Cancer incidence among Armenians in California

INTRODUCTION

California is home to the largest population of Armenians in the United States. The historical categorization of Armenians as 'White' or 'Some Other Race' in population databases has likely masked cancer incidence patterns in this population. This is the first study considering cancer incidence among Armenians in California.

METHODS

We used the Armenian Surname List and birthplace information in the California Cancer Registry to identify Armenians with cancer diagnosed during 1988-2019. We calculated proportional incidence ratios (PIR) among Armenians compared with non-Hispanic Whites (NHWs). As an exploratory analysis, we calculated incidence rate ratios (IRR) during 2006-2015 using Armenian population denominators from the American Community Survey (ACS). We selected PIR as our primary method given uncertainty regarding the use of ACS population estimates for rate calculations.

RESULTS

There were 27,212 cancer diagnoses among Armenians in California, 13,754 among males and 13,458 among females. Armenian males had notably higher proportions of stomach (PIR = 2.39), thyroid (PIR = 1.45), and tobacco-related cancers including bladder (PIR = 1.53), colorectal (PIR = 1.29), and lung (PIR = 1.16) cancers. Higher proportional incidence of cancers including stomach (PIR = 3.24), thyroid (PIR = 1.47), and colorectal (PIR = 1.29) were observed among Armenian females. Exploratory IRR analyses showed higher stomach (IRR = 1.78), bladder (IRR = 1.13), and colorectal (IRR = 1.12) cancers among Armenian males and higher stomach (IRR = 2.54) cancer among Armenian females.

CONCLUSION

We observed higher stomach, colorectal and thyroid cancer incidence among males and females, and tobacco-related cancers among males. Further research is needed to refine Armenian population estimates and understand and address risk factors associated with specific cancers among Armenians in California.

Characterizing risky alcohol use, cigarette smoking, e-cigarette use, and physical inactivity among cancer survivors in the USA-a cross-sectional study

PURPOSE

Unhealthy lifestyle behaviors are associated with inferior health outcomes among cancer survivors, including increased mortality. It is crucial to identify vulnerable subgroups, yet investigations have been limited. Thus, this study aimed to examine sociodemographic and clinical characteristics associated with risky health behaviors among cancer survivors.

METHODS

We used national, cross-sectional survey data (Health Information National Trends Survey, HINTS 2017-2020) for 2579 cancer survivors. We calculated the prevalence of risky alcohol use, current cigarette smoking, e-cigarette use, and not meeting physical activity guidelines. We performed weighted logistic regression to obtain multivariable-adjusted odds ratios (OR) for the association between each unhealthy behavior with sociodemographic and clinical characteristics.

RESULTS

Overall, 25% showed risky alcohol use, 12% were current cigarette smokers, 3% were current e-cigarette users, and 68% did not meet physical activity guidelines. Cancer survivors who were males, non-Hispanic Whites or African Americans, without a college education, not married and with comorbidities or psychological distress were more likely to have unhealthy behaviors. Those with lung disease or depression were 2 times as likely to smoke cigarette or e-cigarettes and those with psychological distress were 1.6 times as likely to be physically inactive. Moreover, risky drinkers (OR = 1.75, 95% CI = 1.22-2.52) and e-cigarette smokers (OR = 16.40, 95% CI 3.29-81.89) were more likely to be current cigarette smokers.

CONCLUSIONS

We identified vulnerable subpopulations of cancer survivors with multiple unhealthy lifestyle behaviors.

IMPLICATIONS FOR CANCER SURVIVORS

Our findings inform clinicians and program and policy makers of the subgroups of cancer survivors to target for multiple health behavior interventions.

Prevalence and associations of poor mental health in the third year of COVID-19: U.S. population-based analysis from 2020 to 2022

BACKGROUND

Poorer mental health was found early in the COVID-19 pandemic, yet mental health in the third year of COVID-19 has not been assessed on a general adult population level in the United States.

METHODS

We used a nationally representative cross-sectional survey (Health Information National Trends Survey, HINTS 5 2020 n = 3,865 and HINTS 6 2022 n = 6,252). The prevalence of poor mental health was examined using a Patient Health Questionnaire-4 scale in 2020 and 2022. We also investigated the factors associated with poor mental health in 2022 using a weighted multivariable logistic regression adjusting for sociodemographic and health status characteristics to obtain the odds ratio (OR).

OUTCOMES

The prevalence of poor mental health in adults increased from 2020 to 2022 (31.5% vs 36.3 %, p = 0.0005). U.S. adults in 2022 were 1.28 times as likely to have poor mental health than early in the pandemic. Moreover, individuals with food insecurity, housing instability, and low income had greater odds of poor mental health (ORs=1.78-2.55). Adults who were females, non-Hispanic Whites, or age 18-64 years were more likely to have poor mental health (ORs=1.46-4.15).

INTERPRETATION

Mental health of U.S. adults worsened in the third year of COVID-19 compared to the beginning of the pandemic.

Disparities in treatment and survival in early-stage hepatocellular carcinoma in California

BACKGROUND AND OBJECTIVES

Curative intent therapy is the standard of care for early-stage hepatocellular carcinoma (HCC). However, these therapies are under-utilized, with several treatment and survival disparities. We sought to demonstrate whether the type of facility and distance from treatment center (with transplant capabilities) contributed to disparities in curative-intent treatment and survival for early-stage HCC in California.

