a smoker. The analysis of the subgroup who reported daily use show non-statistically significantly higher serum cotinine levels in electronic cigarette smokers versus combustible cigarette smokers (β adj = 52.50, P = 0.10). This analysis of recent US data demonstrates that electronic cigarettes expose users to nicotine levels proportionate to, and potentially higher than combustible cigarettes, and thus pose a serious risk of chronic nicotine addiction. This could be particularly relevant in otherwise tobacco naive individuals; future risk of tobacco-related dependence, addiction and relapse, as well as of tobacco-related cancers in these subjects needs to be investigated.

Deferred Action for Childhood Arrivals (DACA) medical students - an examination of their journey and experiences as medical students in limbo

BACKGROUND

Although the value of DACA medical students has been hypothesized, no data are available on their contribution to US healthcare. While the exact number of DACA recipients in medical school is unknown, DACA medical students are projected to represent an increasing proportion of physicians in the future. The current literature on DACA students has not analyzed the experiences of these students.

METHODS

A mixed-methods study on the career intentions and experiences of DACA medical students was performed utilizing survey data and in-depth interviews. The academic performance of a convenience sample of DACA medical students was compared to that of matriculated medical students from corresponding medical schools, national averages, and first-year residents according to specialty.

RESULTS

Thirty-three DACA medical students completed the survey and five participated in a qualitative interview. The average undergraduate GPA (SD) of the DACA medical student sample was 3.7 (0.3), the same as the national GPA of 2017-2018 matriculated medical students. The most common intended residency programs were Internal Medicine (27.2%), Emergency Medicine (15.2%), and Family Medicine (9.1%). In interviews, DACA students discussed their motivation for pursuing medicine, barriers and facilitators that they faced in attending medical school, their experiences as medical students, and their future plans.

CONCLUSIONS

The intent of this sample to pursue medical specialties in which there is a growing need further exemplifies the unique value of these students. It is vital to protect the status of DACA recipients and realize the contributions that DACA physicians provide to US healthcare.

The Impact of Dementia on Cancer Treatment Decision-Making, Cancer Treatment, and Mortality: A Mixed Studies Review

Dementia and cancer occur commonly in older adults. Yet, little is known about the effect of dementia on cancer treatment and outcomes in patients diagnosed with cancer, and no guidelines exist. We performed a mixed studies review to assess the current knowledge and gaps on the impact of dementia on cancer treatment decision-making, cancer treatment, and mortality. A search in PubMed, Medline, and PsycINFO identified 55 studies on older adults with a dementia diagnosis before a cancer diagnosis and/or comorbid cancer and dementia published in English from January 2004 to February 2020. We described variability using range in quantitative estimates, ie, odds ratios (ORs), hazard ratios (HRs), and risk ratios (RR) when appropriate and performed narrative review of qualitative data. Patients with dementia were more likely to receive no curative treatment (including hospice or palliative care) (OR, HR, and RR range = 0.40-4.4, n = 8), while less likely to receive chemotherapy (OR and HR range = 0.11-0.68, n = 8), radiation (OR range = 0.24-0.56, n = 2), and surgery (OR range = 0.30-1.3, n = 4). Older adults with cancer and dementia had higher mortality than those with cancer alone (HR and OR range = 0.92-5.8, n = 33). Summarized findings from qualitative studies consistently revealed that clinicians, caregivers, and patients tended to prefer less aggressive care and gave higher priority to quality of life over life expectancy for those with dementia. Current practices in treatment-decision making for patients with both cancer and dementia are inconsistent. There is an urgent need for treatment guidelines for this growing patient population that considers patient and caregiver perspectives.

