Defining the impact of immune tolerance induction on clinically relevant outcomes in a US cohort of severe hemophilia A

ABSTRACT

Although the near-term benefit of immune tolerance induction (ITI) for the treatment of people with severe hemophilia A with inhibitor is apparent, the magnitude of the longer-term impact of ITI on clinical outcomes remains undefined. We examined the association between receiving ITI and the success of ITI on clinical outcomes including (1) clinical events, (2) health care use, (3) quality of life/function, (4) socioeconomic status, and (5) death, using the Community Counts (CC) registry of US Hemophilia Treatment Centers between 2013 and 2017. Multivariate logistic regression, negative binomial, and Poisson models were used. Included in this study were 3659 people with severe hemophilia A with median age of 21 years when entering the CC registry. Among 576 participants with inhibitors, 485 had received ITI (84%). ITI was successful in 299 (61.7%) and partially successful or failed in 95 (19.5%) or 91 (18.7%), respectively. Those that received ITI had fewer treated bleeds, less chronic pain, better function, and higher educational attainment than those not receiving ITI. Successful vs partially successful and failed ITI was associated with fewer treated bleeds, less health care use, less chronic pain, better function, and fewer missed days of school or work. Mortality was not associated with ITI, regardless of its success. Those with successful ITI had similar rates of treated bleeds, chronic pain, and health care use as those with no inhibitors. Undergoing ITI, particularly if successful, improved clinical outcomes but not mortality. These findings support decision making regarding initiation of ITI and inform future clinical trials.

Race and ethnicity and the success of immune tolerance induction among people with severe haemophilia A in the United States

INTRODUCTION

Immune tolerance induction (ITI) is the only treatment to eradicate inhibitors in people with severe haemophilia A with inhibitors. Since the risk of inhibitor development is greater among Black and Hispanic persons, it has been hypothesized that race and ethnicity may influence ITI success. Limited studies have evaluated this hypothesis.

AIM

To examine the success of ITI according to race and ethnicity.

METHODS

Participants who entered the Community Counts (CC) Registry between 2013 and 2017, were aged ≥3 years at study entry, and received ITI were included (n = 559). The proportion of participants with successful ITI was examined with adjusted prevalence ratios (aPRs) and corresponding 95% confidence intervals (95% CIs).

RESULTS

Among 559 participants, 56.9%, 19.1%, 18.1% and 4.3% were Non-Hispanic (NH) White, NH Black, Hispanic and Asian, respectively, and 1.7% were coded as other or missing. Approximately 80% of Hispanic, NH Black and NH White participants had good/very good prognosis, defined as having a pre-ITI peak inhibitor of < 200 Bethesda Units per millilitre. Nearly 60% of participants (59.7%) achieved successful ITI, 20.7% and 19.5% experienced partially successful or failed ITI, respectively. Successful ITI was non-significantly lower in NH Black (54.2%; aPR = 0.95, 95% CI 0.62-1.44) and Hispanic (55.4%; aPR = 0.89, 95% CI 0.71-1.13) relative to NH White participants (62.6%).

CONCLUSION

In this study, 60% of participants in the CC Registry had successful ITI, consistent with previous studies. The proportion with successful ITI was generally comparable across racial and ethnic groups with similar prognosis. These findings do not support the hypothesis that ITI response varies according to race or ethnicity.

Incarceration History and Access to and Receipt of Health Care in the US

Importance

People with a history of incarceration may experience barriers in access to and receipt of health care in the US.

Objective

To examine the associations of incarceration history and access to and receipt of care and the contribution of modifiable factors (educational attainment and health insurance coverage) to these associations.

Design, Setting, and Participants

Individuals with and without incarceration history were identified from the 2008 to 2018 National Longitudinal Survey of Youth 1979 cohort. Analyses were conducted from October 2022 to December 2023.

Main Measures and Outcomes

Access to and receipt of health care were measured as self-reported having usual source of care and preventive service use, including physical examination, influenza shot, blood pressure check, blood cholesterol level check, blood glucose level check, dental check, and colorectal, breast, and cervical cancer screenings across multiple panels. To account for the longitudinal study design, we used the inverse probability weighting method with generalized estimating equations to evaluate associations of incarceration history and access to care. Separate multivariable models examining associations between incarceration history and receipt of each preventive service adjusted for sociodemographic factors; sequential models further adjusted for educational attainment and health insurance coverage to examine their contribution to the associations of incarceration history and access to and receipt of health care.

Results

A total of 7963 adults with 41 614 person-years of observation were included in this study; of these, 586 individuals (5.4%) had been incarcerated, with 2800 person-years of observation (4.9%). Compared with people without incarceration history, people with incarceration history had lower percentages of having a usual source of care or receiving preventive services, including physical examinations (69.6% vs 74.1%), blood pressure test (85.6% vs 91.6%), blood cholesterol level test (59.5% vs 72.2%), blood glucose level test (61.4% vs 69.4%), dental check up (51.1% vs 66.0%), and breast (55.0% vs 68.2%) and colorectal cancer screening (65.6% vs 70.3%). With additional adjustment for educational attainment and health insurance, the associations of incarceration history and access to care were attenuated for most measures and remained statistically significant for measures of having a usual source of care, blood cholesterol level test, and dental check up only.

Conclusions and Relevance

The results of this survey study suggest that incarceration history was associated with worse access to and receipt of health care. Educational attainment and health insurance may contribute to these associations. Efforts to improve access to education and health insurance coverage for people with an incarceration history might mitigate disparities in care.

Race, ethnicity, and immune tolerance induction in hemophilia A in the United States

Background

In racially diverse communities, treatment of chronic diseases can vary across racial and ethnic groups.

Objectives

To examine healthcare disparities in hemophilia care in the United States by evaluating receipt of immune tolerance induction (ITI) among different racial and ethnic groups.

Methods

In this cross-sectional study, people with severe hemophilia A with an inhibitor who entered the Center for Disease Control and Prevention Community Counts registry between 2013 and 2017, were aged ≥5 years at study entry, and had a history of an inhibitor (n = 614) were included. The proportion of participants receiving ITI was examined according to race and ethnicity in bivariable analysis and multivariable analysis adjusting for demographic and clinical covariates. Unadjusted and adjusted prevalence ratios and corresponding 95% CIs were computed.

Results

Among 614 participants included in the study, 56.4% were non-Hispanic (NH) White, 19.7% were NH Black, 18.4% were Hispanic, and 4.9% were Asian. ITI was received by 85.2% of participants. On bivariable analysis, ITI treatment did not vary by race or ethnicity. On multivariable analysis, NH Black and Hispanic participants were significantly less likely to receive ITI compared to NH White participants (adjusted prevalence ratio, 0.91 [95% CI, 0.84-0.99] and 0.84 [95% CI, 0.75-0.93], respectively).

Conclusion

Although the role of ITI may evolve with growing use of emicizumab and the introduction of new hemophilia treatment products, understanding characteristics that influence care, particularly race and ethnicity, where physician bias and patient mistrust can occur, will remain relevant and applicable to other complex therapies, including gene therapy.

Racial and ethnic differences in reported haemophilia death rates in the United States

INTRODUCTION

People with haemophilia's life expectancies have improved over time. Whether progress has been experienced equitably is unknown.

AIM

To examine recorded haemophilia death (rHD) rates according to race and ethnicity in the United States (US).

METHODS

In this cohort study, rHDs were examined with US National Vital Statistics' 1999-2020 Multiple Cause-of-Death data. rHD was defined as having a haemophilia A (D66) or B (D67) ICD-10 code in the death certificate (underlying or multiple causes of death). Age-adjusted rHD rates were compared with age-adjusted rate ratios (aRR) and 95% Confidence Intervals (CI).

RESULTS

There were 3115 rHDs in males with an rHD rate of 0.98 per 1 million males. Between 1999 and 2020, rHD rates declined by 46% in NH (Non-Hispanic) White, 44% in NH Black (aRR = 0.56, 95%CI 0.43, 0.74), and 42% in Hispanic (aRR = 0.58, 95%CI 0.39, 0.88) males. However, rHD rates remained higher and were on average 30% greater in NH Black versus NH White males (aRR = 1.30 95% CI 1.16, 1.46). Among males with rHD, the median age at death rose from 54.5 to 65.5 years between 1999 and 2020 and was 12 years lower in NH Black (56 years) versus NH White (68 years) males in 2010-2020. There were 930 females with rHD, with an age-adjusted rate of 0.22 per 1 million females, which was consistent between 1999 and 2020.

