Disparities in Stage at Presentation Among Hispanic and Latinx Patients With Non-Small-Cell Lung Cancer in the United States

PURPOSE

Hispanic and Latinx people in the United States are the fastest-growing ethnic group. However, previous studies in non-small-cell lung cancer (NSCLC) often analyze these diverse communities in aggregate. We aimed to identify differences in NSCLC stage at diagnosis in the US population, focusing on disaggregated Hispanic/Latinx individuals.

METHODS

Data from the National Cancer Database from 2004 to 2018 identified patients with primary NSCLC. Individuals were disaggregated by racial and ethnic subgroup and Hispanic country of origin. Ordinal logistic regression adjusting for age, facility type, income, educational attainment, comorbidity index, insurance, and year of diagnosis was used to create adjusted odds ratios (aORs), with higher odds representing diagnosis at later-stage NSCLC.

RESULTS

Of 1,565,159 patients with NSCLC, 46,616 were Hispanic/Latinx (3.0%). When analyzed in the setting of race and ethnicity, Hispanic patients were more likely to be diagnosed with metastatic disease compared with non-Hispanic White (NHW) patients: 47.0% for Hispanic Black, 46.0% Hispanic White, and 44.3% of Hispanic other patients versus 39.1% of non-Hispanic White patients (P < .001 for all). By country of origin, 51.4% of Mexican, 41.7% of Puerto Rican, 44.6% of Cuban, 50.8% of South or Central American, 48.4% of Dominican, and 45.6% of other Hispanic patients were diagnosed with metastatic disease, compared with 39.1% of NHWs. Conversely, 20.2% of Mexican, 26.9% of Puerto Rican, 24.2% of Cuban, 22.5% of South or Central American, 23.7% of Dominican, and 24.5% of other Hispanic patients were diagnosed with stage I disease, compared with 30.0% of NHWs. All Hispanic groups were more likely to present with later-stage NSCLC than NHW patients (greatest odds for Mexican patients, aOR, 1.44; P < .001).

CONCLUSION

Hispanic/Latinx patients with non-small-cell lung cancer were more likely to be diagnosed with advanced disease compared with NHWs. Disparities persisted upon disaggregation by both race and country of origin, with over half of Mexican patients with metastatic disease at diagnosis. Disparities among Hispanic/Latinx groups by race and by country of origin highlight the shortcomings of treating these groups as a monolith and underscore the need for disaggregated research and targeted interventions.

Sexual Health Assessment in Women with Lung Cancer study: Sexual health assessment in women with lung cancer

BACKGROUND

Sexual health is understudied and underreported in patients with lung cancer, and most data precede the approval of widely used targeted therapies and immune checkpoint inhibitors. The authors sought to evaluate the prevalence of sexual dysfunction in women with lung cancer in our current clinical environment.

METHODS

This cross-sectional survey study was administered online to 249 women via the GO2 for Lung Cancer (GO2) Registry, using the Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction Measures questionnaire. Participants were recruited between June 2020 to June 2021. Eligibility criteria included age >18 years, self-identifying as a woman, fluency in English, and a lung cancer diagnosis within 10 years.

RESULTS

Most (67%) had stage IV lung cancer and 47% were receiving targeted therapy; 66% were undergoing active treatment. Despite 54% of participants reporting "recent" sexual activity, most (77%) indicated having little to no interest in sexual activity and 48% reported recent minimal satisfaction with their sex life. The most common reasons negatively affecting participants' satisfaction with their sex life included fatigue (40%) and feeling sad/unhappy (28%). Common reasons for lack of recent sexual activity included lack of interest (68%) and vaginal dryness or pain (30%). Compared to pre-diagnosis, women were significantly less likely to have recent interest in sexual activity. In multivariable logistic-regression, vaginal dryness showed a significant negative association with recent interest in sexual activity.