METHODS

We performed a retrospective analysis of the California Cancer Registry for patients diagnosed with stage I or II primary HCC between 2005 and 2017. Primary and secondary outcomes were receipt of treatment and overall survival, respectively. Multivariable logistic regression and Multivariable Cox proportional hazards regression were used to evaluate associations.

RESULTS

Of 19 059 patients with early-stage HCC, only 36% (6778) received curative-intent treatment. Compared to Non-Hispanic White patients, Hispanic patients were less likely, and Asian/Pacific Islander patients were more likely to receive curative-intent treatment. Our results showed that rural residence, public insurance, lower neighborhood SES, and care at non-National Cancer Institute-designated cancer center were associated with not receiving treatment and decreased survival.

CONCLUSIONS

Although multiple factors influence receipt of treatment for early-HCC, our findings suggest that early intervention programs should target travel barriers and access to specialist care to help improve oncologic outcomes.

Impact of Specialized Treatment Setting on Survival in Adolescent and Young Adult ALL

PURPOSE

Unlike children with ALL who receive cancer care primarily at specialized cancer centers (SCCs; National Cancer Institute and/or Children's Oncology Group centers), adolescents and young adults (AYAs; 15-39 years) receive care in a variety of settings. Using population-based data, we describe where AYAs with ALL receive treatment and determine associations with overall survival (OS).

METHODS

Data from the 2004 to 2018 California (CA, n = 2,283), New York (NY, n = 795), and Texas (TX, n = 955) state cancer registries were used to identify treatment setting of AYAs with newly diagnosed ALL. Multivariable Cox proportional hazards regression models evaluated associations with OS.

RESULTS

Seventy percent were older than 18 years, and 65% were male. A majority in CA (63%) and TX (64%) were Hispanic while most in NY were non-Hispanic White (50%). Treatment at an SCC occurred in 48.2% (CA), 44.4% (NY), and 19.5% (TX). Across states, AYAs who were older or uninsured were less likely to receive treatment at an SCC. Treatment at an SCC was associated with superior OS in CA (hazard ratio [HR], 0.73; 95% CI, 0.63 to 0.85) and TX (HR, 0.61; 95% CI, 0.45 to 0.83); a nonsignificant association was seen in NY (HR, 0.83; 95% CI, 0.64 to 1.08).

CONCLUSION

Only 20%-50% of AYA patients with ALL received frontline treatment at SCCs. Treatment of ALL at an SCC was associated with superior survival, highlighting the importance of policy efforts to improve access and reduce inequities in AYA ALL care.

Cancer survivors with sub-optimal patient-centered communication before and during the early COVID-19 pandemic

OBJECTIVES

Patient-Centered Communication (PCC) is an essential element of patient-centered cancer care. Thus, this study aimed to examine the prevalence of and factors associated with optimal PCC among cancer survivors during COVID-19, which has been less studied.

METHODS

We used national survey (Health Information National Trends Survey) among cancer survivors (n = 2579) to calculate the prevalence (%) of optimal PCC in all 6 PCC domains and overall (mean) by time (before COVID-19, 2017-19 vs. COVID-19, 2020). Multivariable logistic regressions were performed to explore the associations of sociodemographic (age, birth gender, race/ethnicity, income, education, usual source of care), and health status (general health, depression/anxiety symptoms, time since diagnosis, cancer type) factors with optimal PCC.

RESULTS

The prevalence of optimal PCC decreased during COVID-19 overall, with the greatest decrease in managing uncertainty (7.3%). Those with no usual source of care (odd ratios, ORs =1.53-2.29), poor general health (ORs=1.40-1.66), depression/anxiety symptoms (ORs=1.73-2.17) were less likely to have optimal PCC in most domains and overall PCC.

CONCLUSIONS

We observed that the decreased prevalence of optimal PCC, and identified those with suboptimal PCC during COVID-19.

PRACTICE IMPLICATIONS

More efforts to raise awareness and improve PCC are suggested, including education and guidelines, given the decreased prevalence during this public health emergency.

Impact of COVID-19, cancer survivorship and patient-provider communication on mental health in the US Difference-In-Difference

Poor mental health has been found to be more prevalent among those with cancer and is considered a public health crisis since COVID-19. This study assessed the impact of COVID-19 and cancer survivorship on mental health and investigated factors, including online patient-provider communications (OPPC; email/internet/tablet/smartphone), associated with poor mental health prior to and during the early COVID-19. Nationally representative Health Information National Trends Survey data during 2017-2020 (n = 15,871) was used. While the prevalence of poor mental health was high (40-42%), Difference-In-Difference analyses revealed that cancer survivorship and COVID-19 were not associated with poor mental health. However, individuals that used OPPC had 40% higher odds of poor mental health. Low socioeconomic status (low education/income), younger age (18-64 years), and female birth gender were also associated with poor mental health. Findings highlight the persistence of long-standing mental health inequities and identify that OPPC users might be those who need mental health support.

Factors Associated with Online Patient-Provider Communications Among Cancer Survivors in the United States during COVID: A Cross-Sectional Study

BACKGROUND

Online Patient-Provider Communication (OPPC) is crucial in enhancing access to health information, self-care, and related health outcomes among cancer survivors. The necessity of OPPC increased during SARS/COVID-19 (COVID), yet investigations in vulnerable subgroups have been limited.