CONCLUSION

Reported haemophilia-death rates improved in males across all race/ethnicities, but rates were higher Black versus White males. Given the inherent limitations of the current study's data source, further investigation of survival rates and disparities in haemophilia are needed.

Racial and Ethnic Differences in Distress, Depression, and Quality of Life in people with hemophilia

Hemophilia-related distress (HRD) has been shown to be higher among those with lower educational attainment, but potential racial/ethnic differences have not been previously described. Thus, we examined HRD according to race/ethnicity. This cross-sectional study was a planned secondary analysis of the hemophilia-related distress questionnaire (HRDq) validation study data. Adults aged ≥ 18 years with Hemophilia A or B were recruited from one of two hemophilia treatment centers between July 2017-December 2019. HRDq scores can range from 0-120, and higher scores indicate higher distress. Self-reported race/ethnicity was grouped as Hispanic, non-Hispanic White (NHW) and non-Hispanic Black (NHB). Unadjusted and multivariable linear regression models were used to examine mediators of race/ethnicity and HRDq scores. Among 149 participants enrolled, 143 completed the HRDq and were included in analyses. Approximately 17.5% of participants were NHB, 9.1% were Hispanic and 72.0% were NHW. HRDq scores ranged from 2 to 83, with a mean of 35.1 [standard deviation (SD) = 16.5]. Average HRDq scores were significantly higher among NHB participants (mean = 42.6,SD = 20.6; p-value = .038) and similar in Hispanic participants (mean = 33.8,SD = 16.7, p-value = .89) compared to NHW (mean = 33.2,SD = 14.9) participants. In multivariable models, differences between NHB vs NHW participants persisted when adjusting for inhibitor status, severity, and target joint. However, after household income was adjusted for, differences in HRDq scores were no longer statistically significant (β = 6.0 SD = 3.7; p-value = .10). NHB participants reported higher HRD than NHW participants. Household income mediated higher distress scores in NHB compared to NHW participants, highlighting the urgent need to understand social determinants of health and financial hardship in persons with hemophilia.

Past Disruptions in Health Insurance Coverage and Access to Care Among Insured Adults

INTRODUCTION

Although the association between health insurance coverage and access to care is well documented, it is unclear whether the deleterious effects of being uninsured are strictly contemporaneous or whether previous disruptions in coverage have persistent effects. This study addresses this issue using nationally representative data covering 2011-2019 to estimate the extent to which disruptions in health insurance coverage continued to be associated with poor access even after coverage was regained.

METHODS

Analysis was conducted in 2022. Using a nationally representative cohort of insured adults aged 18-64 years (N=39,904) and multivariable logistic regression models, the authors estimated the association between past disruptions in coverage (occurring at least 1 year before) and the risks of lacking a usual source of care provider and having unmet medical need.

RESULTS

Among insured nonelderly adults, the risk of being without a usual source of care provider was between 18% (risk ratio=1.18; 95% CI=1.00, 1.38) and 75% higher (risk ratio=1.75; 95% CI=1.56, 1.93) than for those with continuous coverage; the risk of having unmet medical needs was between 41% (risk ratio=1.41; 95% CI=1.00, 1.83) and 66% (risk ratio=1.66; 95% CI=1.26, 2.06) higher. Longer insurance disruptions were associated with a higher risk of lacking a usual source of care provider.

CONCLUSIONS

Previous disruptions in health insurance coverage continued to be negatively associated with access to care for more than a year after coverage was regained. Improving access to care in the U.S. may require investing in policies and programs that help to strengthen coverage continuity among individuals with insurance coverage rather than focusing exclusively on helping uninsured individuals to gain coverage.

Access to Care Among Adults with Limited English Proficiency

BACKGROUND

There are approximately 25.6 million individuals with limited English proficiency (LEP) in the USA, and this number is increasing.

OBJECTIVE

Investigate associations between LEP and access to care in adults.

DESIGN

Cross-sectional nationally representative survey.

PARTICIPANTS

Adults with (n = 18,908) and without (n = 98,060) LEP aged ≥ 18 years identified from the 2014-2018 Medical Expenditure Panel Survey MAIN MEASURES: Associations between LEP and access to healthcare and preventive services were evaluated with multivariable logistic regression models, stratified by age group (18-64 and ≥ 65 years). The official government definition of LEP (answers "not at all/not well/well" to the question "How well do you speak English?") was used. Access to care included having a usual source of care (and if so, distance from usual source of care, difficulty contacting usual source of care, and provision of extended hours), visiting a medical provider in the past 12 months, having to forego or delay care, and having trouble paying for medical bills. Preventive services included blood pressure and cholesterol check, flu vaccination, and cancer screening.

KEY RESULTS

Adults aged 18-64 years with LEP were significantly more likely to lack a usual source of care (adjusted odds ratios [aOR] = 2.48; 95% confidence interval [CI] = 2.27-2.70), not have visited a medical provider (aOR = 2.02; CI = 1.89-2.16), and to be overdue for receipt of preventive services, including blood pressure check (aOR = 2.00; CI = 1.79-2.23), cholesterol check (aOR = 1.22; CI = 1.03-1.44), and colorectal cancer screening (aOR = 1.58; CI = 1.37-1.83) than adults without LEP. Results were similar among adults aged ≥ 65 years.

CONCLUSIONS

Adults with LEP had consistently worse access to care than adults without LEP. System-level interventions, such as expanding access to health insurance coverage, providing language services, improving provider training in cultural competence, and increasing diversity in the medical workforce may minimize barriers and improve equity in access to care.

Health insurance status and cancer stage at diagnosis and survival in the United States

Previous studies using data from the early 2000s demonstrated that patients who were uninsured were more likely to present with late-stage disease and had worse short-term survival after cancer diagnosis in the United States. In this report, the authors provide comprehensive data on the associations of health insurance coverage type with stage at diagnosis and long-term survival in individuals aged 18-64 years who were diagnosed between 2010 and 2013 with 19 common cancers from the National Cancer Database, with survival follow-up through December 31, 2019. Compared with privately insured patients, Medicaid-insured and uninsured patients were significantly more likely to be diagnosed with late-stage (III/IV) cancer for all stageable cancers combined and separately. For all stageable cancers combined and for six cancer sites-prostate, colorectal, non-Hodgkin lymphoma, oral cavity, liver, and esophagus-uninsured patients with Stage I disease had worse survival than privately insured patients with Stage II disease. Patients without private insurance coverage had worse short-term and long-term survival at each stage for all cancers combined; patients who were uninsured had worse stage-specific survival for 12 of 17 stageable cancers and had worse survival for leukemia and brain tumors. Expanding access to comprehensive health insurance coverage is crucial for improving access to cancer care and outcomes, including stage at diagnosis and survival.

Paid Sick Leave Among Working Cancer Survivors and Its Associations With Use of Preventive Services in the United States

BACKGROUND

We sought to examine the lack of paid sick leave among working cancer survivors by sociodemographic/socioeconomic and employment characteristics and its association with preventive services use in the United States.

METHODS

Working cancer survivors (ages 18-64 years; n=7,995; weighted n=3.43 million) were identified using 2001-2018 National Health Interview Survey data. Adjusted prevalence of lack of paid sick leave by sociodemographic and socioeconomic characteristics, as well as job sector, working hours, and employer size, were generated using multivariable logistic regression models. Separate analyses examined the associations of lack of paid sick leave with use of various preventive services.

RESULTS

Of all working cancer survivors, 36.4% lacked paid sick leave (n=2,925; weighted n=1.25 million), especially those working in food/agriculture/construction/personal services occupations or industries (ranging from 54.9% to 88.5%). In adjusted analyses, working cancer survivors with lower household income (<200% of the federal poverty level, 48.7%), without a high school degree (43.3%), without health insurance coverage (70.6%), and who were self-employed (89.5%), were part-time workers (68.2%), or worked in small businesses (<50 employees, 48.8%) were most likely to lack paid sick leave. Lack of paid sick leave was associated with lower use of influenza vaccine (ages 18-39 years, 21.3% vs 33.3%; ages 40-49 years, 25.8% vs 38.3%; ages 50-64 years, 46.3% vs 52.4%; P<.001 for all), cholesterol screening (ages 18-39 years, 43.1% vs 62.5%; P<.05), and blood pressure check (ages 18-39 years, 43.1% vs 62.5%; P<.05) compared with survivors having paid sick leave.

