Measuring social determinants of health in the All of Us Research Program

To accelerate medical breakthroughs, the All of Us Research Program aims to collect data from over one million participants. This report outlines processes used to construct the All of Us Social Determinants of Health (SDOH) survey and presents the psychometric characteristics of SDOH survey measures in All of Us. A consensus process was used to select SDOH measures, prioritizing concepts validated in diverse populations and other national cohort surveys. Survey item non-response was calculated, and Cronbach's alpha was used to analyze psychometric properties of scales. Multivariable logistic regression models were used to examine associations between demographic categories and item non-response. Twenty-nine percent (N = 117,783) of eligible All of Us participants submitted SDOH survey data for these analyses. Most scales had less than 5% incalculable scores due to item non-response. Patterns of item non-response were seen by racial identity, educational attainment, income level, survey language, and age. Internal consistency reliability was greater than 0.80 for almost all scales and most demographic groups. The SDOH survey demonstrated good to excellent reliability across several measures and within multiple populations underrepresented in biomedical research. Bias due to survey non-response and item non-response will be monitored and addressed as the survey is fielded more completely.

A roadmap to establishing global oncology as a priority initiative within a National Cancer Institute-designated cancer center

As the burden of cancers impacting low- and middle-income countries is projected to increase, formation of strategic partnerships between institutions in high-income countries and low- and middle-income country institutions may serve to accelerate cancer research, clinical care, and training. As the US National Cancer Institute and its Center for Global Health continue to encourage cancer centers to join its global mission, academic cancer centers in the United States have increased their global activities. In 2015, the Helen Diller Family Comprehensive Cancer Center at the University of California, San Francisco, responded to the call for international partnership in addressing the global cancer burden through the establishment of the Global Cancer Program as a priority initiative. In developing the Global Cancer Program, we galvanized institutional support to foster sustained, bidirectional, equitable, international partnerships in global cancer control. Our focus and intent in disseminating this commentary is to share experiences and lessons learned from the perspective of a US-based, National Cancer Institute-designated cancer center and to provide a roadmap for other high-income institutions seeking to strategically broaden their missions and address the complex challenges of global cancer control. Herein, we review the formative evaluation, governance, strategic planning, investments in career development, funding sources, program evaluation, and lessons learned. Reflecting on the evolution of our program during the first 5 years, we observed in our partners a powerful shift toward a locally driven priority setting, reduced dependency, and an increased commitment to research as a path to improve cancer outcomes in resource-constrained settings.

Effects of Wildfire Events on California Radiation Oncology Clinics and Patients

Purpose

The effect of climate-driven events, such as wildfires, on health care delivery and cancer care is a growing concern. Patients with cancer undergoing radiation therapy are particularly vulnerable to treatment interruptions, which have a direct effect on survival. We report the results of a study characterizing the effect of wildfires on radiation oncology clinics and their patients.

Methods and Materials

A survey of California radiation oncologists was used to evaluate emergency preparedness and the effect of wildfires on the delivery of radiation therapy services between 2017 and 2022. Descriptive statistics and Pearson's χ2 tests were performed to investigate potential relationships between provider characteristics, practice settings, and perceptions of the effect of wildfire events. California Department of Forestry and Fire Protection data were employed to map the geographic distribution of wildfires to clinic locations.

Results

Response rate was 12.3% (51/415 radiation oncologists), representing 25% of clinics (43/176) in 41% (24/58) of California counties. Sixty-one percent (31/51) of respondents reported being affected by a wildfire, 2 of which are rural clinics (100%, 2/2) and 29 are (59%, 29/49) metropolitan practices. Of these, 18% (9/51) reported a clinic closure, and 29% (15/51) reported staffing shortages. Respondents reported effects on patients, including having to evacuate (55%, 28/51), cancel/reschedule treatments (53%, 27/51), and experiencing physical, mental, or financial hardship due to wildfires (45%, 23/51). Respondents described effects on clinical operations, including being forced to transfer patients (24%, 12/51), transportation interruptions (37%, 19/51), regional/community evacuations (35%, 18/51), and physical/mental health effects (27%, 14/51) on clinic personnel. Less than half of the respondents (47%, 24/51) reported their workplace had a wildfire emergency preparedness plan. Additionally, geographic analysis revealed that 100% (176/176) of clinics were located within 25 miles of a wildfire.

Conclusions

This study highlights the effects of wildfires on radiation oncology clinics and patients and underscores the need for emergency preparedness planning to minimize the consequences of such disasters.

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.

Educational Attainment and Cancer Incidence in a Large Nationwide Prospective Cohort

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPACT

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

Cancer Research in 2030: A unique strategic planning process at a comprehensive cancer center

Following the successful renewal of its Cancer Center Support Grant (CCSG), leadership of the UCSF Helen Diller Comprehensive Cancer Center (HDFCCC) began a strategic planning process. The motivation was to think about where cancer research was going in the future; and with this vision to define a general scientific direction, mission, and priorities. HDFCCC Leadership began discussions about a new strategic plan in early 2018. From these meetings, the theme of "Cancer Research in 2030" arose: that is, what will cancer research look like in 2030? This forward-looking focus was intended to encourage creativity unconfined by a particular institutional structure or grant mechanism. Focusing on the science paved the way for an innovative, actionable, and motivating strategic planning process. Here, we describe the three-phase process, and the various groups involved across the HDFCCC and UCSF. We present the unique framework based on a cells-to-society model and an individual experience perspective, which led to the development of a logic model and ongoing implementation of tactics and tracking progress. We believe that sharing this process and its results will be of value to cancer centers and cancer researchers across the network of NCI comprehensive cancer centers, and cancer research centers in general.

The Pathways to Prevention program: nutrition as prevention for improved cancer outcomes

Adequate nutrition is central to well-being and health and can enhance recovery during illness. Although it is well known that malnutrition, both undernutrition and overnutrition, poses an added challenge for patients with cancer diagnoses, it remains unclear when and how to intervene and if such nutritional interventions improve clinical outcomes. In July 2022, the National Institutes of Health convened a workshop to examine key questions, identify related knowledge gaps, and provide recommendations to advance understanding about the effects of nutritional interventions. Evidence presented at the workshop found substantial heterogeneity among published randomized clinical trials, with a majority rated as low quality and yielding mostly inconsistent results. Other research cited trials in limited populations that showed potential for nutritional interventions to reduce the adverse effects associated with malnutrition in people with cancer. After review of the relevant literature and expert presentations, an independent expert panel recommends baseline screening for malnutrition risk using a validated instrument following cancer diagnosis and repeated screening during and after treatment to monitor nutritional well-being. Those at risk of malnutrition should be referred to registered dietitians for more in-depth nutritional assessment and intervention. The panel emphasizes the need for further rigorous, well-defined nutritional intervention studies to evaluate the effects on symptoms and cancer-specific outcomes as well as effects of intentional weight loss before or during treatment in people with overweight or obesity. Finally, although data on intervention effectiveness are needed first, robust data collection during trials is recommended to assess cost-effectiveness and inform coverage and implementation decisions.

Early Ascertainment of Breast Cancer Diagnoses Comparing Self-Reported Questionnaires and Electronic Health Record Data Warehouse: The WISDOM Study

PURPOSE

The goal of this study was to use real-world data sources that may be faster and more complete than self-reported data alone, and timelier than cancer registries, to ascertain breast cancer cases in the ongoing screening trial, the WISDOM Study.

METHODS

We developed a data warehouse procedural process (DWPP) to identify breast cancer cases from a subgroup of WISDOM participants (n = 11,314) who received breast-related care from a University of California Health Center in the period 2012-2021 by searching electronic health records (EHRs) in the University of California Data Warehouse (UCDW). Incident breast cancer diagnoses identified by the DWPP were compared with those identified by self-report via annual follow-up online questionnaires.

RESULTS

Our study identified 172 participants with confirmed breast cancer diagnoses in the period 2016-2021 by the following sources: 129 (75%) by both self-report and DWPP, 23 (13%) by DWPP alone, and 20 (12%) by self-report only. Among those with International Classification of Diseases 10th revision cancer diagnostic codes, no diagnosis was confirmed in 18% of participants.