OBJECTIVE

Thus, this study aimed to assess the prevalence of OPPC and sociodemographic and clinical characteristics associated with OPPC among cancer survivors and adults without a history of cancer during COVID vs. pre-COVID.

METHODS

Nationally representative cross-sectional survey data (Health Information National Trends Survey, HINTS 5 2017-2020) was used among cancer survivors (n= 1,900) and adults without a history of cancer (n= 13, 292). COVID included data from February to June 2020. We calculated the prevalence of three types of OPPC, defined as using email/internet, tablet/smartphone, or Electronic Health Records (EHR) for patient-provider communication, in the past 12 months. To investigate the associations of sociodemographic and clinical factors with OPPC, multivariable-adjusted weighted logistic regression was performed to obtain odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

The average prevalence of OPPC increased from pre-COVID to COVID among cancer survivors (39.7% vs. 49.7%, email/internet; 32.2% vs. 37.9%, tablet/smartphone; 19.0% vs. 30.0%, EHR). Cancer survivors (OR=1.32, 95% CI 1.06-1.63) were slightly more likely to use email/internet communications than adults without a history of cancer prior to COVID. Among cancer survivors, email/internet (OR=1.61, 1.08-2.40) and EHR (OR=1.92, 1.22-3.02) were more likely to be used during COVID than pre-COVID. During COVID, subgroups of cancer survivors, including Hispanics (OR=0.26, 0.09-0.71 vs. non-Hispanic Whites), or those with the lowest income (OR=6.14, 1.99-18.92 $50,000 to <$75,000; OR=0.42, 1.56-11.28 ≥ $75,000 vs. <$20,000), with no usual source of care (OR=6.17, 2.12-17.99), or reporting depression (OR=0.33, 0.14-0.78) were less likely to use email/internet and those who were the oldest (OR=9.33, 2.18-40.01 age 35-49; OR=3.58, 1.20-10.70 age 50-64; OR=3.09, 1.09-8.76 age 65-74 vs. ≥75), unmarried (OR=2.26, 1.06-4.86) or had public/no health insurance (ORs=0.19-0.21 Medicare, Medicaid, or Other, vs. private) were less likely to use tablet/smartphone to communicate with providers. Cancer survivors with a usual source of care (OR=6.23, 1.66-23.39) or healthcare office visits within a year (ORs=7.55-8.25) were significantly more likely to use EHR to communicate. While not observed in cancer survivors, lower education level was associated with lower OPPC among adults without a history of cancer during COVID.

CONCLUSIONS

Our findings identified vulnerable subgroups of cancer survivors who were left behind in online patient-provider communications which are becoming an increasing part of healthcare. Those vulnerable subgroups of cancer survivors with lower OPPC should be helped through multidimensional interventions to prevent further inequities.

CLINICALTRIAL

Not applicable.

Construction of the Armenian Surname List (ASL) for public health research

BACKGROUND

There are an estimated 460,000 Armenians in the United States, and more than half live in California. Armenian-Americans are generally represented within the 'White' or 'Some Other Race' race categories in population-based research studies. While Armenians have been included in studies focused on Middle-Eastern populations, there are no studies focused exclusively on Armenians due to a lack of standardized collection of Armenian ethnicity in the United States or an Armenian surname list. To fill this research gap, we sought to construct and evaluate an Armenian Surname List (ASL) for use as an identification tool in public health and epidemiological research studies focused on Armenian populations.

METHODS

Data sources for the ASL included the California Public Use Death Files (CPUDF) and the Middle Eastern Surname List (MESL). For evaluation of the ASL, the California Cancer Registry (CCR) database was queried for surnames with birthplace in Armenia and identified by the MESL.

RESULTS

There are a total of 3,428 surnames in the ASL. Nearly half (1,678) of surnames in the ASL were not identified by the MESL. The ASL captured 310 additional Armenian surnames in the CCR than the MESL.

CONCLUSIONS

The ASL is the first surname list for identifying Armenians in major databases for epidemiological research.

Urinary Biomarkers of Polycyclic Aromatic Hydrocarbons and Timing of Pubertal Development: The California PAH Study

BACKGROUND

Polycyclic aromatic hydrocarbons (PAHs) are endocrine-disrupting chemicals. Few studies have evaluated the association between pubertal development in girls and PAH exposures quantified by urinary biomarkers.

METHODS

We examined associations of urinary PAH metabolites with pubertal development in 358 girls 6-16 years of age from the San Francisco Bay Area enrolled in a prospective cohort from 2011 to 2013 and followed until 2020. Using baseline data, we assessed associations of urinary PAH metabolites with pubertal development stage. In prospective analyses limited to girls who at baseline had not yet started breast (N = 176) or pubic hair (N = 179) development or menstruation (N = 267), we used multivariable Cox proportional hazards regression to assess associations of urinary PAH metabolites with the onset of breast and pubic hair development, menstruation, and pubertal tempo (interval between the onset of breast development and menstruation).