CONCLUSIONS

In the United States, more than one-third of all working cancer survivors and more than half of survivors working for small employers and in certain occupations/industries lack paid sick leave. Survivors with lower household income or educational attainment are particularly vulnerable. Moreover, lack of paid sick leave is associated with lower use of some recommended preventive services, suggesting that ensuring working cancer survivors have access to paid sick leave may be an important mechanism for reducing health disparities.

The first year of the COVID-19 pandemic and health among cancer survivors in the United States

Background

Cancer survivors represent a population with high health care needs. If and how cancer survivors were affected by the first year of the coronavirus disease 2019 (COVID‐19) pandemic are largely unknown.

Methods

Using data from the nationwide, population‐based Behavioral Risk Factor Surveillance System (2017–2020), the authors investigated changes in health‐related measures during the COVID‐19 pandemic among cancer survivors and compared them with changes among adults without a cancer history in the United States. Sociodemographic and health‐related measures such as insurance coverage, employment status, health behaviors, and health status were self‐reported. Adjusted prevalence ratios of health‐related measures in 2020 versus 2017–2019 were calculated with multivariable logistic regressions and stratified by age group (18–64 vs. ≥65 years).

Results

Among adults aged 18–64 years, the uninsured rate did not change significantly in 2020 despite increases in unemployment. The prevalence of unhealthy behaviors, such as insufficient sleep and smoking, decreased in 2020, and self‐rated health improved, regardless of cancer history. Notably, declines in smoking were larger among cancer survivors than nonelderly adults without a cancer history. Few changes were observed for adults aged ≥65 years.

Conclusions

Further research is needed to confirm the observed positive health behavior and health changes and to investigate the role of potential mechanisms, such as the national and regional policy responses to the pandemic regarding insurance coverage, unemployment benefits, and financial assistance. As polices related to the public health emergency expire, ongoing monitoring of longer term effects of the pandemic on cancer survivorship is warranted.

Among cancer survivors aged 18–64 years, the uninsured rate did not change significantly in 2020 despite increases in unemployment. The prevalence of unhealthy behaviors, such as insufficient sleep and smoking, decreased in 2020, and self‐rated health improved, regardless of cancer history.

Relative Harm Perceptions of E-Cigarettes Versus Cigarettes, U.S. Adults, 2018-2020

INTRODUCTION

It is unknown how U.S. adults' relative harm perceptions of E-cigarettes versus cigarettes and associated behaviors changed during the E-cigarette or vaping product use‒associated lung injury epidemic (late 2019) and COVID-19 pandemic (since early 2020).

METHODS

Data from cross-sectional nationally representative Health Information National Trends Survey collected in 2018 (n=3,360), 2019 (n=3,217), and 2020 (n=3,677) (analyzed in 2021) were used to estimate changes in relative harm perceptions of E-cigarettes versus cigarettes (less harmful, as harmful, more harmful, don't know as a measure of uncertainty). In addition, changes in exclusive cigarette smoking, exclusive E-cigarette use, and dual use were estimated for each relative harm perception level.

RESULTS

Perceptions of E-cigarettes as more harmful than cigarettes doubled year on year, increasing most between 2019 and 2020 (2018: 6.8%, 2019: 12.8%, 2020: 28.3%), whereas uncertainty in relative harm declined (2018: 38.2%, 2019: 34.2%, 2020: 24.7%). Less harmful relative perceptions declined (2018:17.6%, 2019:15.3%, 2020:11.4%), whereas as harmful perceptions remained steady (2018: 37.4%, 2019: 37.7%, 2020: 35.6%). Exclusive cigarette smoking increased between 2019 and 2020 among those who perceived E-cigarettes as relatively more harmful (2018: 18.5%; 2019: 8.4%; 2020: 16.3%), exclusive E-cigarette use increased linearly among those who perceived them as relatively less harmful (7.9%, 15.3%, 26.7%), and dual use increased linearly in those who perceived them relatively as harmful (0.1%, 1.4%, 2.9%).

CONCLUSIONS

Perceptions of E-cigarettes as more harmful than cigarettes increased sharply between 2019 and 2020. Increases in tobacco product use were potentially guided by product-specific relative harm perceptions because changes occurred primarily in individuals who perceived their preferred product as relatively less harmful, suggesting the need for accurate messaging of relative and absolute product risks.

Changes in Cancer Screening in the US During the COVID-19 Pandemic

IMPORTANCE

Health care was disrupted in the US during the first quarter of 2020 with the emergence of the COVID-19 pandemic. Early reports in selected samples suggested that cancer screening services decreased greatly, but population-based estimates of cancer screening prevalence during 2020 have not yet been reported.

OBJECTIVE

To examine changes in breast cancer (BC), cervical cancer (CC), and colorectal cancer (CRC) screening prevalence with contemporary national, population-based Behavioral Risk Factor Surveillance System (BRFSS) data.

DESIGN, SETTING, AND PARTICIPANTS

This survey study included respondents from the 2014, 2016, 2018, and 2020 BRFSS surveys who were eligible for BC (women aged 50-74 years), CC (women aged 25-64 years), and CRC (women and men aged 50-75 years) screening. Data analysis was performed from September 2021 to February 2022.

EXPOSURES

Calendar year.

MAIN OUTCOMES AND MEASURES

Self-reported receipt of a recent (defined as in the past year) BC, CC, and CRC screening test. Adjusted prevalence ratios (aPRs) comparing 2020 vs 2018 prevalence and 95% CIs were computed.

RESULTS

In total, 479 248 individuals were included in the analyses of BC screening, 301 453 individuals were included in CC screening, and 854 210 individuals were included in CRC screening, In 2020, among respondents aged 50 to 75 years, 14 815 (11.4%) were Black, 12 081 (12.6%) were Hispanic, 156 198 (67.3%) were White, and 79 234 (29.9%) graduated from college (all percentages are weighted). After 4 years (2014-2018) of nearly steady prevalence, past-year BC screening decreased by 6% between 2018 and 2020 (from 61.6% in 2018 to 57.8% in 2020; aPR, 0.94; 95% CI, 0.92-0.96), and CC screening decreased by 11% (from 58.3% in 2018 to 51.9% in 2020; aPR, 0.89; 95% CI, 0.87-0.91). The magnitude of these decreases was greater in people with lower educational attainment and Hispanic persons. CRC screening prevalence remained steady; past-year stool testing increased by 7% (aPR, 1.07; 95% CI, 1.02-1.12), offsetting a 16% decrease in colonoscopy (aPR, 0.84; 95% CI, 0.82-0.88) between 2018 and 2020.

CONCLUSIONS AND RELEVANCE

In this survey study, stool testing increased and counterbalanced a decrease in colonoscopy during 2020, and BC and CC screening modestly decreased. How these findings might be associated with outcomes is not yet known, but they will be important to monitor, especially in populations with lower socioeconomic status, who experienced greater screening decreases during the COVID-19 pandemic.

American Cancer Society's report on the status of cancer disparities in the United States, 2021

In this report, the authors provide comprehensive and up-to-date US data on disparities in cancer occurrence, major risk factors, and access to and utilization of preventive measures and screening by sociodemographic characteristics. They also review programs and resources that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. The overall cancer death rate is 19% higher among Black males than among White males. Black females also have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. There are also substantial variations in death rates for specific cancer types and in stage at diagnosis, survival, exposure to risk factors, and receipt of preventive measures and screening by race/ethnicity, socioeconomic status, and geographic location. For example, kidney cancer death rates by sex among American Indian/Alaska Native people are ≥64% higher than the corresponding rates in each of the other racial/ethnic groups, and the 5-year relative survival for all cancers combined is 14% lower among residents of poorer counties than among residents of more affluent counties. Broad and equitable implementation of evidence-based interventions, such as increasing health insurance coverage through Medicaid expansion or other initiatives, could substantially reduce cancer disparities. However, progress will require not only equitable local, state, and federal policies but also broad interdisciplinary engagement to elevate and address fundamental social inequities and longstanding systemic racism.

Geographic access to lung cancer screening among eligible adults living in rural and urban environments in the United States

BACKGROUND

Although recommended lung cancer screening with low-dose computed tomography scanning (LDCT) reduces mortality among high-risk adults, annual screening rates remain low. This study complements a previous nationwide assessment of access to lung cancer screening within 40 miles by evaluating differences in accessibility across rural and urban settings for the population aged 50 to 80 years and a subset eligible population based on the 2021 US Preventive Services Task Force LDCT lung screening recommendations.

METHODS

Distances from population centers to screening facilities (American College of Radiology Lung Cancer Screening Registry) were calculated, and the number of individuals who had access within graduating distances, including 10, 20, 40, 50, and 100 miles, were estimated. Census tract results were aggregated to counties, and both geographies were classified with rural-urban schemas.