CONCLUSION

For diagnoses that occurred ≥20 months before the January 1, 2022, UCDW data pull, WISDOM self-reported data via annual questionnaire achieved high accuracy (96%), as confirmed by the cancer registry. More rapid cancer ascertainment can be achieved by combining self-reported data with EHR data from a health system data warehouse registry, particularly to address self-reported questionnaire issues such as timing delays (ie, time lag between participant diagnoses and the submission of their self-reported questionnaire typically ranges from a month to a year) and lack of response. Although cancer registry reporting often is not as timely, it does not require verification as does the DWPP or self-report from annual questionnaires.

Family and personal history of cancer in the All of Us research program for precision medicine

The All of Us (AoU) Research Program is making available one of the largest and most diverse collections of health data in the US to researchers. Using the All of Us database, we evaluated family and personal histories of five common types of cancer in 89,453 individuals, comparing these data to 24,305 participants from the 2015 National Health Interview Survey (NHIS). Comparing datasets, we found similar family cancer history (33%) rates, but higher personal cancer history in the AoU dataset (9.2% in AoU vs. 5.11% in NHIS), Methodological (e.g. survey-versus telephone-based data collection) and demographic variability may explain these between-data differences, but more research is needed.

A complex systems model of breast cancer etiology: The Paradigm II Model

BACKGROUND

Complex systems models of breast cancer have previously focused on prediction of prognosis and clinical events for individual women. There is a need for understanding breast cancer at the population level for public health decision-making, for identifying gaps in epidemiologic knowledge and for the education of the public as to the complexity of this most common of cancers.

METHODS AND FINDINGS

We developed an agent-based model of breast cancer for the women of the state of California using data from the U.S. Census, the California Health Interview Survey, the California Cancer Registry, the National Health and Nutrition Examination Survey and the literature. The model was implemented in the Julia programming language and R computing environment. The Paradigm II model development followed a transdisciplinary process with expertise from multiple relevant disciplinary experts from genetics to epidemiology and sociology with the goal of exploring both upstream determinants at the population level and pathophysiologic etiologic factors at the biologic level. The resulting model reproduces in a reasonable manner the overall age-specific incidence curve for the years 2008-2012 and incidence and relative risks due to specific risk factors such as BRCA1, polygenic risk, alcohol consumption, hormone therapy, breastfeeding, oral contraceptive use and scenarios for environmental toxin exposures.

CONCLUSIONS

The Paradigm II model illustrates the role of multiple etiologic factors in breast cancer from domains of biology, behavior and the environment. The value of the model is in providing a virtual laboratory to evaluate a wide range of potential interventions into the social, environmental and behavioral determinants of breast cancer at the population level.

Abstract 1931: Racialized economic segregation and late-stage colorectal cancer in the United States, 2009-2017

We examined the association between racialized economic segregation and late-stage colorectal cancer (CRC) in the US. All CRC cases diagnosed during 2009-2017 were identified using the United States Cancer Statistics database. Late-stage CRC was determined according to the presence of distant involvement (node or site) of the tumor at diagnosis. Racialized economic segregation was measured at the county level by the Index of Concentration at the Extremes (ICE) using the 2013-2017 American Community Survey estimates. ICE was calculated to show the extent to which individuals’ residence at diagnosis was located in counties of concentrated advantage or disadvantage. Four ICE metrics were considered, consisting of the difference between the number of households with White individuals reporting incomes in the top quintile of the US distribution, and the number of households with non-White (all people of color (POC), Black, Latino, or Asian American/Pacific Islander) individuals reporting incomes in the lowest quintile, divided by the total of households in the county. ICE metrics were further divided into quintiles based on the distribution of all counties in the US, with Q1 denoting least advantaged counties and Q5 the most advantaged counties. Multilevel logistic regression models accounting for clustering at counties were fit. Models were adjusted for age at diagnosis, sex, race and ethnicity, census region and year of diagnosis. A total of 1,356,053 cases were included in the analysis; mean age at diagnosis was 67 years, 52% were men, and 20% of cases had a late-stage diagnosis. In adjusted analysis for ICE-POC, people residing in less advantaged counties had higher odds of late-stage diagnosis than people residing in the most advantaged counties (OR [95% CI], Q1: 1.08 [1.05-1.11], Q2: 1.06 [1.04-1.09], Q3: 1.04 [1.02-1.07], Q4: 1.03 [1.01-1.05], Q5: reference). Similar results were observed on all four ICE metrics. Racialized economic segregation was associated with higher odds of late-stage CRC. These findings underscore the role of institutionalized racism as a driver of health inequities, with laws and policies that led to residential segregation also impacting the conditions for timely preventive care.

Citation Format: Eduardo J. Santiago-Rodriguez, Salma Shariff-Marco, Zinzi D. Bailey, Justin S. White, Isabel E. Allen, Robert A. Hiatt. Racialized economic segregation and late-stage colorectal cancer in the United States, 2009-2017 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1931.

Thirty-year follow-up of the NICHD Study of Early Child Care and Youth Development (SECCYD): the challenges and triumphs of conducting in-person research at a distance

PURPOSE

The purpose of the current study, The National Institute of Child Health and Human Development (NICHD) Study of Health in Early and Adult Life (SHINE), was to build on the landmark Study of Early Child Care and Youth Development (SECCYD), a longitudinal birth cohort initiated in 1991, by conducting a health-focused follow-up of the now adult participants. This effort has produced an invaluable resource for the pursuit of life course research examining links between early life risk and resilience factors and adulthood health and disease risk.

PARTICIPANTS

Of the 927 NICHD SECCYD participants available for recruitment in the current study, 705 (76.1%) participated in the study. Participants were between 26 and 31 years and living in diverse geographic locations throughout the USA.

FINDINGS TO DATE

In descriptive analyses, the sample exhibited risk on health status indicators, especially related to obesity, hypertension and diabetes. Of particular concern, the prevalence of hypertension (29.4%) and diabetes (25.8%) exceeded national estimates in similar-age individuals. Health behaviour indicators generally tracked with the parameters of poor health status, showing a pattern of poor diet, low activity and disrupted sleep. The juxtaposition of the sample's relatively young age (mean=28.6 years) and high educational status (55.6% college educated or greater) with its poor health status is noteworthy, suggesting a dissociation between health and factors that are typically health protective. This is consistent with observed population health trends, which show a worsening of cardiometabolic health status in younger generations of Americans.

FUTURE PLANS

The current study, SHINE, lays the groundwork for future analyses in which the uniquely robust measures collected as a part of the original NICHD SECCYD will be leveraged to pinpoint specific early life risk and resilience factors as well as the correlates and potential mechanisms accounting for variability in health and disease risk indicators in young adulthood.

Disparities in Colorectal Cancer Screening by Time in the U.S. and Race/Ethnicity, 2010-2018

INTRODUCTION

Longer time lived in the U.S. has been associated with worse health outcomes, especially preventable diseases, among racially and ethnically diverse groups of foreign-born individuals. This study evaluated the association between time lived in the U.S. and colorectal cancer screening adherence and whether this relationship differed by race and ethnicity.

METHODS

Data from the National Health Interview Survey for 2010-2018 among adults aged 50-75 years were used. Time in the U.S. was categorized as U.S.-born, foreign-born ≥15 years, and foreign-born <15 years. Colorectal cancer screening adherence was defined according to U.S. Preventive Services Task Force guidelines. Generalized linear models with Poisson distribution were used to calculate adjusted prevalence ratios and 95% CIs. Analyses were conducted in 2020-2022, were stratified by race and ethnicity, accounted for the complex sampling design, and were weighted to be representative of the U.S.