RESULTS

We detected PAH metabolites in >98% of girls. In cross-sectional analyses using baseline data, PAH metabolites were not associated with the pubertal development stage. In prospective analyses, higher concentrations (≥ median) of some PAH metabolites were associated with two-fold higher odds of earlier breast development (2-hydroxy naphthalene, 1-hydroxy phenanthrene, summed hydroxy phenanthrenes) or pubic hair development (1-hydroxy naphthalene) among girls overweight at baseline (body mass index-for-age percentile ≥85) compared with nonoverweight girls with lower metabolites concentrations. PAH metabolites were not associated with age at menarche or pubertal tempo.

CONCLUSIONS

PAH exposures were widespread in our sample. Our results support the hypothesis that, in overweight girls, PAHs impact the timing of pubertal development, an important risk factor for breast cancer.

Predictors of urinary polycyclic aromatic hydrocarbon metabolites in girls from the San Francisco Bay Area

BACKGROUND

Polycyclic aromatic hydrocarbon (PAH) exposures from tobacco smoke, automobile exhaust, grilled or smoked meat and other sources are widespread and are a public health concern, as many are classified as probable carcinogens and suspected endocrine-disrupting chemicals. PAH exposures can be quantified using urinary biomarkers.

METHODS

Seven urinary metabolites of naphthalene, fluorene, phenanthrene, and pyrene were measured in two samples collected from girls aged 6-16 years from the San Francisco Bay Area. We used Spearman correlation coefficients (SCC) to assess correlations among metabolite concentrations (corrected for specific gravity) separately in first (n = 359) and last (N = 349) samples, and to assess consistency of measurements in samples collected up to 72 months apart. Using multivariable linear regression, we assessed variation in mean metabolites across categories of participant characteristics and potential outdoor, indoor, and dietary sources of PAH exposures.

RESULTS

The detection rate of PAH metabolites was high (4 metabolites in ≥98% of first samples; 5 metabolites in ≥95% of last samples). Correlations were moderate to strong between fluorene, phenanthrene and pyrene metabolites (SCC 0.43-0.82), but weaker between naphthalene and the other metabolites (SCC 0.18-0.36). SCC between metabolites in first and last samples ranged from 0.15 to 0.49. When classifying metabolite concentrations into tertiles based on single samples (first or last samples) vs. the average of the two samples, agreement was moderate to substantial (weighted kappa statistics 0.52-0.65). For specific metabolites, concentrations varied by age, race/ethnicity, and body mass index percentile, as well as by outdoor sources (season of sample collection, street traffic), indoor sources (heating with gas, cigarette smoke), and dietary sources (frequent use of grill, consumption of smoked meat or fish) of PAH exposures.

CONCLUSIONS

Urinary PAH exposure was widespread in girls aged 6-16 years and associated with several sources of exposure. Tertile classification of a single urine sample provides reliable PAH exposure ranking.

Assessing the Quality of Electronic Data for 'Fit-for-Purpose' by Utilizing Data Profiling Techniques Prior to Conducting a Survival Analysis for Adults with Acute Lymphoblastic Leukemia

Acute lymphoblastic leukemia affects both children and adults. Rising costs of cancer care and patient burden contribute to the need to study factors influencing outcomes. This study explored the quality of datasets generated from a clinical research institution. The 'fit-for-use' of data prior to examining survival/complications was determined through a systematic approach guided by the Weiskopf et al. 3x3 Data Quality Assessment Framework. Constructs of completeness, correctness, and currency were explored for the data dimensions of patient, variables, and time. There were 11 types of data retrieved. Sufficient data points were found for patient and variable data in each dataset (≥70% of its cells filled with patient level data). Although there was concordance between variables, we found the distribution of lab values and death data to be incorrect. There were missing values for labs ordered and death dates. Our study showed that datasets retrieved can vary, even from the same institution.

Cancer statistics for adolescents and young adults, 2020

Cancer statistics for adolescents and young adults (AYAs) (aged 15-39 years) are often presented in aggregate, masking important heterogeneity. The authors analyzed population-based cancer incidence and mortality for AYAs in the United States by age group (ages 15-19, 20-29, and 30-39 years), sex, and race/ethnicity. In 2020, there will be approximately 89,500 new cancer cases and 9270 cancer deaths in AYAs. Overall cancer incidence increased in all AYA age groups during the most recent decade (2007-2016), largely driven by thyroid cancer, which rose by approximately 3% annually among those aged 20 to 39 years and 4% among those aged 15 to 19 years. Incidence also increased in most age groups for several cancers linked to obesity, including kidney (3% annually across all age groups), uterine corpus (3% in the group aged 20-39 years), and colorectum (0.9%-1.5% in the group aged 20-39 years). Rates declined dramatically for melanoma in the group aged 15 to 29 years (4%-6% annually) but remained stable among those aged 30 to 39 years. Overall cancer mortality declined during 2008 through 2017 by 1% annually across age and sex groups, except for women aged 30 to 39 years, among whom rates were stable because of a flattening of declines in female breast cancer. Rates increased for cancers of the colorectum and uterine corpus in the group aged 30 to 39 years, mirroring incidence trends. Five-year relative survival in AYAs is similar across age groups for all cancers combined (range, 83%-86%) but varies widely for some cancers, such as acute lymphocytic leukemia (74% in the group aged 15-19 years vs 51% in the group aged 30-39 years) and brain tumors (77% vs 66%), reflecting differences in histologic subtype distribution and treatment. Progress in reducing cancer morbidity and mortality among AYAs could be addressed through more equitable access to health care, increasing clinical trial enrollment, expanding research, and greater alertness among clinicians and patients for early symptoms and signs of cancer. Further progress could be accelerated with increased disaggregation by age in research on surveillance, etiology, basic biology, and survivorship.