Non-small cell lung cancer population mortality and stage shift

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Background: Lung cancer population mortality has decreased over the last decade. Smoking cessation, medical therapies, CT screening, and earlier therapeutic interventions may all contribute to this decrease. We investigate the role of stage shift on population mortality of non-small cell lung cancer (NSCLC). Methods: Data from Surveillance, Epidemiology, and End Results (SEER) were queried to assess all patients from 2006-2016 with microscopically confirmed NSCLC. Incidence based mortality was evaluated by year of diagnosis. In order to assess shifts in diagnostic characteristics, stage and histology distributions were examined by year using χ2 tests. Trends were assessed by using the average annual percentage change (AAPC), calculated with JoinPoint software. Kaplan-Meier survival analysis was also performed to assess overall survival according to stage and to compare those missing any stage to those with a reported stage. Results: Between 2006-2016, 312,382 patients in SEER were diagnosed with NSCLC. Incidence based mortality within 5 years of diagnosis for NSCLC has significantly decreased over the last decade (AAPC -3.7 (95% confidence interval (CI): -4.1 - -3.4)). When assessing stage shift, there was a significant association between year of diagnosis and stage (p < 0.0001), with the percent in each year diagnosed at stage I/II increasing from 26.5% to 31.2% from 2006-2016, corresponding to a statistically significant AAPC of 1.5 (95% CI: 0.5-2.5); the percent diagnosed at stage III/IV decreased significantly from 70.8% to 66.1% (AAPC: -0.6 (95% CI: -1.0 - -0.2)). The percent missing staging information was relatively stable in this timeframe and not significant (AAPC: -1.6 (-7.4 - 4.5)). Year of diagnosis was significantly associated with tumor histology (p < 0.0001). There was a statistically significant increase in the percent of those diagnosed with adenocarcinomas, from 42.9% in 2006 to 59.0% in 2016 (AAPC: 3.4 (95% CI: 2.9-3.9)). Median survival for those with stage I/II was 57 (interquartile range (IQR): 18- - ) months; for stage III/IV was 7 (IQR: 2-19) months; and for those missing stage was 10 (IQR: 2-28) months. Patients with stage I/II had significantly better survival compared to those diagnosed with stage III/IV, or missing stage (p < 0.0001). Conclusions: Population-level mortality for NSCLC has decreased from 2006-2016. While advances in treatments, particularly targeted therapeutics have played a role in affecting mortality, our analysis suggests that decreased mortality is also due to a diagnostic shift from later to earlier stage lung cancer. Studies investigating the effectiveness of treatment on lung cancer mortality must take into account the confounding effect of stage shift on survival and mortality outcome.

Using Rapid Research Implementation and Collaborations to Assess the Mental Health Impact of the COVID-19 Pandemic Among Community and Clinical Cohorts

A research initiative was launched during the initial coronavirus disease (COVID-19) outbreak by 3 New York metropolitan area institutions. Collaborators recruited community members and patients from previous research studies to examine COVID-19 experiences and mental health symptoms through self-report surveys. The current report descriptively presents findings from the initial survey characterized by both community and clinical cohorts, and discusses challenges encountered with rapid implementation. The clinical cohort exhibited higher rates of symptoms of mental health difficulties (depression, anxiety, and posttraumatic stress disorder [PTSD]) as compared to the community cohort. COVID-19 positivity rates were similar among both groups and lower than the national average. While both groups reported low rates of job loss, community members reported higher rates of financial difficulty resulting from the pandemic. Findings indicate the need for further collaborative research on the mental health impact of COVID-19.

VATS Pleurectomy Decortication Is a Reasonable Alternative for Higher Risk Patients in the Management of Malignant Pleural Mesothelioma: An Analysis of Short-Term Outcomes

Simple Summary

Malignant pleural mesothelioma (MPM) is an aggressive malignancy that drastically affects a patient’s quality of life. Surgery typically entails radical resection with or without the removal of the underlying lung. In an era where minimally invasive surgery is sought after, MPM remains an anomaly. The purpose of this study is to assess the feasibility of minimally invasive surgery as an alternative to more radical surgery in MPM. We examined short-term outcomes between the radical approaches and minimally invasive surgery and minimally invasive surgery had improved outcomes. Minimally invasive surgery can be considered in patients with MPM.