RESULTS

Approximately 5% of the eligible population did not have access to lung cancer screening facilities within 40 miles; however, different patterns of accessibility were observed at different distances, between regions, and across rural-urban environments. Across all distances and geographies, there was a larger percentage of the population in rural geographies with no access. Although the rural population represented approximately 8% of the eligible population, the larger percentage of the rural population with no access was noteworthy and translated into a larger number of individuals with no access at longer distance thresholds (≥40 miles).

CONCLUSIONS

Disparities in access should be examined as both percentages of the population and numbers of individuals with no access in order to tailor interventions to communities and increase access. Geospatial analysis at the census tract level is recommended to help to identify optimal focus areas and reach the most people.

LAY SUMMARY

As annual lung cancer screening rates remain low, this study examines access to lung cancer screening nationwide and across rural and urban settings. A geographic information system network analysis of census tract-level populations is used to estimate access at different distances, including 10, 20, 40, 50, and 100 miles, and the results are aggregated to counties. Approximately 5% of the eligible population does not have access to screening facilities within 40 miles; however, different patterns of accessibility are observed at different distances, between regions, and across rural-urban environments. Across all distances and geographies, there is a larger percentage of the population in rural geographies with no access.

Changes in breast cancer screening rates among 32 community health centers during the COVID-19 pandemic

Background

Breast cancer screening utilization steeply dropped at the start of the coronavirus disease 2019 (COVID‐19) pandemic. However, the effects on breast cancer screening in lower income populations are unknown. This study examined changes in breast cancer screening rates (BCSRs) during the pandemic among 32 community health centers (CHCs) that provided health care to lower income populations.

Methods

Secondary data from 32 CHCs participating in an American Cancer Society grant program to increase breast cancer screening services were used. BCSRs were defined as the percentage of women aged 50 to 74 years who had a medical visit in the past 12 months (142,207 in 2018, 142,003 in 2019, and 150,630 in 2020) and received a screening mammogram within the last 27 months. BCSRs in July 2020, July 2019, and June 2018 were compared with screening rate ratios (SRRs) and corresponding 95% confidence intervals (CIs).

Results

BCSRs significantly rose by 18% between 2018 and 2019 (from 45.8% to 53.9%; SRR, 1.18; 95% CI, 1.17‐1.18) and then declined by 8% between 2019 and 2020 (from 53.9% to 49.6%; SRR, 0.92; 95% CI, 0.92‐0.93). If the 2018‐2019 BCSR trends had continued through 2020, 63.3% of women would have been screened in 2020 in contrast to the 49.6% who were; this potentially translated into 47,517 fewer mammograms and 242 missed breast cancer diagnoses in this population.

Conclusions

In this study of 32 CHCs, BCSRs declined by 8% from July 2019 to 2020, and this reversed an 18% improvement between July 2018 and 2019. Declining BCSRs among CHCs during the COVID‐19 pandemic call for policies to support and resources to identify women in need of screening.

In this study of 32 community health centers, breast cancer screening rates declined by 8% from July 2019 to 2020. This reverses an 18% improvement between July 2018 and 2019.

Unemployment and cancer screening: Baseline estimates to inform health care delivery in the context of COVID-19 economic distress

Background

During the coronavirus disease 2019 pandemic, US unemployment rates rose to historic highs, and they remain nearly double those of prepandemic levels. Employers are the most common source of health insurance among nonelderly adults. Thus, job loss may lead to a loss of health insurance and reduce access to cancer screening. This study examined associations between unemployment, health insurance, and cancer screening to inform the pandemic's potential impacts on early cancer detection.

Methods

Up‐to‐date and past‐year breast, cervical, colorectal, and prostate cancer screening prevalences were computed for nonelderly respondents (aged <65 years) with 2000‐2018 National Health Interview Survey data. Multivariable logistic regression models with marginal probabilities were used to estimate unemployed‐versus‐employed unadjusted and adjusted prevalence ratios.

Results

Unemployed adults (2000‐2018) were 4 times more likely to lack insurance than employed adults (41.4% vs 10.0%; P < .001). Unemployed adults had a significantly lower up‐to‐date prevalence of screening for cervical cancer (78.5% vs 86.2%; P < .001), breast cancer (67.8% vs 77.5%; P < .001), colorectal cancer (41.9 vs 48.5%; P < .001), and prostate cancer (25.4% vs 36.4%; P < .001). These differences were eliminated after accounting for health insurance coverage.

Conclusions

Unemployment was adversely associated with up‐to‐date cancer screening, and this was fully explained by a lack of health insurance. Ensuring the continuation of health insurance coverage after job loss may mitigate the pandemic's economic distress and future economic downturns' impact on cancer screening.

Unemployment is adversely associated with up‐to‐date cancer screening, and this is fully explained by a lack of health insurance.

Cancer statistics for the US Hispanic/Latino population, 2021

The Hispanic/Latino population is the second largest racial/ethnic group in the continental United States and Hawaii, accounting for 18% (60.6 million) of the total population. An additional 3 million Hispanic Americans live in Puerto Rico. Every 3 years, the American Cancer Society reports on cancer occurrence, risk factors, and screening for Hispanic individuals in the United States using the most recent population-based data. An estimated 176,600 new cancer cases and 46,500 cancer deaths will occur among Hispanic individuals in the continental United States and Hawaii in 2021. Compared to non-Hispanic Whites (NHWs), Hispanic men and women had 25%-30% lower incidence (2014-2018) and mortality (2015-2019) rates for all cancers combined and lower rates for the most common cancers, although this gap is diminishing. For example, the colorectal cancer (CRC) incidence rate ratio for Hispanic compared with NHW individuals narrowed from 0.75 (95% CI, 0.73-0.78) in 1995 to 0.91 (95% CI, 0.89-0.93) in 2018, reflecting delayed declines in CRC rates among Hispanic individuals in part because of slower uptake of screening. In contrast, Hispanic individuals have higher rates of infection-related cancers, including approximately two-fold higher incidence of liver and stomach cancer. Cervical cancer incidence is 32% higher among Hispanic women in the continental US and Hawaii and 78% higher among women in Puerto Rico compared to NHW women, yet is largely preventable through screening. Less access to care may be similarly reflected in the low prevalence of localized-stage breast cancer among Hispanic women, 59% versus 67% among NHW women. Evidence-based strategies for decreasing the cancer burden among the Hispanic population include the use of culturally appropriate lay health advisors and patient navigators and targeted, community-based intervention programs to facilitate access to screening and promote healthy behaviors. In addition, the impact of the COVID-19 pandemic on cancer trends and disparities in the Hispanic population should be closely monitored.

Lung Cancer Screening Eligibility and Screening Patterns Among Black and White Adults in the United States

This cohort study compares the demographics of US adults who are currently being screened for lung cancer and assesses the potential association between proposed changes to the United States Preventive Services Task Force (USPSTF) screening recommendations and screening rates by race and age.

State Variation in Low-Dose Computed Tomography Scanning for Lung Cancer Screening in the United States

BACKGROUND

Annual lung cancer screening (LCS) with low-dose chest computed tomography in older current and former smokers (ie, eligible adults) has been recommended since 2013. Uptake has been slow and variable across the United States. We estimated the LCS rate and growth at the national and state level between 2016 and 2018.

METHODS

The American College of Radiology's Lung Cancer Screening Registry was used to capture screening events. Population-based surveys, the US Census, and cancer registry data were used to estimate the number of eligible adults and lung cancer mortality (ie, burden). Lung cancer screening rates (SRs) in eligible adults and screening rate ratios with 95% confidence intervals (CI) were used to measure changes by state and year.

RESULTS

Nationally, the SR was steady between 2016 (3.3%, 95% CI = 3.3% to 3.7%) and 2017 (3.4%, 95% CI = 3.4% to 3.9%), increasing to 5.0% (95% CI = 5.0% to 5.7%) in 2018 (2018 vs 2016 SR ratio = 1.52, 95% CI = 1.51 to 1.62). In 2018, several southern states with a high lung-cancer burden (eg, Mississippi, West Virginia, and Arkansas) had relatively low SRs (<4%) among eligible adults, whereas several northeastern states with lower lung cancer burden (eg, Massachusetts, Vermont, and New Hampshire) had the highest SRs (12.8%-15.2%). The exception was Kentucky, which had the nation's highest lung cancer mortality rate and one of the highest SRs (13.7%).

CONCLUSIONS

Fewer than 1 in 20 eligible adults received LCS nationally, and uptake varied widely across states. LCS rates were not aligned with lung cancer burden across states, except for Kentucky, which has supported comprehensive efforts to implement LCS.