Late Effects in Survivors of Adolescent and Young Adult Acute Lymphoblastic Leukemia

Background

Knowledge regarding late effects (medical conditions and subsequent neoplasms) in survivors of adolescent and young adult (AYA) acute lymphoblastic leukemia (ALL) is lacking.

Methods

Using the population-based California Cancer Registry linked with California hospitalization data, we evaluated late effects in 1069 AYAs (aged 15-39 years) diagnosed with ALL in California between 1995 and 2012 and surviving a minimum of 3 years from diagnosis.

Results

The estimated 10-year cumulative incidence of subsequent endocrine disease (28.7%, 95% confidence interval [CI] = 25.8% to 31.6%) and cardiac disease (17.0%, 95% CI = 14.6% to 19.5%) were strikingly high; avascular necrosis (9.6%, 95% CI = 7.8% to 11.6%), liver disease (6.5%, 95% CI = 5.0% to 8.3%), respiratory disease (6.2%, 95% CI = 4.8% to 8.0%), seizure and/or stroke (4.3%, 95% CI = 3.1% to 5.8%), renal disease (3.1%, 95% CI = 2.1% to 4.4%), and second neoplasms (1.4%, 95% CI = 0.7% to 2.4%) were estimated to occur at 10 years with the reported frequencies. Multivariable analyses including the entire patient cohort demonstrated that public or no insurance (vs private and/or military insurance) and receipt of hematopoietic cell transplantation were independently associated with the occurrence of all late effects considered. In multivariable analyses limited to the 766 AYAs who were not transplanted, we continued to find a statistically significant association between public and no insurance and the occurrence of all late effects. Frontline regimen type (pediatric vs adult) was not statistically significantly associated with any of the late effect categories.

Conclusions

This large population-based analysis is among the first to describe late effects in survivors of AYA ALL. The strong association between insurance type and late effects suggests that AYAs with public or no insurance may have reduced access to survivorship care following completion of ALL therapy.

A pilot study on the utility of reduced urine collection frequency protocols for the assessment of reproductive hormones in adolescent girls

BACKGROUND

The objectives of this study were to assess the feasibility of and compliance to collecting urine samples in pre- and postmenarcheal girls and to determine if a less than daily collection frequency was sufficient for assessing ovarian function.

METHODS

Twenty-five postmenarcheal girls (11-17 years) collected samples using either a two or a three samples/week protocol during one menstrual cycle. Exposure and mean estrone-1-glucuronide (E1G) and pregnanediol glucuronide concentrations were calculated, and evidence of luteal activity (ELA) was evaluated. Sixteen premenarcheal girls (8-11 years) collected one sample/month for six consecutive months. Samples were analyzed for E1G concentration. Participant compliance was calculated using dates on the urine samples and paper calendars.

RESULTS

Participants collecting three samples/week were more compliant to the protocol than those collecting two samples/week (83.6%±2.6% vs. 66.8%±6.6%; p=0.034). There were no differences (p>0.10) regarding paper calendar return (81.8%±12.2% vs. 92.9%±7.1%), recording menses (55.6%±17.6% vs. 92.3%±7.7%) or sample collection (88.9%±11.1% vs. 84.6%±10.4%) between the two protocols. The average cycle length was 30.5±1.3 days and 32% of cycles had ELA. The premenarcheal girls were 100% compliant to the protocol. Only 68.8% of participants returned the paper calendar and 81.8% of those participants recorded sample collection. The average E1G concentration was 15.9±3.8 ng/mL.

CONCLUSIONS

Use of a less than daily collection frequency during one menstrual cycle in postmenarcheal, adolescent girls is feasible and provides informative data about ovarian function. Collection of one sample/month in premenarcheal girls is feasible and detects the expected low E1G concentrations. Alternate strategies to the use of a paper calendar should be considered.

Outcomes after diagnosis of mycosis fungoides and Sézary syndrome before 30 years of age: a population-based study

IMPORTANCE

Mycosis fungoides and Sézary syndrome (MF/SS) are rare in children and young adults, and thus the incidence and outcomes in this patient population are not well studied.

OBJECTIVE

To assess the incidence and outcomes of MF/SS in patients diagnosed before 30 years of age.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study of 2 population-based cancer registries-the California Cancer Registry (n = 204) and 9 US cancer registries of the Surveillance, Epidemiology, and End Results program (SEER 9; n = 195)-for patients diagnosed with MF/SS before 30 years of age.

MAIN OUTCOMES AND MEASURES

Overall survival was calculated by the Kaplan-Meier method. The risk of a second cancer was assessed by calculating the standard incidence ratio (SIR) comparing observed cancer incidence in patients with MF/SS with the expected incidence in the age-, sex-, and race-standardized general population.