RESULTS

Prevalence of colorectal cancer screening adherence was 63% overall, 64% for U.S.-born, 55% for foreign-born ≥15 years, and 35% for foreign-born <15 years. In fully adjusted models for all individuals, only foreign-born <15 years had lower adherence than U.S.-born (foreign-born ≥15 years: prevalence ratio=0.97 [0.95, 1.00], foreign-born <15 years: prevalence ratio=0.79 [0.71, 0.88]). Results differed by race and ethnicity (p-interaction=0.002). In stratified analyses, findings for non-Hispanic White individuals (foreign-born ≥15 years: prevalence ratio=1.00 [0.96, 1.04], foreign-born <15 years: prevalence ratio=0.76 [0.58, 0.98]) and non-Hispanic Black individuals (foreign-born ≥15 years: prevalence ratio=0.94 [0.86, 1.02], foreign-born <15 years: prevalence ratio=0.61 [0.44, 0.85]) were similar to all individuals. Disparities by time in the U.S. were not observed among Hispanic/Latino individuals (foreign-born ≥15 years: prevalence ratio=0.98 [0.92, 1.04], foreign-born <15 years: prevalence ratio=0.86 [0.74, 1.01]) but persisted among Asian American/Pacific Islander individuals (foreign-born ≥15 years: prevalence ratio=0.84 [0.77, 0.93], foreign-born <15 years: prevalence ratio=0.74 [0.60, 0.93]).

CONCLUSIONS

The relationship between colorectal cancer screening adherence and time in the U.S. varied by race and ethnicity. Culturally and ethnically tailored interventions are needed to improve colorectal cancer screening adherence among foreign-born people, especially among the most recently immigrated individuals.

Enhancing grant-writing expertise in BUILD institutions: Building infrastructure leading to diversity

BACKGROUND

The lack of race/ethnic and gender diversity in grants funded by the National Institutes of Health (NIH) is a persistent challenge related to career advancement and the quality and relevance of health research. We describe pilot programs at nine institutions supported by the NIH-sponsored Building Infrastructure Leading to Diversity (BUILD) program aimed at increasing diversity in biomedical research.

METHODS

We collected data from the 2016-2017 Higher Education Research Institute survey of faculty and NIH progress reports for the first four years of the program (2015-2018). We then conducted descriptive analyses of data from the nine BUILD institutions that had collected data and evaluated which activities were associated with research productivity. We used Poisson regression and rate ratios of the numbers of BUILD pilots funded, students included, abstracts, presentations, publications, and submitted and funded grant proposals.

RESULTS

Teaching workshops were associated with more abstracts (RR 4.04, 95% CI 2.21-8.09). Workshops on grant writing were associated with more publications (RR 2.64, 95% CI 1.64-4.34) and marginally with marginally more presentations. Incentives to develop courses were associated with more abstracts published (RR 4.33, 95% CI 2.56-7.75). Workshops on research skills and other incentives were not associated with any positive effects.

CONCLUSIONS

Pilot interventions show promise in supporting diversity in NIH-level research. Longitudinal modeling that considers time lags in career development in moving from project development to grants submissions can provide more direction for future diversity pilot interventions.

Frailty and risk of mortality in older cancer survivors and adults without a cancer history: Evidence from the National Health and Nutrition Examination Survey, 1999-2014

BACKGROUND

Epidemiologic evidence reporting the role of frailty in survival among older adults with a prior cancer diagnosis is limited.

METHODS

A total of 2050 older adults (≥60 years old) surviving for at least 1 year after a cancer diagnosis and 9474 older adults without a cancer history from the National Health and Nutrition Examination Survey (1999-2014) were included for analysis. The exposure variable, a 45-item frailty index (FI), was categorized on the basis of validated cutoffs (FI ≤ 0.10 [fit], 0.10 < FI ≤ 0.21 [prefrail], and FI > 0.21 [frail]). All-cause mortality was ascertained via the National Death Index. Multivariable Cox proportional hazards models were used to estimate adjusted hazard ratios (aHRs) and 95% confidence interval (CIs) for the FI, and this was followed by restricted cubic splines depicting dose-response curves.

RESULTS

For older cancer survivors, the mean age at the baseline was 72.6 years (SD, 7.1 years); 5.9% were fit, 38.2% were prefrail, and 55.9% were frail. Older adults without a cancer history were slightly younger (mean age, 70.0 years) and less frail (47.9% were frail). At each level of the FI, cancer survivors (1.9 per 100 person-years for FI ≤ 0.10, 3.4 per 100 person-years for 0.10 < FI ≤ 0.21, and 7.5 per 100 person-years for FI > 0.21) had higher mortality than their cancer-free counterparts (1.4 per 100 person-years for FI ≤ 0.10, 2.4 per 100 person-years for 0.10 < FI ≤ 0.21, and 5.4 per 100 person-years for FI > 0.21). The multivariable model suggested a positive association between the FI and all-cause mortality for survivors (aHR for FI > 0.21 vs FI ≤ 0.10, 2.80; 95% CI, 1.73-4.53) and participants without a cancer history (aHR for FI > 0.21 vs FI ≤ 0.10, 2.75; 95% CI, 2.29-3.32). Restricted cubic splines indicated that all-cause mortality risk increased with the FI in a monotonic pattern.

CONCLUSIONS

Frailty is associated with a higher risk of death in older cancer survivors and the elderly without a cancer history.

Catchment Areas, Community Outreach and Engagement Revisited: The 2021 Guidelines for Cancer Center Support Grants from the National Cancer Institute

New guidelines for Cancer Center Support Grants have recently been issued by the NCI that require increased attention to cancer center catchment areas and their community outreach and engagement activities [PAR-21-321]. Past experience with these requirements has engendered some confusion and frustration on the part of both researchers and reviewers that these new guidelines aim to dispel. In this commentary we, as experienced cancer center leaders in population sciences, offer our views on the most important aspects of the new guidelines and provide three examples of the kinds of programs that can apply cancer prevention and control research to improve cancer population health. With 71 NCI-Designated Cancer Centers in 36 states, the potential for broad impact on the reduction of the nation's cancer burden is enormous if the intended application of cancer center research to individuals and populations is fulfilled.

A Socio-Ecological Framework for Cancer Prevention in Low and Middle-Income Countries

Cancer incidence and mortality rates continue to rise globally, a trend mostly driven by preventable cancers occurring in low-and middle-income countries (LMICs). There is growing concern that many LMICs are ill-equipped to cope with markedly increased burden of cancer due to lack of comprehensive cancer control programs that incorporate primary, secondary, and tertiary prevention strategies. Notably, few countries have allocated budgets to implement such programs. In this review, we utilize a socio-ecological framework to summarize primary (risk reduction), secondary (early detection), and tertiary (treatment and survivorship) strategies to reduce the cancer burden in these countries across the individual, organizational, community, and policy levels. We highlight strategies that center on promoting health behaviors and reducing cancer risk, including diet, tobacco, alcohol, and vaccine uptake, approaches to promote routine cancer screenings, and policies to support comprehensive cancer treatment. Consistent with goals promulgated by the United Nations General Assembly on Noncommunicable Disease Prevention and Control, our review supports the development and implementation of sustainable national comprehensive cancer control plans in partnership with local communities to enhance cultural relevance and adoption, incorporating strategies across the socio-ecological framework. Such a concerted commitment will be necessary to curtail the rising cancer and chronic disease burden in LMICs.

Impact of language preference and health literacy on health information-seeking experiences among a low-income, multilingual cohort

OBJECTIVE

We examined the impact of language preference and health literacy on health information-seeking experiences in a multilingual, low-income cohort.

METHODS

We administered a modified Health Information National Trends Survey in English, Spanish, and Chinese to a sample of San Francisco city/county residents. Using multivariable logistic regression analyses, we assessed how language and health literacy impact health information-seeking experiences (confidence, effort, frustration, quality concerns, and difficulty understanding information), adjusting for age, gender, race/ethnicity, education, usual place of care, health status, information-seeking behaviors, and smartphone ownership.

RESULTS

Of 1000 participants (487 English-speaking, 256 Spanish-speaking, 257 Chinese-speaking), 820 (82%) reported at least one negative health information-seeking experience. Chinese-language was associated with frustration (aOR = 2.56; 1.12-5.86). Difficulty understanding information was more likely in Spanish-language respondents (aOR = 3.58; 1.25-10.24). Participants with limited health literacy reported more effort (aOR = 1.97; 1.22-3.17), frustration (aOR = 2.09; 1.28-3.43), concern about quality (aOR = 2.72; 1.60-4.61), and difficulty understanding information (aOR = 2.53; 1.58-4.05). Language and literacy impacted confidence only in the interaction term between Chinese-speakers and health literacy.