Abstract

Surgery is a mainstay of treatment allowing for debulking of tumor and expansion of the lung for improvement in median survival and quality of life for patients with malignant pleural mesothelioma (MPM). Although optimal surgical technique remains open for debate—extrapleural pneumonectomy (EPP) vs. pleurectomy/decortication (P/D)—minimally invasive surgery (VATS-P/D) remains underutilized in the management of MPM. We examined whether VATS-P/D is a feasible alternative to EPP and P/D. We evaluated the New York Statewide Planning and Research Cooperative System (SPARCS) from 2007–2017 to assess the short-term complications of EPP vs. P/D, including a subanalysis of open P/D vs. VATS-P/D. There were 331 patients with open surgery; 269 with P/D and 62 with EPP. There were 384 patients with P/D; 269 were open and 115 VATS. Rates of any complication were similar between EPP and P/D patients, but EPP had significantly higher rates of cardiovascular complications. After adjusting for confounders, those with a VATS approach were less likely to have any complication, compared to an open approach and significantly less likely to have a pulmonary complication. VATS-P/D remains a viable alternative to radical surgery in MPM patients allowing for improved short-term outcomes.

Racial Differences in Gastroenteropancreatic Neuroendocrine Tumor Treatment and Survival in the United States

OBJECTIVES

The objective of this study was to evaluate racial differences in cancer treatment and survival in gastroenteropancreatic neuroendocrine tumor (GEP-NET) patients.

METHODS

Using the Surveillance, Epidemiology, and End Results Registry, we identified patients with GEP-NETs of the stomach, small intestine (SI), colon, rectum, appendix, and pancreas diagnosed between 1973 and 2014. Demographic, cancer, and treatment information were collected and compared using χ2 tests. Multivariable logistic and Cox regression were used to determine disparities in receiving treatment and overall survival.

RESULTS

We identified 19,031 GEP-NET patients: 2839 were non-Hispanic Blacks, 12,832 non-Hispanic Whites, 2098 Hispanics, and 1262 Asians. African Americans and Hispanics with SI and pancreatic NETs were less likely to be treated with surgery (odds ratio, 0.6; 95% confidence interval [CI], 0.46-0.69; odds ratio, 0.71; 95% CI, 0.51-0.99, respectively). African American race was not an independent predictor of survival; there was a strong trend in stomach, SI, and pancreas NETs (hazard ratio [HR], 1.31; 95% CI, 1-1.7; HR, 1.2; 95% CI, 0.99-1.45; HR, 1.22; 95% CI, 1-1.48, respectively).

CONCLUSIONS

Our study provides evidence of racial disparities in treatment and survival across GEP-NET primary sites and racial groups. Further studies should be performed to improve our understanding of the reason for these disparities.

The Impact of Smoking on the Association between Perfluoroalkyl Acids (PFAS) and Thyroid Hormones: A National Health and Nutrition Examination Survey Analysis

Perfluoroalkyl acids (PFAS) are known endocrine disrupting chemicals, potentially affecting thyroid function. Smoking has been associated with PFAS levels as well as with thyroid function. The impact of smoking on the association between PFAS and thyroid function remains to be elucidated, so the objective was to assess the effect of PFAS exposure on thyroid function in the general population, stratified by smoking status, using the National Health and Nutrition Examination Survey (NHANES). NHANES adult participants who were part of the 2011–2012 laboratory subsample and had PFAS and thyroid function measured were included (n = 1325). Adjusted linear regression models and stratified analyses were performed. There was a significant positive association between perfluorooctanesulfonic acid (PFOS) (p = 0.003), perfluorononanoic acid (PFNA) (p = 0.014), total PFAS (p = 0.004) concentrations and free T4 (FT4). No significant associations were found between perfluorooctanoic acid (PFOA), PFOS, perfluorohexane sulfonate (PFHxS), PFNA, total PFAS and total T4 (TT4) or thyroid stimulating hormone (TSH). In non-smokers, a significant positive association was found between PFOS (p = 0.003), PFHxS (p = 0.034), PFNA (p = 0.012), total PFAS (p = 0.003) and FT4 while no significant associations were found in smokers. The present study showed that increased PFAS exposure was associated with increased FT4 in non-smokers, while no association was found in smokers. These results confirm that smoking modifies the association between PFAS exposure and thyroid function.