CONCLUSIONS

Sexual dysfunction is prevalent in women with lung cancer. Sexual health should be integrated into routine care for patients with lung cancer.

Large language models to identify social determinants of health in electronic health records

Social determinants of health (SDoH) play a critical role in patient outcomes, yet their documentation is often missing or incomplete in the structured data of electronic health records (EHRs). Large language models (LLMs) could enable high-throughput extraction of SDoH from the EHR to support research and clinical care. However, class imbalance and data limitations present challenges for this sparsely documented yet critical information. Here, we investigated the optimal methods for using LLMs to extract six SDoH categories from narrative text in the EHR: employment, housing, transportation, parental status, relationship, and social support. The best-performing models were fine-tuned Flan-T5 XL for any SDoH mentions (macro-F1 0.71), and Flan-T5 XXL for adverse SDoH mentions (macro-F1 0.70). Adding LLM-generated synthetic data to training varied across models and architecture, but improved the performance of smaller Flan-T5 models (delta F1 + 0.12 to +0.23). Our best-fine-tuned models outperformed zero- and few-shot performance of ChatGPT-family models in the zero- and few-shot setting, except GPT4 with 10-shot prompting for adverse SDoH. Fine-tuned models were less likely than ChatGPT to change their prediction when race/ethnicity and gender descriptors were added to the text, suggesting less algorithmic bias (p < 0.05). Our models identified 93.8% of patients with adverse SDoH, while ICD-10 codes captured 2.0%. These results demonstrate the potential of LLMs in improving real-world evidence on SDoH and assisting in identifying patients who could benefit from resource support.

Genomic Characterization of Aggressive Breast Cancer in Younger Women

PURPOSE

Although breast cancer (BC) risk increases with age, BC in younger women is more aggressive with higher mortality compared with older women. We characterize the genomic landscape of BCs in younger women.

METHODS

Clinicopathologic, molecular, and genomic differences across age groups (< 40 years, 40-60 years, > 60 years) in female BC patients were investigated in two large cohorts [AACR-GENIE8.1 (n = 11,594) and METABRIC (n = 2509)]. Cox-proportional regression analyzed the prognostic impact of age groups for disease-specific survival (DSS) and recurrence-free survival (RFS) in METABRIC and progression-free survival (PFS) in GENIE cohorts. Chi-squared test was used to assess statistical associations between genomic alterations and age groups.

RESULTS

Survival analysis showed that women < 40 years had shorter DSS [hazard ratio (HR): 1.52, p = 0.005], RFS (HR: 1.4, p = 0.006), and PFS (HR: 1.82, p = 0.0003) compared with women 40-60 years, and shorter RFS (HR: 1.5, p = 0.001) and PFS (HR: 2.95, p < 0.0001) compared with women > 60 years. Molecular subtypes in the METABRIC cohort showed women < 40 years were enriched with basal, and HER2+ subtypes, and less enriched with luminal A and B subtype (p < 0.0001). Characterization of genomic alterations in both cohorts demonstrated that BCs in women < 40 years were more enriched with TP53 mutations (FDR < 0.0001), BRCA1 mutations (FDR = 0.01), ERBB2 amplifications (FDR < 0.001), CDK12 amplifications (FDR < 0.001), and PPM1D amplifications (FDR < 0.001). In contrast, BCs in older women (> 60 years) were more enriched with PIK3CA, KMT2C, and CDH1 mutations (FDR < 0.0001).

CONCLUSIONS

BCs in young women are associated with shorter survival and more aggressive genomic features, including mutations in TP53 and BRCA1, and amplifications in ERBB2 and CDK12. These findings have the potential to impact clinical trial design and treatment.

Comprehensive genomic profiling and treatment patterns across ancestries in advanced prostate cancer: a large-scale retrospective analysis

BACKGROUND

Men of African ancestry experience the greatest burden of prostate cancer globally, but they are under-represented in genomic and precision medicine studies. Therefore, we sought to characterise the genomic landscape, comprehensive genomic profiling (CGP) utilisation patterns, and treatment patterns across ancestries in a large, diverse, advanced prostate cancer cohort, to determine the impact of genomics on ancestral disparities.