Association between disparities in intergenerational economic mobility and cause-specific mortality among Black and White persons in the United States

BACKGROUND

Evidence about the association between structural racism and mortality in the United States is limited. We examined the association between ongoing structural racism, measured as inequalities in adulthood income between White and Black children with similar parental household income (economic mobility gap) in a recent birth cohort, and Black-White disparities in death rates (mortality gap) overall and for major causes.

METHODS

Sex-, race/ethnicity-, and county-specific data were used to examine sex-specific associations between economic mobility and mortality gaps for all causes combined, heart diseases, cerebrovascular diseases, chronic obstructive pulmonary disease (COPD), injury/violence, all malignant cancers, and 14 cancer types. Economic mobility data for 1978-1983 birth cohorts and death rates during 2011-2018 were obtained from the Opportunity Atlas and National Center for Health Statistics, respectively. Data from 471 counties were included in analyses of all-cause mortality at ages 30-39 years during 2011-2018 (corresponding to partially overlapping 1978-1983 birth cohorts); and from 1,572 and 1,248 counties in analyses of all-cause and cause-specific mortality in all ages combined, respectively.

RESULTS

In ages 30-39 years, a one percentile increase in the economic mobility gap was associated with a 6.8 % (95 % confidence interval 1.8 %-11.8 %) increase in the Black-White mortality gap among males and a 13.5 % (8.9 %-18.1 %) increase among females, based on data from 471 counties. In all ages combined, the corresponding percentages based on data from 1,572 counties were 10.2 % (7.2 %-13.2 %) among males and 14.8 % (11.4 %-18.2 %) among females, equivalent to an increase of 18.4 and 14.0 deaths per 100,000 in the mortality gap, respectively. Similarly, strong associations between economic mobility gap and mortality gap in all ages were found for major causes of death, notably for potentially preventable conditions, including COPD, injury/violence, and cancers of the lung, liver, and cervix.

CONCLUSIONS

Economic mobility gap conditional on parental income in a recent birth cohort as a marker of ongoing structural racism is strongly associated with Black-White disparities in all-cause mortality and mortality from several causes.

Health Insurance Disruptions and Care Access and Affordability in the U.S

INTRODUCTION

Health insurance is associated with better care in the U.S., but little is known about the associations of coverage disruptions (i.e., periods without insurance) with care access, receipt, and affordability.

METHODS

Adults aged 18-64 years with current private (n=124,746), public (n=30,932), or no (n=31,802) insurance coverage were identified from the 2011-2018 National Health Interview Survey. Data were analyzed in 2020. Separate multivariable logistic regressions evaluated the associations of having coverage disruptions or being uninsured with care access, receipt, and affordability.

RESULTS

Overall, 5.0% of currently insured adults with private and 10.7% with public insurance reported a coverage disruption in the previous year, representing nearly 9.1 million adults in 2018. Among currently uninsured, 24.9% reported coverage loss within the previous year, representing nearly 8.1 million adults in 2018. Among adults with current private or current public coverage, disruptions were associated with lower receipt of all preventive services (AOR=0.42, 95% CI=0.37, 0.46 and AOR=0.48, 95% CI=0.40, 0.58, respectively), with forgoing any needed care because of cost (AOR=4.79, 95% CI=4.44, 5.17 and AOR=4.28, 95% CI=3.86, 4.75), and with medication nonadherence because of cost (AOR=3.55, 95% CI=3.13, 4.03 and AOR=4.09, 95% CI=3.43, 4.88) compared with that among adults with continuous coverage (p<0.05). Longer disruptions among currently insured adults were significantly associated with worse care access, receipt, and affordability, with dose-response patterns. Currently uninsured adults, especially those with longer uninsured periods, reported significantly worse care access, receipt, and affordability than currently insured adults with coverage disruptions or continuous coverage.

CONCLUSIONS

Findings highlight the importance of continuous insurance coverage; disruptions owing to the COVID-19 pandemic will likely have adverse consequences for care access and affordability.

Prostate Cancer Incidence 5 Years After US Preventive Services Task Force Recommendations Against Screening

BACKGROUND

Previous studies reported that prostate cancer incidence rates in the United States declined for local-stage disease and increased for regional- and distant-stage disease following the US Preventive Services Task Force recommendations against prostate-specific antigen-based screening for men aged 75 years and older in 2008 and for all men in 2012. It is unknown, however, whether these patterns persisted through 2016.

METHODS

Based on the US Cancer Statistics Public Use Research Database, we examined temporal trends in invasive prostate cancer incidence from 2005 to 2016 in men aged 50 years and older stratified by stage (local, regional, and distant), age group (50-74 years and 75 years and older), and race and ethnicity (all races and ethnicities, non-Hispanic Whites, and non-Hispanic Blacks) with joinpoint regression models to estimate annual percent changes. Tests of statistical significance are 2-sided (P < .05).

RESULTS

For all races and ethnicities combined, incidence for local-stage disease declined beginning in 2007 in men aged 50-74 years and 75 years and older, although the decline stabilized during 2013-2016 in men aged 75 years and older. Incidence decreased by 6.4% (95% CI = 4.9%-9% to 7.9%) per year from 2007 to 2016 in men aged 50-74 years and by 10.7% (95% CI = 6.2% to 15.0%) per year from 2007 to 2013 in men aged 75 years and older. In contrast, incidence for regional- and distant-stage disease increased in both age groups during the study period. For example, distant-stage incidence in men aged 75 years and older increased by 5.2% (95% CI = 4.2% to 6.1%) per year from 2010 to 2016.

CONCLUSIONS

Regional- and distant-stage prostate cancer incidence continue to increase in the United States in men aged 50 years and older, and future studies are needed to identify reasons for the rising trends.

Screening for Colorectal Cancer in the United States: Correlates and Time Trends by Type of Test

BACKGROUND

It is strongly recommended that adults aged 50-75 years be screened for colorectal cancer. Recommended screening options include colonoscopy, sigmoidoscopy, CT colonography, guaiac fecal occult blood testing (FOBT), fecal immunochemical testing (FIT), or the more recently introduced FIT-DNA (FIT in combination with a stool DNA test). Colorectal cancer screening programs can benefit from knowledge of patterns of use by test type and within population subgroups.

METHODS

Using 2018 National Health Interview Survey (NHIS) data, we examined colorectal cancer screening test use for adults aged 50-75 years (N = 10,595). We also examined time trends in colorectal cancer screening test use from 2010-2018.

RESULTS

In 2018, an estimated 66.9% of U.S. adults aged 50-75 years had a colorectal cancer screening test within recommended time intervals. However, the prevalence was less than 50% among those aged 50-54 years, those without a usual source of health care, those with no doctor visits in the past year, and those who were uninsured. The test types most commonly used within recommended time intervals were colonoscopy within 10 years (61.1%), FOBT or FIT in the past year (8.8%), and FIT-DNA within 3 years (2.7%). After age-standardization to the 2010 census population, the percentage up-to-date with CRC screening increased from 61.2% in 2015 to 65.3% in 2018, driven by increased use of stool testing, including FIT-DNA.

CONCLUSIONS

These results show some progress, driven by a modest increase in stool testing. However, colorectal cancer testing remains low in many population subgroups.

IMPACT

These results can inform efforts to achieve population colorectal cancer screening goals.

Updated Review of Major Cancer Risk Factors and Screening Test Use in the United States in 2018 and 2019, with a Focus on Smoking Cessation

Cancer prevention and early detection efforts are central to reducing cancer burden. Herein, we present estimates of cancer risk factors and screening tests in 2018 and 2019 among US adults, with a focus on smoking cessation. Cigarette smoking reached a historic low in 2019 (14.2%) partly because 61.7% (54.9 million) of all persons who had ever smoked had quit. Yet, the quit ratio was <45% among lower-income, uninsured, and Medicaid-insured persons, and was <55% among Black, American Indian/Alaska Native, lower-educated, lesbian, gay or bisexual, and recent immigrant persons, and in 12 of 17 Southern states. Obesity levels remain high (2017-2018: 42.4%) and were disproportionately higher among Black (56.9%) and Hispanic (43.7%) women. HPV vaccination in adolescents 13 to 17 years remains underutilized and over 40% were not up-to-date in 2019. Cancer screening prevalence was suboptimal in 2018 (colorectal cancer ≥50 years: 65.6%; breast ≥45 years: 63.2%; cervical 21-65 years: 83.7%), especially among uninsured adults (colorectal: 29.8%; breast: 31.1%). This snapshot of cancer prevention and early detection measures was mixed, and substantial racial/ethnic and socioeconomic disparities persisted. However, gains could be accelerated with targeted interventions to increase smoking cessation in under-resourced populations, stem the obesity epidemic, and improve screening and HPV vaccination coverage.