CONCLUSION

We found that negative health information-seeking experiences were common in non-English speaking populations those with limited health literacy.

PRACTICE IMPLICATIONS

Health communication efforts should consider both language preference and health literacy to ensure accessibility for all patients.

Socioeconomic status and colorectal cancer screening behaviors in a vulnerable multiethnic population

OBJECTIVE

Despite some progress in recent years, colorectal cancer (CRC) screening adherence in the United States is still suboptimal, particularly among disadvantaged groups. In this study, we assessed the association between socioeconomic status (SES) and self-reported screening non-adherence (SNA) in a sample of racial/ethnic minorities living in San Francisco, California.

DESIGN/METHODS

A total of 376 participants of the San Francisco version of the Health Information National Trends Survey (SF-HINTS) with ages 50-75 years were included in this cross-sectional study. SNA was defined as not reporting blood stool test within the past year and not reporting sigmoidoscopy/colonoscopy within the past 10 years. Poisson regression models with robust variance estimators were used to evaluate the relation of SES with SNA, adjusting for measured confounders. Results are reported as prevalence ratios (PR) and 95% confidence intervals (95% CI).

RESULTS

Overall SNA was 40%. In multivariable models including all respondents, retired participants had significantly lower SNA prevalence than employed participants (PR = 0.46, 95% CI = 0.26 0.83). In stratified analyses by race/ethnicity, Black respondents with less than high school (PR = 1.93, 95% CI = 1.09, 3.43) and those with high school or equivalent (PR = 1.88, 95% CI = 1.16, 3.04) had significantly higher SNA prevalence than those with at least some college. Among non-Hispanic Asian/Pacific Islanders, those disabled had significantly higher prevalence of SNA as compared to employed people (PR = 4.26, 95% CI = 2.11, 8.60). None of the SES indicators were significantly associated to SNA among Hispanics.

CONCLUSIONS

Participants with lower SES characteristics were less likely to adhere to CRC screening guidelines and being retired was a predictor of compliance. There was evidence of heterogeneity in associations between SES and CRC screening by race/ethnicity. Life circumstances of retired people could provide insights for designing interventions aimed to improve CRC screening uptake in these priority groups. Future efforts should consider mechanisms underlying differences by race/ethnicity.

Exploring factors associated with hepatitis B screening in a multilingual and diverse population

BACKGROUND

Racial/ethnic minorities bear a disproportionate burden of hepatitis B virus (HBV) infection and disease. Disparities in HBV screening contribute to worse outcomes for communities of color. We examined the impact of race/ethnicity, language preference, and having a usual place of care on HBV screening in a multilingual, urban cohort.

METHODS

We used questions from the Health Information National Trends Survey and added validated questions about healthcare access and health literacy. We administered this survey in English, Spanish, and Chinese to a selected convenience sample of San Francisco city/county residents in 2017, with pre-specified targets for populations with known cancer disparities: 25% Spanish-speaking, 25% Chinese-speaking, and 25% Black Americans. Using weighted multivariable logistic regression analyses, we assessed how race/ethnicity, language preference, and having a usual place of care impacts self-report of HBV screening.

RESULTS

Overall, 1027 participants completed the survey (50% of surveys administered in English, 25% in Spanish, and 25% in Chinese). Only 50% of participants reported HBV screening. In multivariable analysis, Black (OR = 0.20, 95% CI 0.08-0.49), Latinx (OR = 0.33, 95% CI 0.13-0.85), Asian (OR = 0.31, 95% CI 0.10, 0.94), and 'Other' race/ethnicity (OR = 0.17, 95% CI 0.05-0.53) respondents had lower odds of HBV screening compared to non-Hispanic White respondents. Participants who had insurance had increased odds of HBV screening (OR = 2.70, 95% CI 1.48-4.93).

CONCLUSIONS

HBV screening disparities persist for Black Americans, Asian Americans, Latinx, and the uninsured. Future studies should explore reasons why current strategies have not been implemented or are not successful, particularly in addressing racial/ethnic and insurance disparities.

From Cancer Epidemiology to Policy and Practice: the Role of a Comprehensive Cancer Center

Purpose of Review

Cancer incidence and mortality are decreasing, but inequities in outcomes persist. This paper describes the San Francisco Cancer Initiative (SF CAN) as a model for the systematic application of epidemiological evidence to reduce the cancer burden and associated inequities.

Recent Findings

SF CAN is a multi-institutional implementation of existing evidence on the prevention and early detection of five common cancers (i.e., breast, prostate, colorectal, liver, and lung/tobacco-related cancers) accounting for 50% of cancer deaths in San Francisco. Five Task Forces follow individual logic models designating inputs, outputs, and outcomes. We describe the progress made and the challenges faced by each Task Force after 5 years of activity.

Summary

SF CAN is a model for how the nation’s Comprehensive Cancer Centers are ideally positioned to leverage cancer epidemiology for evidence-based initiatives that, along with genuine community engagement and multiple stakeholders, can reduce the population burden of cancer.

Risk Factors Associated With Early-Onset Esophageal Cancer in Tanzania

Eastern Africa is one of several regions affected by high incidence rates of esophageal squamous cell carcinoma (ESCC). A unique epidemiologic feature of ESCC in Eastern Africa is the high incidence in young people, with one-third of cases diagnosed at age < 45 years. This study aimed to investigate risk factors for early-onset ESCC in Tanzania through a secondary analysis of a matched case-control study.

Data from Tanzania show esophageal cancer risk factors in East Africa may differ across age groups.

Cancer Risk Behaviors, Cancer Beliefs, and Health Information Seeking Among Under-Represented Populations in San Francisco: Differences by Sexual Orientation and Gender Identity

Purpose

Sexual and gender minority (SGM) individuals in the United States are at increased risk of cancer compared to the non-SGM population. Understanding how SGM persons perceive cancer risk and their practices and preferences for accessing health information is key for improving the preventive and health care services they receive.

Methods

In this cross-sectional study, we analyzed data from the San Francisco Health Information National Trends Survey. SGM individuals were identified by self-report. Differences in cancer risk factors, cancer beliefs, and health information seeking were evaluated by SGM status using multivariable logistic regression models.

Results

Out of 1027 participants, 130 (13%) reported being SGM individuals. Current smoking (odds ratio [OR]=1.93, 95% confidence interval [CI]=1.24-3.01) and alcohol use (OR=1.69, 95% CI=1.10-2.59) were more common among SGM persons than among non-SGM persons. No differences by SGM status were observed in health information seeking behaviors, preferences, and cancer beliefs, but SGM participants reported significantly higher odds of feeling frustrated (OR=1.78, 95% CI=1.20-2.64) and having concerns about the quality of the information (OR=1.54, 95% CI=1.03-2.31) during their most recent health information search.

Conclusions

Intervention efforts aimed at SGM individuals with current use of tobacco and/or alcohol should be expanded. SGM communities also need improved access to consistent, reliable, and accurate sources of health information. Their increased frustration when seeking health information and concerns about the quality of the information they find have important implications for SGM health and care, and the drivers of these differences merit further evaluation.

Geographic Variation in Obesity at the State Level in the All of Us Research Program

INTRODUCTION

National obesity prevention strategies may benefit from precision health approaches involving diverse participants in population health studies. We used cohort data from the National Institutes of Health All of Us Research Program (All of Us) Researcher Workbench to estimate population-level obesity prevalence.

METHODS

To estimate state-level obesity prevalence we used data from physical measurements made during All of Us enrollment visits and data from participant electronic health records (EHRs) where available. Prevalence estimates were calculated and mapped by state for 2 categories of body mass index (BMI) (kg/m2): obesity (BMI >30) and severe obesity (BMI >35). We calculated and mapped prevalence by state, excluding states with fewer than 100 All of Us participants.

RESULTS

Data on height and weight were available for 244,504 All of Us participants from 33 states, and corresponding EHR data were available for 88,840 of these participants. The median and IQR of BMI taken from physical measurements data was 28.4 (24.4- 33.7) and 28.5 (24.5-33.6) from EHR data, where available. Overall obesity prevalence based on physical measurements data was 41.5% (95% CI, 41.3%-41.7%); prevalence of severe obesity was 20.7% (95% CI, 20.6-20.9), with large geographic variations observed across states. Prevalence estimates from states with greater numbers of All of Us participants were more similar to national population-based estimates than states with fewer participants.