RESULTS

The incidence of MF/SS is rare before 30 years of age, with an incidence rate of 0.05 per 100,000 persons per year before age 20 years and 0.12 per 100,000 persons per year between ages 20 and 29 years in the California Cancer Registry. At 10 years, patients with MF/SS had an overall survival of 94.3% (95% CI, 89.6%-97.2%) in the California Cancer Registry and 88.9% (95% CI, 82.4%-93.2%) in SEER 9. In SEER 9, there was a significant excess risk of all types of second cancers combined (SIR, 3.40; 95% CI, 1.55-6.45), particularly lymphoma (SIR, 12.86; 95% CI, 2.65-37.59) and melanoma (SIR, 9.31; 95% CI, 8.75-33.62). In the California Cancer Registry, the SIR for risk of all types of second cancers was similar to that in SEER 9 (SIR, 3.45; 95% CI, 0.94-8.83), although not statistically significant.

CONCLUSIONS AND RELEVANCE

Young patients with MF/SS have a favorable outcome, despite a strong suggestion of an increased risk of second primary cancers. Prolonged follow-up is warranted to definitively assess their risk of developing second cancers in a lifetime.

Hodgkin lymphoma incidence in California Hispanics: influence of nativity and tumor Epstein-Barr virus

PURPOSE

For classical Hodgkin lymphoma (HL), migrant studies could elucidate contributions of environmental factors (including Epstein-Barr virus (EBV)) to the lower rates in non-whites. Given the well-described etiologic complexity of HL, this research requires a large, immigrant population, such as California Hispanics.

METHODS

With 1988-2004 California Cancer Registry data (2,595 Hispanic, 8,637 white HL cases) and tumor cell EBV status on a subset (218 Hispanics, 656 whites), we calculated ethnicity- and nativity-specific HL incidence rates simultaneously by age, sex, and histologic subtype, and tumor cell EBV prevalence.

RESULTS

Compared with white rates, Hispanic HL rates were lower overall (70 %) and for nodular sclerosis HL, particularly among young adults (60-65 % for females). However, they were higher among children (200 %) and older adults, and for mixed cellularity HL. Compared with rates in foreign-born Hispanics, rates in US-born Hispanics were higher among young adults (>threefold in females), lower for children and adults over age 70, and consistently intermediate compared with rates in whites. EBV tumor prevalence was 67, 32, and 23 % among foreign-born Hispanics, US-born Hispanics, and whites, respectively, although with variation by age, sex, and histology.

CONCLUSIONS

Findings strongly implicate environmental influences, such as nativity-related sociodemographic differences, on HL occurrence. In addition, lower young adult rates and higher EBV prevalence in US-born Hispanics than in whites raise questions about the duration/extent of environmental change for affecting HL rates and also point to ethnic differences in genetic susceptibility. Lesser variation in mixed cellularity HL rates and greater variation in rates for females across groups suggest less modifiable factors interacting with environmental influences.

Abstract A40: Body size and racial/ethnic differences in breast cancer survival

Background: Studies of body size and breast cancer prognosis have primarily been conducted in non-Latina White women with little research to date in racial/ethnic minority groups. We investigated body size (body mass index [BMI], waist-hip-ratio [WHR], waist-height-ratio [WHtR], waist circumference [WC]) and survival by race/ethnicity (non-Latina White, African American, Asian American, and Latina) in the California Breast Cancer Survivorship Consortium (CBCSC).

Methods: The CBCSC represents 12,025 breast cancer patients diagnosed with primary invasive breast cancer from 1993-2007 from six California-based studies of breast cancer etiology or prognosis. Data on body size, race/ethnicity, and relevant covariates previously collected from in-person interview or mailed questionnaire were harmonized and pooled. Clinical characteristics and mortality information were obtained from the California Cancer Registry. Body size measures included minimum 6 months pre-diagnosis BMI in kg/m2 (underweight &lt;18.5, normal 18.5-&lt;25, overweight 25-&lt;30, obese 30-&lt;35, severely obese 35-&lt;40, morbidly obese ≥40), and median 1 year post-diagnosis WHR, WHtR, and WC (quartiles). Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the associations of each body size measure with all-cause and breast cancer-specific (BC) mortality, adjusted for sociodemographic, lifestyle, clinical, and treatment covariates.

Results: Among 11,351 women with BMI data (6,044 non-Latina Whites, 1,886 African Americans, 1,451 Asian Americans, 1,864 Latinas, and 106 others), a total of 2,744 deaths (1,445 BC-related) were observed after a mean (SD) follow-up of 11.0 (3.8) years. Underweight and morbidly obese women had a statistically significant increased risk of overall mortality compared to normal-weight women (underweight HR=1.47; 95% CI: 1.13, 1.90 and morbidly obese HR=1.43; 95% CI: 1.16, 1.77; p for trend=0.012; departure from linearity p=0.005) while obese and severely obese women had borderline significant increased risks. Similar yet attenuated associations were found for BC mortality. Women in the highest WHR quartile compared to those in the lowest quartile had a significant increased risk of both overall death (HR=1.30; 95% CI: 1.10, 1.55) and BC death (HR=1.36; 95% CI: 1.07, 1.73) with a positive trend of larger WHR and increasing risk (p for trend&lt;0.05). WHtR and WC had similar associations with mortality as WHR. Compared to the entire cohort, non-Latina Whites had an analogous U-shaped association of BMI with mortality risk, while African Americans and Asian Americans had no associations at any BMI level. Latinas had elevated risks only among the morbidly obese. In contrast, larger WHR was associated with mortality in African Americans (p for trend&lt;0.001) while no associations with WHR were found in non-Latina Whites. Asian Americans had elevated risks only in the top WHR quartile. WHtR and WC were not associated with mortality in any race/ethnicity group.