Trends in E-Cigarette Use by Age Group and Combustible Cigarette Smoking Histories, U.S. Adults, 2014-2018

INTRODUCTION

The trends in e-cigarette prevalence and population count of users according to cigarette smoking histories are unknown. These data are needed to inform public health actions against a rapidly changing U.S. e-cigarette market.

METHODS

Data collected between 2014 and 2018 (analyzed in 2020) from cross-sectional, nationally representative National Health Interview Surveys were used to estimate current e-cigarette prevalence, adjusted prevalence differences (percentage points), and population counts of users. Analyses were stratified by age group (younger, 18-29 years, n=25,445; middle age, 30-49 years, n=47,745; older, ≥50 years, n=79,517) and cigarette smoking histories (current smokers, recent quitters [quit <1 year ago], near-term quitters [quit 1-8 years ago], long-term quitters [quit >8 years ago], never smokers).

RESULTS

Among younger adults, e-cigarette use increased in all groups of smokers, with notable increases between 2014 and 2018 among never smokers (1.3%-3.3%, adjusted prevalence difference=2%, p<0.001) and near-term quitters (9.1%-19.2%, adjusted prevalence difference=8.8%, p=0.024). Conversely, the only substantial increase in e-cigarette use between 2014 and 2018 among middle-aged (5.8%-14.4%, adjusted prevalence difference=8.2%, p<0.001) and older (6.3%-9.5%, adjusted prevalence difference=3.3%, p=0.045) adults was among near-term quitters. The largest absolute population increase in e-cigarette users between 2014 and 2018 was among younger-adult never smokers (0.49-1.35 million), followed by near-term quitters among middle-aged (0.36-0.95 million), younger (0.23-0.57 million), and older (0.35-0.50 million) adults.

CONCLUSIONS

The continuous increase among younger-adult never smokers suggests a rise in primary nicotine initiation with e-cigarettes. The concomitant increase among near-term quitters of all age groups suggests continuing e-cigarette use among smokers who may have switched from cigarettes previously.

Proportion of cancer cases and deaths attributable to alcohol consumption by US state, 2013-2016

BACKGROUND

Alcohol consumption is an established risk factor for several cancer types, but there are no contemporary published estimates of the state-level burden of cancer attributed to alcoholic beverage consumption. Such estimates are needed to inform public policy and cancer control efforts. We estimated the proportion and number of incident cancer cases and cancer deaths attributable to alcohol consumption by sex in adults aged ≥30 years in all 50 states and the District of Columbia in 2013-2016.

METHODS

Age-, sex-, and state-specific cancer incidence and mortality data (2013-2016) were obtained from the US Cancer Statistics database. State-level, self-reported age and sex stratified alcohol consumption prevalence was estimated using the 2003-2006 Behavioral Risk Factor Surveillance System surveys and adjusted with state sales data.

RESULTS

The proportion of alcohol-attributable incident cancer cases ranged from 2.9 % (95 % confidence interval: 2.7 %-3.1 %) in Utah to 6.7 % (6.4 %-7.0 %) in Delaware among men and women combined, from 2.7 % (2.5 %-3.0 %) in Utah to 6.3 % (5.9 %-6.7 %) in Hawaii among men, and from 2.7 % (2.4 %-3.0 %) in Utah to 7.7 % (7.2 %-8.3 %) in Delaware among women. The proportion of alcohol-attributable cancer deaths also varied considerably across states: from 1.9 % to 4.5 % among men and women combined, from 2.1% to 5.0% among men, and from 1.4 % to 4.4 % among women. Nationally, alcohol consumption accounted for 75,199 cancer cases and 18,947 cancer deaths annually.

CONCLUSION

Alcohol consumption accounts for a considerable proportion of cancer incidence and mortality in all states. Implementing state-level policies and cancer control efforts to reduce alcohol consumption could reduce this cancer burden.

Abstract S09-04: Unemployment and cancer screening: Baseline estimates to inform health care provision in the context of COVID-19 economic distress

Introduction: During the COVID-19 pandemic, the unemployment rate has sharply risen from 3.5% in February 2020 to 13.3% in May 2020, a level not seen since the Great Depression. There are an estimated 21.0 million unemployed adults in the United States. Employers are the most common source of health insurance among working-aged adults and their families. Thus, job loss may lead to loss of insurance and reduce access to cancer screening, which can detect cancer at earlier, more treatable stages, and reduce cancer mortality. In this study, we examined sequential associations between unemployment, health insurance, and cancer screening to inform COVID’s potential longer-lasting impacts on early cancer detection.

Methods: Up-to-date (UTD) and recent (past-year) breast (BC) and colorectal cancer (CRC) screening prevalence were computed among respondents aged 50-64 years in 2000-2018 National Health Interview Survey data. Respondents were grouped as unemployed (not working but looking BC n=852; CRC n=1,747) and employed (currently working BC n=19,013; CRC n= 36,566). A series of logistic regression models with predicted marginal probabilities were used to estimate unemployed vs. employed unadjusted (PR) and adjusted prevalence ratios (aPR) and corresponding 95% Confidence Intervals (CI).

Results: Unemployed adults were four times as likely to be uninsured as employed adults (41.4% v 10.0%, p-value &lt;0.001). Unemployment was associated with lower UTD breast (67.8% vs 77.5%, p-value&lt;0.001, PR=0.82, 95%CI 0.77,0.87) and colorectal (49.4% and 60.1%, p-value&lt;0.001, PR=0.86, 95%CI 0.80, 0.92) cancer screening prevalence. These differences remained after adjusting for race/ethnicity, age, and sex, but were eliminated after accounting for health insurance. Patterns and magnitudes of PR and aPRs were similar for past-year CRC and BC screening prevalence.

Conclusion: Unemployment was adversely associated with guideline-recommended and potentially life-saving breast and colorectal cancer screening. Compared to the employed, the unemployed disproportionately lacked health insurance, which accounted for their lower cancer screening utilization. Expanding and ensuring health insurance coverage after job loss may mitigate COVID-19’s economic impacts on cancer screening.

Citation Format: Stacey A. Fedewa, K. Robin Yabroff, Zhiyuan Zheng, Priti Bandi, Ann Goding Sauer, Robert A. Smith, Nigar Nargis, Jeffrey Drope, Ahmedin Jemal. Unemployment and cancer screening: Baseline estimates to inform health care provision in the context of COVID-19 economic distress [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr S09-04.

Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society

The American Cancer Society (ACS) recommends that individuals with a cervix initiate cervical cancer screening at age 25 years and undergo primary human papillomavirus (HPV) testing every 5 years through age 65 years (preferred); if primary HPV testing is not available, then individuals aged 25 to 65 years should be screened with cotesting (HPV testing in combination with cytology) every 5 years or cytology alone every 3 years (acceptable) (strong recommendation). The ACS recommends that individuals aged >65 years who have no history of cervical intraepithelial neoplasia grade 2 or more severe disease within the past 25 years, and who have documented adequate negative prior screening in the prior 10 years, discontinue all cervical cancer screening (qualified recommendation). These new screening recommendations differ in 4 important respects compared with the 2012 recommendations: 1) The preferred screening strategy is primary HPV testing every 5 years, with cotesting and cytology alone acceptable where access to US Food and Drug Administration-approved primary HPV testing is not yet available; 2) the recommended age to start screening is 25 years rather than 21 years; 3) primary HPV testing, as well as cotesting or cytology alone when primary testing is not available, is recommended starting at age 25 years rather than age 30 years; and 4) the guideline is transitional, ie, options for screening with cotesting or cytology alone are provided but should be phased out once full access to primary HPV testing for cervical cancer screening is available without barriers. Evidence related to other relevant issues was reviewed, and no changes were made to recommendations for screening intervals, age or criteria for screening cessation, screening based on vaccination status, or screening after hysterectomy. Follow-up for individuals who screen positive for HPV and/or cytology should be in accordance with the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors.

Changes in Black-White Difference in Lung Cancer Incidence among Young Adults

Background

We previously reported that lung cancer incidence between Blacks and Whites younger than 40 years of age converged in women and approached convergence in men. Whether this pattern has continued in contemporary young birth cohorts is unclear.