CONCLUSION

All of Us participants had a high prevalence of obesity, with state-level geographic variation mirroring national trends. The diversity among All of Us participants may support future investigations on obesity prevention and treatment in diverse populations.

Patterns of Early Life Weight Gain and Female Onset of Puberty

Context

Prepubertal obesity is a well-established predictor of earlier pubertal onset, which is itself a risk factor for poor health and well-being. Identifying specific patterns of weight gain in early life may help explain differential risk for earlier pubertal onset.

Objective

The objective of the study was to examine patterns of weight gain across infancy and early childhood in relation to pubertal onset outcomes.

Design, Setting, and Participants

Participants were 426 girls in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development, a longitudinal birth cohort of children and their families followed between birth and adolescence.

Main Outcome Measures

Three pubertal onset outcomes were examined, including age at menarche and ages at Tanner stage II for dimensions of breast and pubic hair development.

Results

In infancy (birth to 15 months), greater percent weight gain and higher birthweight predicted earlier pubertal onset for all outcomes (Ps < 0.05). In early childhood (24 months to grade 1), body mass index (BMI) trajectories reflecting BMI values that were persistently high or changed from low to high over time (vs BMI values that were stable at median or low levels), predicted younger ages at menarche and the onset of breast (Ps < 0.05), but not pubic hair (Ps > 0.05), development. All associations were independent of breastfeeding, maternal menarcheal age, and race/ethnicity.

Conclusions

Distinct patterns of early life weight gain predict differential risk for earlier onset puberty. Focusing on these patterns for earlier and more targeted intervention may help lessen life course linkages between prepubertal obesity, accelerated pubertal development, and negative postpubertal outcomes.

Elevated risk thresholds predict endocrine risk-reducing medication use in the Athena screening registry

Risk-reducing endocrine therapy use, though the benefit is validated, is extremely low. The FDA has approved tamoxifen and raloxifene for a 5-year Breast Cancer Risk Assessment Tool (BCRAT) risk ≥ 1.67%. We examined the threshold at which high-risk women are likely to be using endocrine risk-reducing therapies among Athena Breast Health Network participants from 2011-2018. We identified high-risk women by a 5-year BCRAT risk ≥ 1.67% and those in the top 10% and 2.5% risk thresholds by age. We estimated the odds ratio (OR) of current medication use based on these thresholds using logistic regression. One thousand two hundred and one (1.2%) of 104,223 total participants used medication. Of the 33,082 participants with 5-year BCRAT risk ≥ 1.67%, 772 (2.3%) used medication. Of 2445 in the top 2.5% threshold, 209 (8.6%) used medication. Participants whose 5-year risk exceeded 1.67% were more likely to use medication than those whose risk was below this threshold, OR 3.94 (95% CI = 3.50-4.43). The top 2.5% was most strongly associated with medication usage, OR 9.50 (8.13-11.09) compared to the bottom 97.5%. Women exceeding a 5-year BCRAT ≥ 1.67% had modest medication use. We demonstrate that women in the top 2.5% have higher odds of medication use than those in the bottom 97.5% and compared to a risk of 1.67%. The top 2.5% threshold would more effectively target medication use and is being tested prospectively in a randomized control clinical trial.

Childhood Socioeconomic Status and Menarche: A Prospective Study

PURPOSE

The relationship between socioeconomic status (SES) and menarche has implications for understanding social level influences on early life development and adult disease, including breast cancer, but remains ill defined. We report here results from the Breast Cancer and the Environment Research Program, which permitted a longitudinal study of age at menarche in relationship to childhood SES in a diverse cohort of 1,069 girls across three urban areas of the United States.

METHODS

We assessed the association of SES index quintiles with age at pubertal onset with breast budding and subsequent tempo to the age at menarche between 2004 and 2015 using multiple-event Cox regression models to estimate hazard ratios and 95% confidence intervals.

RESULTS

In an unadjusted model, lower SES was predictive of both earlier pubertal onset and tempo and thus earlier age at menarche in trends across quintiles. After adjusting for the potentially mediating effects of body mass index, SES trends remained significant for both outcomes. After adjusting for both body mass index and race/ethnicity, the association with SES remained substantial for pubertal onset but was much diminished and nonsignificant for tempo and thus age at menarche.

CONCLUSIONS

These results suggest that a lower SES environment and social adversity affect the age at menarche primarily by hastening pubertal onset rather than by shortening tempo.

Early Life Adversity and Pubertal Timing: Implications for Cardiometabolic Health

OBJECTIVE

To identify early life adversity (ELA) risk factors for earlier pubertal timing, itself a risk factor for poor cardiometabolic health, and to determine whether such ELA-related risk may be mediated by pre-pubertal body mass index (BMI).

METHODS

Subjects included 426 female participants in a prospective birth cohort study, the NICHD Study of Early Child Care and Youth Development. Survival analysis models were fit to examine ELA exposures, representing childhood socioeconomic status (SES), maternal sensitivity, mother-child attachment, and negative life events, along with child health indicators and covariates, in relation to pubertal timing outcomes, including age at menarche and ages at Tanner stage II for breast and pubic hair development.

RESULTS

Higher childhood SES emerged as an independent predictor of older age at menarche, showing each one standard deviation increase in childhood SES corresponded to a 1.3% increase in age at menarche (factor change = 1.013; 1.003-1.022; p < .01), but did not predict breast or pubic hair development (ps > .05). In mediation analyses, indirect (mediated) effects of mother-child attachment on the pubertal timing outcomes, via pre-pubertal BMI, were all statistically significant (ps < .05).

CONCLUSIONS

Higher childhood SES predicted directly, and secure (vs. insecure) mother-child attachment predicted indirectly (via pre-pubertal BMI), later pubertal timing, suggesting these factors may protect girls from earlier pubertal development. By extension, clinical implications are that intervention strategies designed to lessen ELA- and pre-pubertal obesity-related risk may be effective in remediating life course pathways linking ELA, accelerated pubertal development, and cardiometabolic risk.

Cancer and climate change

The acute impact of climate change on human health is receiving increased attention, but little is known or appreciated about the effect of climate change on chronic diseases, particularly cancer. This Review provides a synopsis of what is known about climate change and the exposures it generates relevant to cancer. In the context of the world's cancer burden and the probable direction we could expect to follow in the absence of climate change, this scoping review of the literature summarises the effects that climate change is having on major cancers, from environmental exposures to ultraviolet radiation, air pollution, disruptions in the food and water supply, environmental toxicants, and infectious agents. Finally, we explore the effect of climate change on the possible disruption of health systems that have been essential to cancer control practice. We conclude with potential responses and opportunities for intervention.

A Complex Systems Model of Breast Cancer Etiology: The Paradigm II Conceptual Model

BACKGROUND

The etiology of breast cancer is a complex system of interacting factors from multiple domains. New knowledge about breast cancer etiology continues to be produced by the research community, and the communication of this knowledge to other researchers, practitioners, decision makers, and the public is a challenge.

METHODS

We updated the previously published Paradigm model (PMID: 25017248) to create a framework that describes breast cancer etiology in four overlapping domains of biologic, behavioral, environmental, and social determinants. This new Paradigm II conceptual model was part of a larger modeling effort that included input from multiple experts in fields from genetics to sociology, taking a team and transdisciplinary approach to the common problem of describing breast cancer etiology for the population of California women in 2010. Recent literature was reviewed with an emphasis on systematic reviews when available and larger epidemiologic studies when they were not. Environmental chemicals with strong animal data on etiology were also included.

RESULTS

The resulting model illustrates factors with their strength of association and the quality of the available data. The published evidence supporting each relationship is made available herein, and also in an online dynamic model that allows for manipulation of individual factors leading to breast cancer (https://cbcrp.org/causes/).

CONCLUSIONS

The Paradigm II model illustrates known etiologic factors in breast cancer, as well as gaps in knowledge and areas where better quality data are needed.

IMPACT

The Paradigm II model can be a stimulus for further research and for better understanding of breast cancer etiology.