Conclusion: In this large, multiethnic study of breast cancer patients, we found that those with extreme BMI and increased WHR had the worse survival but that the associations varied by race/ethnicity. Obesity and body fat distribution around breast cancer diagnosis appear to have differential effects on survival depending on race/ethnicity.

Funded by the California Breast Cancer Research Program

Citation Format: Marilyn L. Kwan, Bette J. Caan, Valerie S. Lee, Esther M. John, Scarlett Lin Gomez, Salma Shariff-Marco, Theresa H. Keegan, Allison W. Kurian, Leslie Bernstein, Yani Lu, Iona Cheng, Kristine R. Monroe, Richard Sposto, Cheryl Vigen, Anna H. Wu. Body size and racial/ethnic differences in breast cancer survival. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A40.

Lymphoid malignancies in U.S. Asians: incidence rate differences by birthplace and acculturation

BACKGROUND

Malignancies of the lymphoid cells, including non-Hodgkin lymphomas (NHL), HL, and multiple myeloma, occur at much lower rates in Asians than other racial/ethnic groups in the United States. It remains unclear whether these deficits are explained by genetic or environmental factors. To better understand environmental contributions, we examined incidence patterns of lymphoid malignancies among populations characterized by ethnicity, birthplace, and residential neighborhood socioeconomic status (SES) and ethnic enclave status.

METHODS

We obtained data about all Asian patients diagnosed with lymphoid malignancies between 1988 and 2004 from the California Cancer Registry and neighborhood characteristics from U.S. Census data.

RESULTS

Although incidence rates of most lymphoid malignancies were lower among Asian than white populations, only follicular lymphoma (FL), chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), and nodular sclerosis (NS) HL rates were statistically significantly lower among foreign-born than U.S.-born Asians with incidence rate ratios ranging from 0.34 to 0.87. Rates of CLL/SLL and NS HL were also lower among Asian women living in ethnic enclaves or lower SES neighborhoods than those living elsewhere.

CONCLUSIONS

These observations support strong roles of environmental factors in the causation of FL, CLL/SLL, and NS HL.

IMPACT

Studying specific lymphoid malignancies in U.S. Asians may provide valuable insight toward understanding their environmental causes.

Global DNA methylation levels in girls with and without a family history of breast cancer

Lower levels of global DNA methylation in white blood cell (WBC) DNA have been associated with adult cancers. It is unknown whether individuals with a family history of cancer also have lower levels of global DNA methylation early in life. We examined global DNA methylation in WBC (measured in three repetitive elements, LINE1, Sat2 and Alu, by MethyLight and in LINE1 by pyrosequencing) in 51 girls ages 6-17. Compared to girls without a family history of breast cancer, methylation levels were lower for all assays in girls with a family history of breast cancer, and statistically significantly lower for Alu and LINE1 pyrosequencing. After adjusting for age, body mass index (BMI), and Tanner stage, only methylation in Alu was associated with family history of breast cancer. If these findings are replicated in larger studies, they suggest that lower levels of global WBC DNA methylation observed later in life in adults with cancer may also be present early in life in children with a family history of cancer.

Abstract B125: Genomic methylation levels in white blood cell DNA among young girls

Lower levels of genomic DNA methylation in white blood cell DNA (WBC) have been observed in individuals with breast or other cancers. Genomic methylation in WBC has been also associated with risk factors for cancer in adulthood; data on the association with exposures earlier in life are limited. Using information from 31 girls 6 to 17 years of age from families enrolled in the Breast Cancer Family Registry, and 20 girls of similar age from families without breast cancer, we conducted a pilot study to examine whether genomic methylation in WBC is associated with selected breast cancer risk factors. Genomic methylation levels were measured by MethyLight for three repetitive elements (LINE1, Sat2M1 and AluM2), the luminometric methylation assay (LUMA), and LINE1-pyrosequencing. We found that age of menarche was inversely correlated with LINE1 MethyLight (r=−0.41, p=0.02) and pyrosequencing methylation (r=−0.48, p=0.01) levels. Girls with a body mass index (BMI, kg/m2) between 18.5 and 24.9 had lower methylation of LINE1 pyrosequencing compared with girls with higher or lower BMI values. Genomic methylation levels, measured by LUMA, AluM2 MethyLight, and LINE1 pyrosequencing, differed between girls with and without a family history of breast cancer. These data, if replicated in larger samples, suggest that breast cancer risk factors may be associated with genomic methylation in WBC in early life.

Citation Information: Cancer Prev Res 2010;3(1 Suppl):B125.