METHODS

In this large-scale retrospective analysis, the CGP-based genomic landscape was evaluated in biopsy sections from 11 741 patients with prostate cancer, with ancestry inferred using a single nucleotide polymorphism-based approach. Admixture-derived ancestry fractions for each patient were also interrogated. Independently, clinical and treatment information was retrospectively reviewed for 1234 patients in a de-identified US-based clinicogenomic database. Prevalence of gene alterations, including actionable gene alterations, was assessed across ancestries (n=11 741). Furthermore, real-world treatment patterns and overall survival was assessed in the subset of patients with linked clincogenomic information (n=1234).

FINDINGS

The CGP cohort included 1422 (12%) men of African ancestry and 9244 (79%) men of European ancestry; the clinicogenomic database cohort included 130 (11%) men of African ancestry and 1017 (82%) men of European ancestry. Men of African ancestry received more lines of therapy before CGP than men of European ancestry (median of two lines [IQR 0-8] vs one line [0-10], p=0·029). In genomic analyses, ancestry-specific mutational landscapes were observed, but the prevalence of alterations in AR, the DNA damage response pathway, and other actionable genes were similar across ancestries. Similar genomic landscapes were observed in analyses that accounted for admixture-derived ancestry fractions. After undergoing CGP, men of African ancestry were less likely to receive a clinical study drug compared with men of European ancestry (12 [10%] of 118 vs 246 [26%] of 938, p=0·0005).

INTERPRETATION

Similar rates of gene alterations with therapy implications suggest that differences in actionable genes (including AR and DNA damage response pathway genes) might not be a main driver of disparities across ancestries in advanced prostate cancer. Later CGP utilisation and a lower rate of clinical trial enrolment observed in men of African ancestry could affect genomics, outcomes, and disparities.

FUNDING

American Society for Radiation Oncology, Department of Defense, Flatiron Health, Foundation Medicine, Prostate Cancer Foundation, and Sylvester Comprehensive Cancer Center.

The Current State of Departmental Diversity, Equity, and Inclusion Efforts Within US Academic Radiation Oncology Departments

PURPOSE

Promoting a diverse workforce of health care professionals that delivers equitable patient care is an important goal in oncology, as in all of medicine. Although most medical schools have a diversity office and associated initiatives, little is known about radiation oncology (RO) department-level efforts to promote diversity, equity, and inclusion (DEI). We describe the current state of DEI leadership and initiatives in RO departments in the US to guide future policies and programs.

METHODS AND MATERIALS

A total of 124 US RO departments affiliated with a medical school were contacted to identify departmental DEI leadership. Identified DEI leaders were asked to complete an anonymous survey assessing characteristics of their departmental DEI leadership, committee/organizational structure, activities, and perceived barriers to, and effect of, their work. Descriptive statistics are reported.

RESULTS

Among 85 RO departments that responded (68.5% response rate), 48 (56.5%) reported having a departmental DEI leader. Thirty-four DEI leaders completed the survey (70.8%). Of those who answered each survey question, most DEI leaders were assistant or associate professors (n = 24, 82.8%), women (n = 19, 73.1%), and identified with at least one non-White race or Hispanic ethnicity (n = 15, 53.6%). Nineteen (57.6%) had an associated departmental DEI committee; with 10 of these starting in 2020 or later. Few DEI leaders had administrative support (38.2%), funding (29.4%), protected time (23.5%), or increased compensation for added duties Fifteen (50.0%) believed their DEI-focused efforts were considered for promotion. The most reported initiatives included offering programming/education, supporting students from backgrounds underrepresented in medicine, improving recruitment practices/hiring, and implementing pipeline/pathway projects. The perceived impact of DEI initiatives included an increased culture of respect (89.7%), improved health care disparity awareness (75.9%), and improved systemic/structural racism awareness (79.3%).