Abstract IA02: Science to policy for a ban on the sale of menthol and flavored tobacco products: The San Francisco Cancer Initiative (SF CAN)

The San Francisco Cancer Initiative (SF CAN) seeks to implement evidence-based interventions for the top five most prevalent cancers for which prevention and early detection procedures are available. In San Francisco, breast, prostate, colorectal, liver, and lung and other tobacco-caused cancers account for 48% of cancer mortality, and cancer is now the leading cause of death. SF CAN uses a “collective impact” structure whereby multiple health systems, the Department of Public Health, safety net clinics, nongovernmental agencies, and community groups all work together on the same goal of accelerating the reduction in cancer mortality at the population level, with the University of California San Francisco (UCSF) serving as the backbone entity. SF CAN has been active for 3 years and is supported by philanthropy, grants, and in-kind contributions from collaborative partners. Implementation work is carried out by five task forces, each made up of members from UCSF and collaborating institutions and agencies. The Tobacco Task Force, led by Dr. Stanton Glantz and his colleagues, has sought to have an impact on the use of menthol and flavored cigarettes on African Americans and other targeted ethnic groups, youth, and young adult tobacco use and tobacco cessation among homeless and substance-abusing populations within the city. Some of the interventions they are implementing, based on scientific evidence of impact, have had or will have direct policy implications. Foremost among these has been the use of evidence on the impact of menthol cigarettes, commonly used by African American, Latino, and LGBT communities. The Task Force investigators assembled data on both the biologic mechanisms by which menthol additives increase the likelihood of addiction and the historical data from examination of documents obtained through legal channels from the tobacco industry. These data were first supplied to the FDA to assist in their decision-making and then made available to San Francisco Supervisors for their consideration for actions by local government ordinance. After consideration of the evidence and motivated by the health issues of their constituents, they wrote an ordinance completely banning the sale of all flavored tobacco products (including menthol). The ordinance passed unanimously in June 2017 and was signed into law by then-Mayor Lee. A petition drive to revoke the ordinance by referendum, heavily financed by RJ Reynolds Tobacco (maker of the leading menthol cigarette, Newport) with support from other tobacco companies, failed with 68% of voters in favor of keeping the ban. The ordinance went into effect in July 2018 with systematic outreach and education to retailers of tobacco by the SF DPH, and initial inspections were begun in Dec 2018 and have continued as routine since April of 2019 and found strong by tobacco outlets. This and other efforts at policy change in tobacco that have been conducted in the area of health economics of tobacco use and in the institution of smoke-free areas in homeless shelters around the city will be described.

Citation Format: Robert A. Hiatt. Science to policy for a ban on the sale of menthol and flavored tobacco products: The San Francisco Cancer Initiative (SF CAN) [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 IA02.

The Use of Technology for Communicating With Clinicians or Seeking Health Information in a Multilingual Urban Cohort: Cross-Sectional Survey

Background

Technology is being increasingly used to communicate health information, but there is limited knowledge on whether these strategies are effective for vulnerable populations, including non–English speaking or low-income individuals.

Objective

This study assessed how language preferences (eg, English, Spanish, or Chinese), smartphone ownership, and the type of clinic for usual source of care (eg, no usual source of care, nonintegrated safety net, integrated safety net, private or community clinic, academic tertiary medical center, or integrated payer-provider) affect technology use for health-related communication.

Methods

From May to September 2017, we administered a nonrandom, targeted survey to 1027 English-, Spanish-, and Chinese-speaking San Francisco residents and used weighted multivariable logistic regression analyses to assess predictors of five technology use outcomes. The three primary predictors of interest—language preference, smartphone ownership, and type of clinic for usual care—were adjusted for age, gender, race or ethnicity, limited English proficiency, educational attainment, health literacy, and health status. Three outcomes focused on use of email, SMS text message, or phone apps to communicate with clinicians. The two other outcomes were use of Web-based health videos or online health support groups.

Results

Nearly one-third of participants watched Web-based health videos (367/1027, 35.74%) or used emails to communicate with their clinician (318/1027, 30.96%). In adjusted analyses, individuals without smartphones had significantly lower odds of texting their clinician (adjusted odds ratio [aOR] 0.27, 95% CI 0.13-0.56), using online health support groups (aOR 0.14, 95% CI 0.04-0.55), or watching Web-based health videos (aOR 0.31, 95% CI 0.15-0.64). Relative to English-speaking survey respondents, individuals who preferred Chinese had lower odds of texting their clinician (aOR 0.25, 95% CI 0.08-0.79), whereas Spanish-speaking survey respondents had lower odds of using apps to communicate with clinicians (aOR 0.34, 95% CI 0.16-0.75) or joining an online support group (aOR 0.30, 95% CI 0.10-0.92). Respondents who received care from a clinic affiliated with the integrated safety net, academic tertiary medical center, or integrated payer-provider systems had higher odds than individuals without a usual source of care at using emails, SMS text messages, or apps to communicate with clinicians.

Conclusions

In vulnerable populations, smartphone ownership increases the use of many forms of technology for health purposes, but device ownership itself is not sufficient to increase the use of all technologies for communicating with clinicians. Language preference impacts the use of technology for health purposes even after considering English proficiency. Health system factors impact patients’ use of technology-enabled approaches for communicating with clinicians. No single factor was associated with higher odds of using technology for all health purposes; therefore, existing disparities in the use of digital health tools among diverse and vulnerable populations can only be addressed using a multipronged approach.

Factors associated with biomedical research participation within community-based samples across 3 National Cancer Institute-designated cancer centers

BACKGROUND

Engaging diverse populations in biomedical research, including biospecimen donation, remains a national challenge. This study examined factors associated with an invitation to participate in biomedical research, intent to participate in biomedical research in the future, and participation in biomedical research and biospecimen donation among a diverse, multilingual, community-based sample across 3 distinct geographic areas.

METHODS

Three National Cancer Institute-designated cancer centers engaged in community partnerships to develop and implement population health assessments, reaching a convenience sample of 4343 participants spanning their respective catchment areas. Data harmonization, multiple imputation, and multivariable logistic modeling were used.

RESULTS

African Americans, Hispanic/Latinos, and other racial minority groups were more likely to be offered opportunities to participate in biomedical research compared to whites. Access to care, history of cancer, educational level, survey language, nativity, and rural residence also influenced opportunity, intent, and actual participation in biomedical research.

CONCLUSIONS

Traditionally underserved racial and ethnic groups reported heightened opportunity and interest in participating in biomedical research. Well-established community partnerships and long-standing community engagement around biomedical research led to a diverse sample being reached at each site and may in part explain the current study findings. However, this study illustrates an ongoing need to establish trust and diversify biomedical research participation through innovative and tailored approaches. National Cancer Institute-designated cancer centers have the potential to increase opportunities for diverse participation in biomedical research through community partnerships and engagement. Additional work remains to identify and address system-level and individual-level barriers to participation in both clinical trials and biospecimen donation for research.

Breast Cancer in San Francisco: Disentangling Disparities at the Neighborhood Level

BACKGROUND

This study uses a novel geographic approach to summarize the distribution of breast cancer in San Francisco and aims to identify the neighborhoods and racial/ethnic groups that are disproportionately affected by this disease.

METHODS

Nine geographic groupings were newly defined on the basis of racial/ethnic composition and neighborhood socioeconomic status. Distribution of breast cancer cases from the Greater Bay Area Cancer Registry in these zones were examined. Multivariable logistic regression models were used to determine neighborhood associations with stage IIB⁺ breast cancer at diagnosis. Cox proportional hazards regression was used to estimate the hazard ratios for all-cause and breast cancer-specific mortality.

RESULTS

A total of 5,595 invasive primary breast cancers were diagnosed between January 1, 2006 and December 31, 2015. We found neighborhood and racial/ethnic differences in stage of diagnosis, molecular subtype, survival, and mortality. Patients in the Southeast (Bayview/Hunter's Point) and Northeast (Downtown, Civic Center, Chinatown, Nob Hill, Western Addition) areas were more likely to have stage IIB⁺ breast cancer at diagnosis, and those in the East (North Beach, Financial District, South of Market, Mission Bay, Potrero Hill) and Southeast were more likely to be diagnosed with triple-negative breast cancers (TNBC). Compared with other racial/ethnic groups, Blacks/African Americans (B/AA) experienced the greatest disparities in breast cancer-related outcomes across geographic areas.