Prevalence of Cytopenia in the General Population-A National Health and Nutrition Examination Survey Analysis

BACKGROUND

Cytopenia, a reduced count of blood cells manifesting as anemia, neutropenia, and/or thrombocytopenia is frequently associated with other medical conditions. However, a cytopenia may not be accompanied by a known determinant and in some of these cases, may be a precursor to pre-malignancies or hematologic cancers. Little is known about the prevalence of these unexplained cytopenias and their distribution in the population.

MATERIALS AND METHODS

The National Health and Nutrition Examination Survey (NHANES) from 1999 to 2002 was used to identify those with a cytopenia in the general population. Those without an identifiable determinant in the NHANES were classified as having unexplained cytopenia. Weighted frequencies were examined to assess the prevalence of unexplained cytopenia in the population. Distribution of blood counts comparing those with unexplained cytopenia to the general population was examined. Multivariable logistic regression was conducted to assess the association between unexplained cytopenia and demographic factors.

RESULTS

Of the 7,962 people in the sample, 236 (2.0%) had any cytopenia and 86 (0.9%) had an unexplained cytopenia. Approximately 43% of all cytopenias were not accompanied by a clinical determinant. Unexplained cytopenia was more common in men (1.1%) than in women (0.7%) and in Non-Hispanic Black participants (3.4%). Among those with an unexplained cytopenia, the majority (74.8%) manifested as neutropenia. Compared to those with no cytopenia, those with unexplained cytopenia were significantly less likely to be female, have body mass index ≥30 kg/m2, and work in the service industry, and were significantly more likely to be non-Hispanic Black.

CONCLUSIONS

This is the first study to examine the prevalence of unexplained cytopenia in a nationally representative sample and may serve as a baseline for comparison with other populations. Future research to identify risk factors for development of malignant hematological disorders among those with unexplained cytopenia is warranted.

Clinical Course of Cancer Patients With COVID-19: A Retrospective Cohort Study

Background

Complications in cancer patients with coronavirus disease 2019 (COVID-19) have not been examined. This analysis aimed to compare characteristics of COVID-19 patients with and without cancer and assess whether cancer is associated with COVID-19 morbidity or mortality.

Methods

COVID-19-positive patients with an inpatient or emergency encounter at the Mount Sinai Health System between March 1, 2020, and May 27, 2020, were included and compared across cancer status on demographics and clinical characteristics. Multivariable logistic regressions were used to model the associations of cancer with sepsis, venous thromboembolism, acute kidney injury, intensive care unit admission, and all-cause mortality.

Results

There were 5556 COVID-19-positive patients included, 421 (7.6%) with cancer (325 solid, 96 nonsolid). Those with cancer were statistically significantly older, more likely to be non-Hispanic Black and to be admitted to the hospital during their encounter, and had more comorbidities than noncancer COVID-19 patients. Cancer patients were statistically significantly more likely to develop sepsis (adjusted odds ratio [OR_adj] = 1.31, 95% confidence interval [CI] = 1.06 to 1.61) and venous thromboembolism (OR_adj = 1.77, 95% CI = 1.01 to 3.09); there was no statistically significant difference in acute kidney injury (OR_adj = 1.10, 95% CI = 0.87 to 1.39), intensive care unit admissions (OR_adj = 1.04, 95% CI = 0.80 to 1.34), or mortality (OR_adj = 1.02, 95% CI = 0.81 to 1.29).

Conclusions

COVID-19 patients with cancer may have a higher risk for adverse outcomes. Although there was no statistically significant difference in mortality, COVID-19 patients with cancer have statistically significantly higher risk of thromboembolism and sepsis. Further research is warranted into the potential effects of cancer treatments on inflammatory and immune responses to COVID-19 and on the efficacy of anticoagulant therapy in these patients.

Adjuvant radiation therapy alone is associated with improved overall survival compared to hormonal therapy alone in older women with estrogen receptor positive early stage breast cancer

Background

Breast conserving surgery (BCS) and adjuvant hormonal therapy (HT) without radiation therapy (RT) is an acceptable approach for older women with early stage, estrogen receptor (ER) positive breast cancer. Toxicity and compliance remain issues with HT. Adjuvant RT alone may have better compliance, but its efficacy in the absence of HT is unclear. We aim to assess patterns of adjuvant therapy and survival outcomes among older women with early stage, ER positive (ER+) breast cancer.