CONCLUSIONS

Departmental DEI efforts are increasingly common within RO, however, the structure, resources, and recognition associated with DEI work are variable. Additional dedicated resources and recognition for these efforts will help ensure a culture of inclusive excellence for the RO workforce and patients.

Radiation Oncology residency training program integration of diversity, equity, and inclusion: An Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee (ARRO EISC) inaugural program director survey

PURPOSE

To investigate United States (US) radiation oncology (RO) program directors' (PDs) attitudes and practices regarding racial/ethnic diversity, equity, and inclusion (DEI) to better understand potential impact on underrepresented in medicine (UIM) residents in RO.

METHODS AND MATERIALS

A 28-item survey was developed using the validated Ethnic Harassment Experiences Scale and the Daily Life Experiences subscale, as well as input from DEI leaders in RO. The survey was IRB-approved and administered to RO PDs. PDs were provided with the American Association of Medical Colleges (AAMC) definition of underrepresented in medicine (UIM), that is "Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population." Descriptive statistics were used in analysis.

RESULTS

The response rate was 71% (64/90). Institutional Culture and Beliefs: 42% responded that they had a department DEI director. A minority (17%, N=11) agreed "I believe that people from UIM backgrounds have equal access to quality tertiary education in the US." The majority (97%, N=62) agreed "My program values residents from UIM backgrounds." Support and Resources: Majority (78%, N=50) agreed "My program has resources in place to assist/provide support for resident physicians from UIM backgrounds." Interview and Recruitment: Most PDs (53%) had not taken part in activities aimed at recruiting UIM residents and 17% had interviewed no UIM applicants in the past 5 years for residency. Resident experiences of Racism: 17% (N=11) agreed "UIM residents in my program have reported incidents of racism to me," and 28% (N=18) agreed "I believe that UIM residents in my program have been treated differently because of their race/ethnicity by faculty, staff, co-residents or patients.".

CONCLUSION

Most PDs reported that they did not believe that UIM residents were treated differently in their department because of their race/ethnicity, and only a minority had received reports of racial discrimination experienced by residents. These data are in contrast to resident experiences, and suggest a disconnect between DEI perceptions and resident experiences among US RO PDs that should be addressed through increased programmatic action and evaluation.

Tailored Mentorship for the Underrepresented and Allies in Radiation Oncology: The Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee Mentorship Experience

PURPOSE

There are limited opportunities for mentorship for underrepresented in medicine (URM) trainees and physicians in radiation oncology (RO). The purpose of this study was to create and evaluate a formal mentorship program open to URMs and allies with interests in diversity, equity, and inclusion.

METHODS AND MATERIALS

A mentorship program incorporating a virtual platform was designed by the Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee. It was structured to include 6 sessions over 6 months with matched mentor-mentee pairs based on responses to a publicized online interest form. A compilation of evidence-based guidelines was provided to optimize the mentorship relationship. Linked pre- and postprogram surveys were administered to collect demographic data, define baseline goals and level of support, and evaluate program satisfaction.

RESULTS

Thirty-five mentor-mentee pairs were matched; 31 mentees completed the preprogram survey and 17 completed the postprogram survey. Preprogram, only 3 mentees (9.7%) reported satisfaction with current mentorship and 5 (16%) reported mechanisms or mentorship in place at their program to support URMs. On the postprogram survey, mentees reported high satisfaction with areas of mentorship, mentor attributes, and the program overall. Opportunities for improvement include implementation of mechanisms to enhance communication with mentor-mentee pairs and maintain longitudinal engagement.

CONCLUSIONS

In the first tailored mentorship program in RO for URMs and those with diversity, equity, and inclusion interests, our results demonstrate that there is self-reported interest for better mentorship for URMs in RO, and that a nationwide structured mentorship program can address participants' goals with high satisfaction. Program expansion could provide URMs and allies in RO more opportunities for career development and promote a greater sense of community and inclusion within the field.