CONCLUSIONS

San Francisco neighborhoods with lower socioeconomic status and larger minority populations experience worse breast cancer outcomes.

IMPACT

Our findings, which reveal breast cancer disparities at sub-county geographic levels, have implications for population-level health interventions.

Environmental Tobacco Smoke Exposure in Relation to Family Characteristics, Stressors and Chemical Co-Exposures in California Girls

Childhood environmental tobacco smoke (ETS) exposure is a risk factor for adverse health outcomes and may disproportionately burden lower socioeconomic status groups, exacerbating health disparities. We explored associations of demographic factors, stressful life events, and chemical co-exposures, with cotinine levels, among girls in the CYGNET Study. Data were collected from families of girls aged 6–8 years old in Northern California, through clinic exams, questionnaires and biospecimens (n = 421). Linear regression and factor analysis were conducted to explore predictors of urinary cotinine and co-exposure body burdens, respectively. In unadjusted models, geometric mean cotinine concentrations were higher among Black (0.59 ug/g creatinine) than non-Hispanic white (0.27), Asian (0.32), or Hispanic (0.34) participants. Following adjustment, living in a rented home, lower primary caregiver education, and lack of two biologic parents in the home were associated with higher cotinine concentrations. Girls who experienced parental separation or unemployment in the family had higher unadjusted cotinine concentrations. Higher cotinine was also associated with higher polybrominated diphenyl ether and metals concentrations. Our findings have environmental justice implications as Black and socio-economically disadvantaged young girls experienced higher ETS exposure, also associated with higher exposure to other chemicals. Efforts to reduce ETS and co-exposures should account for other disparity-related factors.

How current reporting practices may mask differences: A call for examining cancer-specific demographic enrollment patterns in cancer treatment clinical trials

Background

A lack of diversity among clinical trial (CT) participants remains a critical problem. Few studies have examined recruitment variability in cancer treatment CTs by cancer type. Given the increasing organ-specific specialization of oncologic care, an understanding of this variability may affect institutional recruitment practices.

Methods

This study examines three data sources from 2010 through 2014. The analyzed sample includes 3,580 CT participants identified in the institutional Clinical Trials Management System (CTMS) database and 20,305 incident cases of invasive cancer within a Comprehensive Cancer Center (CCC) institutional catchment area. A total of 341,114 incident cases of primary invasive cancer were identified through the California Cancer Registry (CCR). The primary study measurements were sociodemographic characteristics of the three populations (age, sex, race/ethnicity, and health insurance).

Results

Racial/ethnic disparities were observed, with more incident cases of Whites seen in cancer center (68%) and enrolled in CTs (72%) compared to incident cases in catchment area (67%) (p < 0.001) overall. More older adults (65) were enrolled in prostate cancer CTs (58%) than seen in cancer center (45%) (p < 0.001). Alternatively, fewer older adults were enrolled in breast and colorectal CTs than seen in cancer center (p < 0.001). Among colon (p < 0.001), breast (p < 0.001), and prostate (p<0.001) cancer types, insurance type significantly varied between incident cases in catchment area, cancer center, and among CT participants. For colorectal cancer, no difference in sex distribution was observed overall. A significant difference in insurance type within each cancer type was observed (p < 0.001).

Conclusions

These findings suggest that reporting overall recruitment frequencies may mask differences by cancer type.

Longitudinal study of age of menarche in association with childhood concentrations of persistent organic pollutants

BACKGROUND

Age at female puberty is associated with adult morbidities, including breast cancer and diabetes. Hormonally active chemicals are suspected of altering pubertal timing. We examined whether persistent organic pollutants (POPs) are associated with age at menarche in a longitudinal study.

METHODS

We analyzed data for females enrolled at age 6-8 years in the Breast Cancer and Environment Research Program from California and Ohio. Participants were followed annually 2004-2013 and provided serum (mean age 7.8 years) for measurement of polychlorinated biphenyl (PCB), organochlorine pesticide (OCP), and polybrominated diphenyl ether (PBDE) concentrations. Age of menarche was assigned based on parental and participant reported dates and ages of menarche. Adjusted hazard ratios (aHRs) for menarchal onset were calculated with Cox proportional regression. Body mass index (BMI), potentially on the causal pathway, was added to parallel analyses.

RESULTS

Age of menarche was later with higher summed PCB levels (median 11.9 years in quartile 1 [Q1] versus 12.7 in quartile 4 [Q4]) and OCP levels (12.1 years versus 12.4, respectively). When adjusting for all covariates except BMI, higher POP concentrations were associated with later age at menarche (Q4 versus Q1 aHRs: PBDEs 0.75 [95% CI 0.58, 0.97], PCBs 0.67 [95% CI 0.5, 0.89], and OCPs 0.66 [95% CI 0.50, 0.89]). Additional adjustment for BMI attenuated aHRs; PCB aHR approached the null.

CONCLUSION

Findings revealed later onset of menarche with higher concentrations of certain POPs, possibly through an association with BMI. Altered pubertal timing may have long lasting effects on reproductive health and disease risk, so continued attention is important for understanding the biological processes affected by hormonally active chemicals.

Perfluorooctanoate and changes in anthropometric parameters with age in young girls in the Greater Cincinnati and San Francisco Bay Area

METHODS

We conducted a study of per- and polyfluoroalkyl substance biomarkers, including PFOA, in girls from Greater Cincinnati (CIN, N = 353) and the San Francisco Bay Area (SFBA, N = 351). PFOA was measured in the baseline serum sample collected in 2004-2007 of 704 girls at age 6-8 years. Mixed effects models were used to derive the effect of PFOA on BMI, waist-to-height and waist-to-hip ratios over increasing age in this longitudinal cohort.

RESULTS

Median PFOA serum concentrations were 7.3 (CIN) and 5.8 (SFBA) ng/mL, above the U.S. population median for children 12-19 years in 2005-2006 (3.8 ng/mL). Log-transformed serum PFOA had a strong inverse association with BMIz in the CIN girls (p = 0.0002) and the combined two-site data (p = 0.0008); the joint inverse effect of PFOA and Age*PFOA weakened at age at 10-11 years. However, in the SFBA group alone, the relationship was not significant (p = 0.1641) with no evidence of changing effect with age. The effect of PFOA on waist:height ratio was similar to BMIz at both sites, but we did not find a significant effect of PFOA on waist:hip ratio in either the CIN or SFBA girls.

CONCLUSIONS

PFOA is associated with decreased BMI and waist:height ratio in young girls, but the strength of the relationship decreases with age. Site heterogeneity may be due to greater early life exposure in Cincinnati.

DISCLAIMER

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Use of trade names is for identification only and does not imply endorsement by the CDC, the Public Health Service, or the US Department of Health and Human Services.

Longitudinal Changes in Volumetric Breast Density in Healthy Women across the Menopausal Transition

BACKGROUND

Mammographic breast density declines during menopause. We assessed changes in volumetric breast density across the menopausal transition and factors that influence these changes.

METHODS

Women without a history of breast cancer, who had full field digital mammograms during both pre- and postmenopausal periods, at least 2 years apart, were sampled from four facilities within the San Francisco Mammography Registry from 2007 to 2013. Dense breast volume (DV) was assessed using Volpara on mammograms across the time period. Annualized change in DV from pre- to postmenopause was estimated using linear mixed models adjusted for covariates and per-woman random effects. Multiplicative interactions were evaluated between premenopausal risk factors and time to determine whether these covariates modified the annualized changes.

RESULTS

Among the 2,586 eligible women, 1,802 had one premenopausal and one postmenopausal mammogram, 628 had an additional perimenopausal mammogram, and 156 had two perimenopausal mammograms. Women experienced an annualized decrease in DV [-2.2 cm³ (95% confidence interval, -2.7 to -1.7)] over the menopausal transition. Declines were greater among women with a premenopausal DV above the median (54 cm³) versus below (DV, -3.5 cm³ vs. -1.0 cm³; P < 0.0001). Other breast cancer risk factors, including race, body mass index, family history, alcohol, and postmenopausal hormone therapy, had no effect on change in DV over the menopausal transition.