Methods

We examined 5-year age-specific lung cancer incidence in Blacks and Whites younger than 55 years of age by sex and calculated the Black-to-White incidence rate ratios (IRRs) and smoking prevalence ratios by birth cohort using nationwide incidence data from 1997 to 2016 and smoking data from 1970 to 2016 from the National Health Interview Survey.

Results

Five-year age-specific incidence decreased in successive Black and White men born since circa 1947 and women born since circa 1957, with the declines steeper in Blacks than Whites. Consequently, the Black-to-White IRRs became unity in men born 1967-1972 and reversed in women born since circa 1967. For example, the Black-to-White IRRs in ages 40-44 years born between 1957 and 1972 declined from 1.92 (95% confidence interval [CI] = 1.82 to 2.03) to 1.03 (95% CI = 0.93 to 1.13) in men and from 1.32 (95% CI = 1.24 to 1.40) to 0.71 (95% CI = 0.64 to 0.78) in women. Similarly, the historically higher sex-specific smoking prevalence in Blacks than Whites disappeared in men and reversed in women born since circa 1965. The exception to these patterns is that the incidence became higher in Black men than White men born circa 1977-1982.

Conclusions

The historically higher lung cancer incidence in young Blacks than young Whites in the United States has disappeared in men and reversed in women, coinciding with smoking patterns, though incidence again became higher in Black men than White men born circa 1977-1982.

Financial Hardship, Healthcare Utilization, and Health Among U.S. Cancer Survivors

INTRODUCTION

This study examined associations of both medical and nonmedical financial hardships with healthcare utilization and self-rated health among cancer survivors.

METHODS

The National Health Interview Survey (2013-2017) was used to identify cancer survivors (aged 18-64 years: n=4,939; aged ≥65 years: n=6,972). A total of 4 levels of medical financial hardship intensities were created with measures from material, psychological, and behavioral domains. A total of 5 levels of nonmedical financial hardship intensities were created with measures in food insecurity and worry about other economic needs (e.g., housing expenses). Generalized ordinal logistic regression examined associations between medical and nonmedical financial hardship intensities and emergency department visits, use of preventive services and cancer screenings, and self-rated health. All analyses were performed in 2019.

RESULTS

In adjusted analyses, cancer survivors with higher medical financial hardship intensity (Level 4 vs Level 1; aged 18-64 years: 42% vs 26.2%, p<0.001; aged ≥65 years: 37.6% vs 24.3%, p=0.001) and higher nonmedical financial hardship intensity (Level 5 vs Level 1; aged 18-64 years: 37.2% vs 27.9%, p=0.011) had more emergency department visits. Moreover, cancer survivors with higher medical financial hardship intensity had lower influenza vaccine (Level 4 vs Level 1; aged 18-64 years: 45.6% vs 52.5%, p=0.036; aged ≥65 years: 64.6% vs 75.6%, p=0.008) and lower breast cancer screening levels (Level 4 vs Level 1; 46.8% vs 61.2%, p=0.001). Similar patterns were found between higher financial hardship intensities and worse self-rated health.

CONCLUSIONS

Higher medical and nonmedical financial hardships are independently associated with more emergency department visits, lower receipt of some preventive services, and worse self-rated health in cancer survivors. With growing healthcare costs, unmet medical and nonmedical financial needs may worsen health disparities among cancer survivors.

State Variation in Early-Onset Colorectal Cancer in the United States, 1995-2015

The extent to which the increase in early-onset colorectal cancer (CRC) in the United States varies geographically is unknown. We analyzed changes in CRC incidence and risk factors among people aged 20-49 years by state using high-quality population-based cancer registry data provided by the North American Association of Central Cancer Registries and national survey data, respectively. Early-onset CRC incidence was mostly stable among blacks and Hispanics but increased in 40 of 47 states among non-Hispanic whites, most prominently in western states. For example, rates increased in Washington from 6.7 (per 100 000) during 1995-1996 to 11.5 during 2014-2015 (rate ratio = 1.73, 95% confidence interval = 1.48 to 2.01) and in Colorado from 6.0 to 9.5 (rate ratio = 1.57, 95% confidence interval = 1.30 to 1.91). Nevertheless, current CRC incidence was highest in southern states. From 1995 to 2005, increases occurred in obesity prevalence in all states and heavy alcohol consumption in one-third of states, but neither were correlated with CRC incidence trends. Early-onset CRC is increasing most rapidly among whites in western states. Etiologic studies are needed to explore early life colorectal carcinogenesis.

Current Prevalence of Major Cancer Risk Factors and Screening Test Use in the United States: Disparities by Education and Race/Ethnicity

Overall cancer death rates in the United States have declined since 1990. The decline could be accelerated by eliminating socioeconomic and racial disparities in major risk factors and screening utilization. We provide an updated review of the prevalence of modifiable cancer risk factors, screening, and vaccination for U.S. adults, focusing on differences by educational attainment and race/ethnicity. Individuals with lower educational attainment have higher prevalence of modifiable cancer risk factors and lower prevalence of screening versus their more educated counterparts. Smoking prevalence is 6-fold higher among males without a high school (HS) education than female college graduates. Nearly half of women without a college degree are obese versus about one third of college graduates. Over 50% of black and Hispanic women are obese compared with 38% of whites and 15% of Asians. Breast, cervical, and colorectal cancer screening utilization is 20% to 30% lower among those with <HS education compared with college graduates. Screening for breast, cervical, and colorectal cancers is also lower among Hispanics, Asians, and American Indians/Alaska Natives relative to whites and blacks. Enhanced, multilevel efforts are needed to further reduce the prevalence of modifiable risk factors and improve screening and vaccination, particularly among those with lower socioeconomic status and racial/ethnic minorities.

Abstract B106: Cervical cancer screening modalities by state, 2016

Introduction: The Papanicolaou (Pap) test has long been a recommended cervical cancer screening modality. However, for women age 30-65 years, recommendations of the American Cancer Society and the US Preventive Services Task Force (USPSTF) now include testing for human papillomavirus (HPV) in conjunction with Pap test every five years (co-testing) or Pap testing alone. Additionally, draft USPSTF recommendations issued in 2017 include primary HPV testing for women 30-65 years. HPV co-testing is the preferred cervical cancer screening method in this age group because abnormalities are less likely to be missed. It is unknown how test modality varies by geography and insurance status, but such information could be useful for cancer control efforts. We examined prevalence estimates of cervical cancer screening modality among women age 30-65 years by state and insurance status.

Methods: Nonpregnant female respondents age 30-65 years with intact uteri and complete information on HPV and Pap testing (n=83,715) were selected from 2016 Behavioral Risk Factor Surveillance System data. Cervical cancer screening modality was categorized as co-testing (HPV and Pap testing in the past five years), HPV testing alone (in the past 5 years), and Pap testing alone (in the past 3 years), among those recently screened. SAS-callable SUDAAN was used to generate weighted, age-adjusted prevalence estimates.

Results: The prevalence of recent cervical cancer screening ranged from 79.9% in Idaho to 92.4% in Massachusetts (median=87.4%). Among those who were recently screened, Pap testing (range: 49.7%-73.3%; median=62.0%) was more common than co-testing (range: 26.1%-48.9%; median=37.4%) or HPV testing alone (&lt;2%). Although modality varied widely by state, in the District of Columbia (DC), Maine, and New York the prevalence of co-testing approached that of Pap testing where 48.9%, 45.9%, 44.2% were co-tested and 49.7%, 53.8%, and 54.6% had Pap testing alone, respectively. Generally, the prevalence of co-testing was lower in Southern and Midwestern states compared to states in other regions. The prevalence of recent screening was about 18% higher among the insured (median=89.1%) compared to the uninsured (median=71.2%). Among both the insured (median=61.5%) and uninsured (median=65.1%) Pap testing was the most common modality, but co-testing was more common in the insured (median=38.1%) than uninsured (median=34.9%).

Discussion: In 2016, most women had recently been screened for cervical cancer; however, utilization was notably lower among the uninsured than the insured. Among those who had been recently screened, the prevalence of Pap testing was higher than co-testing in all states, but was most similar in DC, Maine, and New York. Pap testing was even more common than co-testing among the uninsured compared to the insured. Efforts to educate women and their providers on the benefits of HPV co-testing may be needed.

Citation Format: Ann Goding Sauer, Ahmedin Jemal, Stacey A. Fedewa. Cervical cancer screening modalities by state, 2016 [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B106.