Chromosome 8q arm overexpression is associated with worse prostate cancer prognosis

OBJECTIVE

Chromosome 8q arm (chr8q) is the most amplified chromosomal segment in advanced metastatic castration-resistant prostate cancer after chXq12. These regions harbor important oncogenes driving prostate cancer progression, including MYC that plays a role in various hallmarks of cancer, including cell cycle progression and immune surveillance. Herein we characterize the co-expression patterns of chr8q genes and their clinical utility in more than 7,000 radical prostatectomy samples.

MATERIALS AND METHODS

Copy Number alterations of 336 genes on chr8q21 to chr8q24 were extracted from 2 primary prostate cancer cohorts (TCGA, n = 492; MSK-primary, n = 856) and 3 metastatic prostate cancer cohorts (MSK-met, N = 432; MSK-mCSPC, N = 424; SU2CPNAS, n = 444) from cBioPortal. Expression data for the 336 genes was extracted from 6,135 radical prostatectomy samples from Decipher GRID registry. For survival analysis, patients were grouped into top 10% and top 25% by band expression and were compared with the remaining cohort. Hazard ratios were calculated using Cox proportional hazards models.

RESULTS

Genes on chr8q were highly co-amplified and co-expressed. Copy number alterations and overexpression of chr8q genes in primary disease were associated with higher Gleason scores, increased risk of metastases, and increased prostate cancer specific mortality. Additionally, our data demonstrated high expression of MYC alone was not associated with differences in metastases free survival while high expression of other chr8q bands was associated with decreased metastases free survival. By combining chr8q data with an established genomic classifier like Decipher, we were able to develop a new model that was better at predicting metastases than Decipher alone.

CONCLUSIONS

Our findings highlight the clinical utility of chr8q data, which can be used to improve prognostication and risk prediction in localized prostate cancer.

Spanish Adaptation and Evaluation of Clinical Discussion Guides: Communicating the External Beam Radiotherapy Experience (CEBRE) en Español

PURPOSE

Cancer is the leading cause of death for the Hispanic/Latinx United States (US) community, which comprises 64% of the US population with limited English proficiency. Despite the common use of radiation therapy for cancer treatment, there is a dearth of radiation therapy educational materials-at appropriate reading levels-available in Spanish. To address the gap in patient-centered educational resources for communicating with Spanish-speaking patients about radiation therapy, we sought to linguistically and culturally adapt the Communicating the External Beam Radiotherapy Experience (CEBRE) clinical discussion guide series into Spanish.

METHODS AND MATERIALS

From January to December 2021, we developed and applied a stepwise methodology for Spanish adaptation of the discussion guides involving (1) professional translation; (2) interprofessional review for linguistic and cultural appropriateness and medical accuracy; (3) design review; and (4) evaluation for readability, understandability, and actionability using validated tools. We applied 4 indices for readability evaluation: Gilliam-Peña-Mountain, Läsbarhetsindex, Rate Index, and the Spanish Simple Measure of Gobbledygook. Two trained reviewers assessed understandability and actionability using the Patient Education Materials Assessment Tool.

RESULTS

After 2 revision rounds, 4 CEBRE en español discussion guides were produced through an interprofessional, iterative translation and linguistic/cultural adaptation process. Readability scores across the 4 guides ranged from 4.3 to 7.3 grade-level equivalents, thereby meeting the American Medical Association's 8th-grade standard. Patient Education Materials Assessment Tool analysis yielded near-perfect scores along understandability and actionability domains.

CONCLUSIONS

The stepwise linguistic/cultural adaptation process yielded a patient-centered guide that is appropriately readable, understandable, and actionable for Spanish-speaking patients receiving radiation therapy in the US. Future work should include an external evaluation of CEBRE en español by clinicians and patients. The methodology described can be applied to adapting resources for patient-centered communication in other fields of medicine and into other languages as part of an interprofessional approach to delivering equitable health care for all.