CONCLUSIONS

High premenopausal DV was a strong predictor of greater reductions in DV across the menopausal transition.

IMPACT

We found that few factors other than premenopausal density influence changes in DV across the menopausal transition, limiting targeted prevention efforts.

Combined effect of volumetric breast density and body mass index on breast cancer risk

BACKGROUND

Breast density and body mass index (BMI) are used for breast cancer risk stratification. We evaluate whether the positive association between volumetric breast density and breast cancer risk is strengthened with increasing BMI.

METHODS

The San Francisco Mammography Registry and Mayo Clinic Rochester identified 781 premenopausal and 1850 postmenopausal women with breast cancer diagnosed between 2007 and 2015 that had a screening digital mammogram at least 6 months prior to diagnosis. Up to three controls (N = 3535) were matched per case on age, race, date, mammography machine, and state. Volumetric percent density (VPD) and dense volume (DV) were measured with Volpara™. Breast cancer risk was assessed with logistic regression stratified by menopause status. Multiplicative interaction tests assessed whether the association of density measures was differential by BMI categories.

RESULTS

The increased risk of breast cancer associated with VPD was strengthened with higher BMI for both premenopausal (p_interaction = 0.01) and postmenopausal (p_interaction = 0.0003) women. For BMI < 25, 25-30, and ≥ 30 kg/m², ORs for breast cancer for a 1 SD increase in VPD were 1.24, 1.65, and 1.97 for premenopausal, and 1.20, 1.55, and 2.25 for postmenopausal women, respectively. ORs for breast cancer for a 1 SD increase in DV were 1.39, 1.33, and 1.51 for premenopausal (p_interaction = 0.58), and 1.31, 1.34, and 1.65 (p_interaction = 0.03) for postmenopausal women for BMI < 25, 25-30 and ≥ 30 kg/m², respectively.

CONCLUSIONS

The effect of volumetric percent density on breast cancer risk is strongest in overweight and obese women. These associations have clinical relevance for informing prevention strategies.

Screening mammography use in older women according to health status: a systematic review and meta-analysis

Background

The extent to which screening mammography (SM) recommendations in older women incorporate life expectancy factors is not well established.

Objective

The objective of this review was to evaluate evidence on SM utilization in older women by life expectancy factors.

Data sources

We searched Medline, Embase and Web of Science from January 1991 to March 2016.

Study selection

We included studies examining SM utilization in women ages ≥65 years that measured life expectancy using comorbidity, functional limitations or health or prognostic status.

Data extraction and synthesis

ORs and 95% CIs were extracted and grouped by life expectancy category. Findings were aggregated into pooled ORs and 95% CIs and meta-analyzed by life expectancy category.

Main outcomes and measures

The primary outcome was SM utilization within the last 5 years. Life expectancy factors included number of comorbidities, Charlson Comorbidity Index (CCI), activities of daily living, instrumental activities of daily living, self-reported health status and 5-year prognostic indices.

Results

Of 2,606 potential titles, we identified 25 meeting the inclusion criteria (comorbidity: eight studies, functional status: 11 studies and health/prognostic status: 13 studies). Women with higher CCI scores had decreased SM utilization (pooled OR: 0.75, 95% CI: 0.67–0.85), but increased absolute number of comorbidities were weakly associated with increased SM utilization (pooled OR: 1.17, 95% CI: 1.00–1.36). Women with more functional limitations had lower SM use odds than women with no limitations (pooled OR: 0.72, 95% CI: 0.62–0.83). Screening utilization odds were lower among women with poor vs excellent health (pooled OR: 0.85, 95% CI: 0.74–0.96).

Conclusion

Greater CCI score, functional limitations and lower perceived health were associated with decreased SM use, whereas higher absolute number of comorbidities was associated with increased SM use. SM guidelines should consider these factors to improve assessments of potential benefits and harms in older women.

Age, comorbidity, life expectancy, and pulmonary nodule follow-up in older veterans

Background

Pulmonary nodule guidelines do not indicate how to individualize follow-up according to comorbidity or life expectancy.

Objectives

To characterize comorbidity and life expectancy in older veterans with incidental, symptom-detected, or screen-detected nodules in 2008–09 compared to 2013–14. To determine the impact of these patient factors on four-year nodule follow-up among the 2008–09 subgroup.

Design

Retrospective cohort study.

Setting

Urban Veterans Affairs Medical Center.

Participants

243 veterans age ≥65 with newly diagnosed pulmonary nodules in 2008–09 (followed for four years through 2012 or 2013) and 446 older veterans diagnosed in 2013–14.

Measurements

The primary outcome was receipt of any follow-up nodule imaging and/or biopsy within four years after nodule diagnosis. Primary predictor variables included age, Charlson-Deyo Comorbidity Index (CCI), and life expectancy. Favorable life expectancy was defined as age 65–74 with CCI 0 while limited life expectancy was defined as age ≥85 with CCI ≥1 or age ≥65 with CCI ≥4. Interaction by nodule size was also examined.

Results

From 2008–09 to 2013–14, the number of older veterans diagnosed with new pulmonary nodules almost doubled, including among those with severe comorbidity and limited life expectancy. Overall among the 2008–09 subgroup, receipt of nodule follow-up decreased with increasing comorbidity (CCI ≥4 versus 0: adjusted RR 0.61, 95% CI 0.39–0.95) with a trend towards decreased follow-up among those with limited life expectancy (adjusted RR 0.69, 95% CI 0.48–1.01). However, we detected an interaction effect with nodule size such that comorbidity and life expectancy were associated with decreased follow-up only among those with nodules ≤6 mm.

Conclusions

We found some individualization of pulmonary nodule follow-up according to comorbidity and life expectancy in older veterans with smaller nodules only. As increased imaging detects nodules in sicker patients, guidelines need to be more explicit about how to best incorporate comorbidity and life expectancy to maximize benefits and minimize harms for patients with nodules of all sizes.

No one to turn to: low social support and the incidence of undesired pregnancy in the United States

OBJECTIVE

Young women may experience social barriers to achieving their reproductive goals. This analysis explored whether low social support may contribute to the high incidence of undesired pregnancy in young women in the United States.

STUDY DESIGN

Using 6 months of data from a prospective cohort of 970 women ages 18-22 years in the United States, we described contraceptive use and applied multivariable logistic regression and standardization to estimate adjusted odds and absolute risk of undesired pregnancy among women reporting low social support versus higher social support. We investigated several measures of contraceptive use as possible explanations for this pathway.

RESULTS

Sixty-five pregnancies were reported in the 6 months of the study, of which 30 (46%) were classified as undesired prior to conception. Among young women who reported low social support, 8% reported an undesired pregnancy during the study period as compared to 3% of the young women who reported higher levels of social support. Among non-black women, those who reported low social support had nearly seven times the odds of an undesired pregnancy as compared to women who reported higher social support (aOR: 6.8, 95%CI: 1.7, 27.1). We found no association between social support and undesired pregnancy among young black women. Contraceptive method use differed by social support at baseline, and throughout follow-up.

CONCLUSIONS

Low social support - defined as the feeling of not having anyone to turn to - may be a risk factor for persistently high levels of undesired pregnancy among young women in the U.S. This association may be driven by differences in contraceptive use by level of social support.

IMPLICATIONS

Interventions to increase young women's perceptions of social support may reduce the risk of undesired pregnancy for some individuals.

New Directions in Cancer Control and Population Sciences

Cancer control science has been evolving since it first became a focus for cancer research and program activities a century ago. The evolution of the field has responded to historical megatrends along the way that keep it relevant to the cancer-related needs of society. This commentary describes some of the key trends and developments now influencing cancer control and population sciences that reflect societal change and new tools and concepts in modern biomedical science. New directions include the impact of climate change, health care delivery research, the growth of population health science, data science, precision medicine, data sharing, implementation science, and new technologies, including social media and new geospatial methodologies. Cancer Epidemiol Biomarkers Prev; 26(8); 1165-9. ©2017 AACR.