Differences in breast cancer subtype distribution exist among ethnic subgroups of Asian women in California

Abstract #2088

Background: Distinct breast cancer subtypes have been identified by gene expression analysis. Little is known about the distribution of these subtypes among Asian women. We previously reported an increased frequency of HER2-positive breast cancers among certain ethnic subgroups of Asian women in California. To follow up on that finding in detail, we undertook the current analysis to explore factors associated with differences in breast cancer subtype distribution among Asian women in California.&#x2028; Methods: We defined immunohistochemical surrogates for each breast cancer subtype among Chinese, Japanese, Filipina, Korean, Vietnamese and South Asian patients in the population-based California Cancer Registry diagnosed in the period 1999-2005. Subtypes were defined using combinations of immunohistochemical markers: luminal A (ER+ and/or PR+, HER2-), luminal B (ER+ and/or PR+, HER2+), basal-like (ER-, PR-, HER2-) and HER2+/ER- (ER-, PR-, HER2+). Polytomous logistic regression was used to evaluate associations between breast cancer subtype and age, race, AJCC stage, tumor grade, tumor histology, socioeconomic status, nativity and hospital ownership (private vs. public). Models were used to compare differences in these characteristics simultaneously across the four breast cancer subtypes.&#x2028; Results: Of 12,245 Asian women diagnosed with invasive breast cancer, 7,217 (59%) women had data for all three immunohistochemical markers. The majority of breast cancers among Japanese women were of the luminal A subtype (67%), with a low frequency of basal-like (10%) and HER2+ (22%) cancers. Korean, Filipina and Vietnamese women had a high frequency of HER2+ cancers (35%, 31% and 31%, respectively) compared to Non-Hispanic White women diagnosed during this period (n=12,996, 21%). In regression analyses among Asian women, the four subtypes varied significantly in their associations with age group (p=0.01), detailed Asian ethnicity (p&lt;0.0001), stage (p&lt;0.0001), grade (p&lt;0.0001), histology (p&lt;0.0001), year of diagnosis (continuous; p=0.03) and hospital ownership (p&lt;0.0001). However, there was no significant variation among the subtypes in their relationships with socioeconomic status (p=0.94) or nativity (p=0.29).&#x2028; Conclusions: Differences in the distribution of breast cancer subtypes exist among Asian women according to ethnicity, as well as other demographic and disease characteristics. These differences were not associated with place of birth or socioeconomic status. Breast cancers among Japanese women had the most favorable subtype distribution, while Korean women had the least favorable distribution. Further study may identify genetic and environmental risk factors responsible for these differences, with implications for prevention and treatment.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2088.

Racial/ethnic variation in EBV-positive classical Hodgkin lymphoma in California populations

Epstein-Barr virus (EBV) is detected in the tumor cells of some but not all Hodgkin lymphoma (HL) patients, and evidence indicates that EBV-positive and -negative HL are distinct entities. Racial/ethnic variation in EBV-positive HL in international comparisons suggests etiologic roles for environmental and genetic factors, but these studies used clinical series and evaluated EBV presence by differing protocols. Therefore, we evaluated EBV presence in the tumors of a large (n = 1,032), racially and sociodemographically diverse series of California incident classical HL cases with uniform pathology re-review and EBV detection methods. Tumor EBV-positivity was associated with Hispanic and Asian/Pacific Islander (API) but not black race/ethnicity, irrespective of demographic and clinical factors. Complex race-specific associations were observed between EBV-positive HL and age, sex, histology, stage, neighborhood socioeconomic status (SES), and birth place. In Hispanics, EBV-positive HL was associated not only with young and older age, male sex, and mixed cellularity histology, but also with foreign birth and lower SES in females, suggesting immune function responses to correlates of early childhood experience and later environmental exposures, respectively, as well as of pregnancy. For APIs, a lack of association with birth place may reflect the higher SES of API than Hispanic immigrants. In blacks, EBV-positive HL was associated with later-stage disease, consistent with racial/ethnic variation in certain cytokine polymorphisms. The racial/ethnic variation in our findings suggests that EBV-positive HL results from an intricate interplay of early- and later-life environmental, hormonal, and genetic factors leading to depressed immune function and poorly controlled EBV infection.

Lung cancer incidence in never smokers

PURPOSE

Lung cancer is a leading cause of cancer death worldwide. Although smoking remains the predominant cause of lung cancer, lung cancer in never smokers is an increasingly prominent public health issue. However, data on this topic, particularly lung cancer incidence rates in never smokers, are limited.

METHODS

We reviewed the existing literature on lung cancer incidence and mortality rates among never smokers and present new data regarding rates in never smokers from the following large, prospective cohorts: Nurses' Health Study; Health Professionals Follow-Up Study; California Teachers Study; Multiethnic Cohort Study; Swedish Lung Cancer Register in the Uppsala/Orebro region; and First National Health and Nutrition Examination Survey Epidemiologic Follow-Up Study.

RESULTS

Truncated age-adjusted incidence rates of lung cancer among never smokers age 40 to 79 years in these six cohorts ranged from 14.4 to 20.8 per 100,000 person-years in women and 4.8 to 13.7 per 100,000 person-years in men, supporting earlier observations that women are more likely than men to have non-smoking-associated lung cancer. The distinct biology of lung cancer in never smokers is apparent in differential responses to epidermal growth factor receptor inhibitors and an increased prevalence of adenocarcinoma histology in never smokers.

CONCLUSION

Lung cancer in never smokers is an important public health issue, and further exploration of its incidence patterns, etiology, and biology is needed.