Methods

The National Cancer Data Base (NCDB) was used to identify 130,194 women age ≥65 years with invasive ER+, node negative breast cancer diagnosed between 2004 and 2015. All patients underwent BCS. Kaplan‐Meier survival curves were used to examine overall survival (OS). The association between adjuvant therapy and OS was assessed in multivariable Cox proportional hazards regression models.

Results

Unadjusted 5/10‐year OS rates were 90.0%/64.3% for HT and RT, 84.2%/54.9% for RT alone, 78.7%/44.5% for HT alone, and 71.6%/38.0% for no treatment; p<0.001 for all. Compared to HT alone, the 10‐year multivariable hazard ratio (HR) for death for RT alone was 0.86 (95% CI 0.82‐0.91). In propensity‐matched patients who received RT alone or HT alone (n=21,326), RT alone had significantly better survival at 5 (HR_adj: 0.84) and 10 (HR_adj: 0.87) years.

Conclusions

Older women with early stage ER+ breast cancer who undergo BCS and receive both HT and RT have the best survival, while RT as single‐modality therapy had higher rates of OS at 5 and 10 years compared to HT alone.

Three months of informational trends in COVID-19 across New York City

In the midst of widespread community transmission of coronavirus disease 2019 (COVID-19) in New York, residents have sought information about COVID-19. We analyzed trends in New York State (NYS) and New York City (NYC) data to quantify the extent of COVID-19-related queries. Data on the number of 311 calls in NYC, Google Trend data on the search term 'Coronavirus' and information about trends in COVID-19 cases in NYS and the USA were compiled from multiple sources. There were 1228 994 total calls to 311 between 22 January 2020 and 22 April 2020, with 50 845 calls specific to COVID-19 in the study period. The proportion of 311 calls related to COVID-19 increased over time, while the 'interest over time' of the search term 'Coronavirus' has exponentially increased since the end of February 2020. It is vital that public health officials provide clear and up-to-date information about protective measures and crucial communications to respond to information-seeking behavior across NYC.

Abstract B096: Predictors of survival in black and white patients with malignant pleural mesothelioma

Purpose: Malignant pleural mesothelioma (MPM) is a rare cancer, particularly among black patients, with a very poor prognosis. There is only one study directly examining prognostic factors of survival in white and black patients with MPM, based on SEER. The goal of this study was to use a large, nationwide cancer database to examine factors associated with survival in black and white patients with MPM. Methods: We used the National Cancer Database (NCDB) to identify black and white patients diagnosed with MPM from 2004-2013. Multivariable Cox proportional hazards models, stratified by race, were used to assess factors associated with overall survival (OS), using adjusted hazards ratios (HRadj) and 95% confidence intervals (CI). Covariates included age, gender, ethnicity, zip-code level education and income, insurance, Charlson-Deyo comorbidity score, histology, laterality, stage, receipt of treatment (surgery, chemotherapy, radiotherapy), hospital characteristics, and year of diagnosis. Results: There were 15,828 patients included; 15,109 white (95.5%) and 719 black (4.5%). After adjustment, black patients were significantly younger, living in areas characterized by lower educational attainment and income, more likely to be on Medicaid, to be from the South and to live closer to their hospital. Though not significant, black patients were less likely to receive surgery, radiotherapy, and chemotherapy than white patients. There were several differences in factors associated with OS for black and white patients. OS was significantly worse for older patients, but the association was stronger in black patients (HRadj [white]: 1.86, 95% CI: 1.56-2.21; HRadj [black]: 7.18, 95% CI: 3.39-15.20 for ≥80 vs. &lt;50 years). A higher comorbidity score was associated with worse OS (HRadj [white]: 1.28, 95% CI: 1.19-1.37; HRadj [black]: 1.53, 95% CI: 1.12-2.09 for comorbidity score ≥2 vs.0). Among white patients, women had significantly better survival (HRadj: 0.81, 95% CI: 0.77-0.85), but not so among black patients (HRadj: 0.95, 95% CI: 0.74-1.21). Both groups derived benefit from radiotherapy (HRadj [white]: 0.84, 95% CI: 0.75-0.94; HRadj [black]: 0.41, 95% CI: 0.21-0.82) and chemotherapy (HRadj [white]: 0.67, 95% CI: 0.64-0.70; HRadj [black]: 0.75, 95% CI: 0.60-0.94); only white patients had significantly better OS with surgery (HRadj [white]: 0.78, 95% CI: 0.74-0.83; HRadj [black]: 1.06, 95% CI: 0.76-1.48). Conclusion: Prognostic factors associated with better OS vary by race. Some of these differences may reflect poorer access to quality healthcare among black patients and compounded socioeconomic effects. Differences in previous asbestos exposure with race could also play a role in the biology of the disease. Further work is needed to untangle these differences to determine best care practices and improve prognosis for all patients.