Colorectal cancer statistics, 2020

Colorectal cancer (CRC) is the second most common cause of cancer death in the United States. Every 3 years, the American Cancer Society provides an update of CRC occurrence based on incidence data (available through 2016) from population-based cancer registries and mortality data (through 2017) from the National Center for Health Statistics. In 2020, approximately 147,950 individuals will be diagnosed with CRC and 53,200 will die from the disease, including 17,930 cases and 3,640 deaths in individuals aged younger than 50 years. The incidence rate during 2012 through 2016 ranged from 30 (per 100,000 persons) in Asian/Pacific Islanders to 45.7 in blacks and 89 in Alaska Natives. Rapid declines in incidence among screening-aged individuals during the 2000s continued during 2011 through 2016 in those aged 65 years and older (by 3.3% annually) but reversed in those aged 50 to 64 years, among whom rates increased by 1% annually. Among individuals aged younger than 50 years, the incidence rate increased by approximately 2% annually for tumors in the proximal and distal colon, as well as the rectum, driven by trends in non-Hispanic whites. CRC death rates during 2008 through 2017 declined by 3% annually in individuals aged 65 years and older and by 0.6% annually in individuals aged 50 to 64 years while increasing by 1.3% annually in those aged younger than 50 years. Mortality declines among individuals aged 50 years and older were steepest among blacks, who also had the only decreasing trend among those aged younger than 50 years, and excluded American Indians/Alaska Natives, among whom rates remained stable. Progress against CRC can be accelerated by increasing access to guideline-recommended screening and high-quality treatment, particularly among Alaska Natives, and elucidating causes for rising incidence in young and middle-aged adults.

The Affordable Care Act and access to care across the cancer control continuum: A review at 10 years

Lack of health insurance coverage is strongly associated with poor cancer outcomes in the United States. The uninsured are less likely to have access to timely and effective cancer prevention, screening, diagnosis, treatment, survivorship, and end-of-life care than their counterparts with health insurance coverage. On March 23, 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law, representing the largest change to health care delivery in the United States since the introduction of the Medicare and Medicaid programs in 1965. The primary goals of the ACA are to improve health insurance coverage, the quality of care, and patient outcomes, and to maintain or lower costs by catalyzing changes in the health care delivery system. In this review, we describe the main components of the ACA, including health insurance expansions, coverage reforms, and delivery system reforms, provisions within these components, and their relevance to cancer screening and early detection, care, and outcomes. We then highlight selected, well-designed studies examining the effects of the ACA provisions on coverage, access to cancer care, and disparities throughout the cancer control continuum. Finally, we identify research gaps to inform evaluation of current and emerging health policies related to cancer outcomes.

Prevalence of Cigarette Smoking among Patients with Different Histologic Types of Kidney Cancer

BACKGROUND

Cigarette smoking is causally linked to renal cell carcinoma (RCC). However, associations for individual RCC histologies are not well described. Newly available data on tobacco use from population-based cancer registries allow characterization of associations with individual RCC types.

METHODS

We analyzed data for 30,282 RCC cases from 8 states that collected tobacco use information for a National Program of Cancer Registry project. We compared the prevalence and adjusted prevalence ratios (aPR) of cigarette smoking (current vs. never, former vs. never) among individuals diagnosed between 2011 and 2016 with clear cell RCC, papillary RCC, chromophobe RCC, renal collecting duct/medullary carcinoma, cyst-associated RCC, and unclassified RCC.

RESULTS

Of 30,282 patients with RCC, 50.2% were current or former cigarette smokers. By histology, proportions of current or formers smokers ranged from 38% in patients with chromophobe carcinoma to 61.9% in those with collecting duct/medullary carcinoma. The aPRs (with the most common histology, clear cell RCC, as referent group) for current and former cigarette smoking among chromophobe RCC cases (4.9% of our analytic sample) were 0.58 [95% confidence interval (CI), 0.50-0.67] and 0.88 (95% CI, 0.81-0.95), respectively. Other aPRs were slightly increased (papillary RCC and unclassified RCC, current smoking only), slightly decreased (unclassified RCC, former smoking only), or not significantly different from 1.0 (collecting duct/medullary carcinoma and cyst-associated RCC).

CONCLUSIONS

Compared with other RCC histologic types, chromophobe RCC has a weaker (if any) association with smoking.

IMPACT

This study shows the value of population-based cancer registries' collection of smoking data, especially for epidemiologic investigation of rare cancers.

Colorectal Cancer in the Young: Epidemiology, Prevention, Management

Colorectal cancer (CRC) incidence rates in the United States overall have declined since the mid-1980s because of changing patterns in risk factors (e.g., decreased smoking) and increases in screening. However, this progress is increasingly confined to older adults. CRC occurrence has been on the rise in patients younger than age 50, often referred to as early-onset disease, since the mid-1990s. Young patients are more often diagnosed at an advanced stage and with rectal disease than their older counterparts, and they have numerous other unique challenges across the cancer management continuum. For example, young patients are less likely than older patients to have a usual source of health care; often need a more complex treatment protocol to preserve fertility and sexual function; are at higher risk of long-term and late effects, including subsequent primary malignancies; and more often suffer medical financial hardship. Diagnosis is often delayed because of provider- and patient-related factors, and clinicians must have a high index of suspicion if young patients present with rectal bleeding or changes in bowel habits. Educating primary care providers and the larger population on the increasing incidence and characteristic symptoms is paramount. Morbidity can further be averted by increasing awareness of the criteria for early screening, which include a family history of CRC or polyps and a genetic predisposition.

Geographic and sociodemographic differences in cervical cancer screening modalities

Cervical cancer screening recommendations for women aged 30-65 years include co-testing (high-risk human papillomavirus [hrHPV] with Pap testing) every five years or Pap testing alone every three years. Geographic variations of these different screening modalities across the United States have not been examined. We selected 82,426 non-pregnant women aged 30-65 years from the 2016 Behavioral Risk Factor Surveillance System with data on sociodemographics, hysterectomy, and cervical cancer screening, representing 42 states and the District of Columbia. Logistic regression models with predicted marginal probabilities were used to calculate state-level prevalence estimates of recent cervical cancer screening and uptake of co-testing, Pap testing, and hrHPV testing among those who were recently screened. Analysis was conducted in 2018-2019. Recent screening prevalence ranged from 80.0% (Idaho) to 92.2% (Massachusetts), with more state-level geographic variability in co-testing than Pap testing alone. Uptake of co-testing ranged from 27.5% (Utah) to 49.9% (District of Columbia); compared to the national estimate, co-testing was lower in 12 states and higher in six states. Overall, Midwestern and Southern states had the lowest uptake of co-testing whereas Northeastern states had the highest. Sociodemographic, healthcare, and behavioral factors accounted for some but not all state-level variation in co-testing. There was substantial state-level variability in co-testing prevalence, which was lowest in Midwestern and Southern states; the variation was not entirely explained by individual sociodemographic, healthcare, and behavioral factors. Future studies should monitor the impact of geographic variations in screening modalities on state-level differences in cervical cancer incidence, survival, and mortality.

Prevalence of 'one and done' in adenoma detection rates: results from the New Hampshire Colonoscopy Registry

Background and study aims  Adenoma detection rate (ADR), the proportion of an endoscopist's screening colonoscopies in which at least one adenoma is found, is an established quality metric. Several publications have suggested that a technique referred to as "one and done," where less attention is paid to additional polyp detection following discovery of one likely adenoma, may be occurring 1 2 3 . To investigate whether this practice occurs and provide additional context to the significance of ADR, we examined ADR by single and multiple adenomas in the statewide New Hampshire Colonoscopy Registry (NHCR). Patients and methods  A total of 25,324 NHCR patients receiving screening colonoscopies between 2009 and 2014 by 69 endoscopists were analyzed. ADR was dichotomized into high (≥ 20 %) and low (< 20 %) based on 2006 recommended targets in place during the time of the study. ADR-plus (the average number of adenomas in colonoscopies with > 1 adenoma) was dichotomized at mean values into high (≥ 1.5) and low (< 1.5). As suggested by others, a high ADR but low ADR-plus was used to indicate the "one and done" approach. Results  Among endoscopists with an ADR ≥ 20 %, only 5 (7.2 %) had low ADR-plus values and were classified as "one and done." Results for serrated polyp detection were similar. ADR and ADR-plus decreased monotonically with increasing years since residency ( P values for trend ADR = 0.02; ADR-plus = 0.003) after adjusting for patient risk factors. Conclusion  "One and done" infrequently occurred among endoscopists with high ADR in a large statewide registry. The need to replace ADR with other polyp detection metrics (such as ADR-plus) to accurately ascertain performance quality is not supported by these findings.