Citation Format: Naomi Alpert, Maaike van Gerwen, Nisha Ohri, Raja Flores, Emanuela Taioli. Predictors of survival in black and white patients with malignant pleural mesothelioma [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 B096.

Abstract B108: Disparities in clinical and demographic characteristics among Asian/Pacific Islander and non-Hispanic White newly diagnosed lung cancer patients

Purpose: Racial disparities persist among patients with lung cancer (LC), and are well documented among Non-Hispanic Whites (NHW), Blacks, and Hispanics. However they have not been adequately studied among the ethnic subgroups of Asian/Pacific Islanders (API). API populations are heterogeneous in many ways, including country of origin, cultural diversity, health behaviors, and health outcomes, but they are often treated as a single group. The goal of this study is to compare the clinical and demographic characteristics at LC diagnosis between API subgroups and NHW patients.

Methods: NHW and API patients aged ≥ 18 years diagnosed with malignant LC from 1990 to 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) Program. API population was divided into 8 ethnic subgroups (ES): Filipino, Chinese, Japanese, Asian Indian/Pakistani, Korean, Vietnamese, Hawaiian/Pacific Islander, and Other. Multivariable logistic regression and multinomial logistic regression models with NHW as the reference were used to estimate odds ratios (OR) and 95% confidence intervals (CI) to assess independent associations of LC patient clinical and demographic factors with API and ES.

Results: There were 522,702 NHW and 41,479 API LC patients. API was significantly younger (ORadj: 0.53, 95% CI: 0.49-0.58 for ≥80 vs. ≤39 years) than NHW, with differences according to ES (range of effects: ORadj [Asian Indian/Pakistani]: 0.10, 95% CI: 0.07-0.14; ORadj [Japanese]: 2.73, 95% CI: 1.91-3.92). API patients and ES subgroups were less likely to be female (ORadj: 0.84, 95% CI: 0.83-0.86); API patients were less likely to be never married (ORadj: 0.71, 95% CI: 0.69-0.74), and so was for ES except for Hawaiian/Pacific Islanders, who were more likely to be never married (ORadj: 1.15, 95% CI: 1.05-1.27). API were more likely to be diagnosed at a later stage (ORadj: 1.31, 95% CI: 1.27-1.35 for stage IV vs. stage I); this was similar across ES. API patients were significantly less likely to be diagnosed with a squamous cell carcinoma (ORadj: 0.54, 95% CI: 0.52-0.55, compared to adenocarcinoma); effects ranged from ORadj[Vietnamese]: 0.37, 95% CI: 0.33-0.41 to ORadj [Hawaiian/Pacific Islander]: 0.89, 95% CI: 0.82-0.97.

Conclusion: At diagnosis, significant disparities in demographic and clinical characteristics exist between NHW and API patients overall, as well as across the eight major API ethnic subgroups. These findings indicate that treating API patients as a single population may miss crucial biological, environmental and behavioral differences. It may be beneficial to view these subgroups separately when developing strategies for prevention and efficacious treatment.

Citation Format: Parth Bhargav Patel, Naomi Alpert, Raja Flores, Emanuela Taioli. Disparities in clinical and demographic characteristics among Asian/Pacific Islander and non-Hispanic White newly diagnosed lung cancer patients [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 B108.

Assessing non-aggressiveness of untreated, local and regional, papillary thyroid cancer

OBJECTIVES

With a steadily increasing thyroid cancer incidence, information regarding cancer aggressiveness is essential to determine which patients may be suitable for active surveillance. This study assessed the extent of non-aggressiveness of untreated, local and regional stage, papillary thyroid cancer.

MATERIALS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) registry and included 1423 local stage and 337 regional stage papillary thyroid cancer cases. Thyroid cancer specific survival was estimated conditional on the absence of death due to competing causes using competing risk methods. Stratified analyses were done to determine non-aggressiveness among different patient and tumor characteristics.

RESULTS

The overall rate of non-aggressiveness for local stage thyroid cancer was 99.34% (95% CI: 99.33-99.35%), with a rate of non-aggressiveness of 98.85% (95% CI: 98.77-98.93%) for males and 99.48% (95% CI: 99.46-99.49%) for females (p = 0.055). Rate of non-aggressiveness was significantly lower in patients >60 years compared to patients ≤60 years (p < 0.001). Although the rate of non-aggressiveness was the same for tumors ≤10 mm and tumors of 11-20 mm, tumors measuring >20 mm had a significantly lower rate of non-aggressiveness (p = 0.002). The overall rate of non-aggressiveness for regional stage thyroid cancer was 72.58% (95% CI: 70.61-74.56%).

CONCLUSION

We found high rates of non-aggressiveness in untreated, local stage, papillary thyroid cancer, particularly in younger patients with small (≤2 cm) thyroid cancer, suggesting that these patients may be good candidates for active surveillance.

Prognostic factors of survival in patients with malignant pleural mesothelioma: an analysis of the National Cancer Database

Malignant pleural mesothelioma (MPM) is a rare disease with a very poor prognosis. Previous studies have indicated that women experience longer survival compared with men. We analyzed 16 267 eligible patients (21.3% females) in the National Cancer Database to evaluate which clinical factors are independently predictive of longer survival. After adjusting for all covariates, survival was significantly better in females compared with males [HRadj: 0.81, 95% confidence interval (CI): 0.77-0.85]. Other factors significantly associated with better survival were younger age at diagnosis, higher income, lower comorbidity score, epithelial histology, earlier stage and receipt of surgical or medical treatment. After propensity matching, survival was significantly better for females compared with males [hazard ratio (HR): 0.86, 95% CI: 0.80-0.94]. After propensity matching within the epithelial group, survival remained significantly better for females compared with males (HR: 0.85, 95% CI: 0.74-0.97). This study adds information to the known significant gender survival difference in MPM by disentangling the effect of gender from the effect of age and histology, two known independent factors affecting survival. Circulating estrogen, present in young but not older women, and higher expression of the estrogen receptor beta in epithelial mesothelioma have been suggested to play a role in gender survival differences. These findings may lead to exploring new therapeutic options, such as targeting estrogen receptor beta, and considering hormonal therapy including estrogens for patients with otherwise limited prognosis.

An overview of existing mesothelioma registries worldwide, and the need for a US Registry

The association between asbestos exposure, mainly in occupational settings, and malignant mesothelioma has been well established; this has prompted several countries to establish mesothelioma epidemiologic surveillance programs often at the request of national agencies. This review compares currently existing mesothelioma registries worldwide to develop a concept model for a US real-time case capture mesothelioma registry. Five countries were identified with a mesothelioma specific registry, including Italy, France, UK, Australia, and South Korea. All, except the UK, used interviews to collect exposure data. Linkage with the national death index was available or was in future plans for all registries. The registries have limited information on treatment, quality of life, and other patient-centered outcomes such as symptoms and pain management. To thoroughly collect exposure data, "real-time" enrollment is preferable; to maximize the capture of mesothelioma cases, optimal coverage, and a simplified consent process are needed.