Using Holistic Residency Applicant Review and Selection in Radiation Oncology to Enhance Diversity and Inclusion, an ASTRO SCAROP-ADROP-ARRO Collaboration

Disproportionate gender, racial, and ethnic diversity remains in the radiation oncology physician workforce despite widespread awareness and longitudinal efforts to improve representation. In this collaborative review, we define the rationale and components of holistic review and how it can be best utilized to provide a comprehensive evaluation of applicants to residency programs in radiation oncology. We initially discuss the current state of diversity in the field of radiation oncology and highlight the components of the residency selection process that may serve to perpetuate existing biases. Subsequently, the ACGME and AAMC holistic review framework is reviewed in detail to demonstrate the balanced assessment of potential applicants. The implementation of holistic review in medical school and residency selection to-date are examined to underscore the potential value of holistic review in the radiation oncology residency selection process. Finally, recommendations for the practical implementation of holistic review in radiation oncology trainee selection are outlined.

Disparities in Primary Breast Cancer Stage at Presentation Among Hispanic Subgroups

BACKGROUND

Although the United States (US) Hispanic population consists of diverse communities, prior breast cancer studies often analyze this group in aggregate. Our aim was to identify differences in breast cancer stage at presentation in the US population, with a particular focus on Hispanic subgroups.

METHODS

Data from the National Cancer Database (NCDB) from 2004 to 2017 were used to select women with primary breast cancer; individuals were disaggregated by racial and ethnic subgroup and Hispanic country of origin. Ordinal logistic regression was used to create adjusted odds ratios (aORs) with 95% confidence intervals (CIs), with higher odds representing presentation at later-stage breast cancer. Subgroup analysis was conducted based on tumor receptor status.

RESULTS

Overall, among 2,282,691 women (5.2% Hispanic), Hispanic women were more likely to live in low-income and low-educational attainment neighborhoods, and were also more likely to be uninsured. Hispanic women were also more likely to present at later-stage primary breast cancer when compared with non-Hispanic White women (aOR 1.19, 95% CI 1.18-1.21; p < 0.01). Stage disparities were demonstrated when populations were disaggregated by country of origin, particularly for Mexican women (aOR 1.55, 95% CI 1.51-1.60; p < 0.01). Disparities worsened among both racial and country of origin subgroups in women with triple-negative disease.

CONCLUSION

Later breast cancer stage at presentation was observed among Hispanic populations when disaggregated by racial subgroup and country of origin. Socioeconomic disparities, as well as uncaptured disparities in access and/or differential care, may drive these observed differences. Future studies with disaggregated data are needed to characterize outcomes in Hispanic communities and develop targeted interventions.

Radiation Oncology resident perspectives on diversity, equity, and inclusion: an Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee (ARRO EISC) inaugural resident survey

PURPOSE

In this study, radiation oncology residents were surveyed on perceptions of diversity, equity, inclusion, and belonging in their residency training programs.

METHODS AND MATERIALS

A 23-item survey was developed by the Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee resident members and faculty advisors. The survey was divided into 4 sections: institutional culture, support and resources, interview and recruitment, and experiences of bias. The survey was sent individually to residents from all Accreditation Council for Graduate Medical Education-accredited radiation oncology programs.

RESULTS

The survey was issued to 757 residents. A total of 319 residents completed the survey, for a response rate of 42%. All postgraduate years and geographic regions were represented. Significant racial, ethnic, and gender differences were present in survey response patterns. White residents (94%, 164 of 174) and male residents (96%, 186 of 194) were more likely to strongly agree/agree that they were treated with respect by their colleagues and their coworkers than other racial groups (P < .005) or gender groups (P < .008). Only 3% (5 of 174) of White residents strongly agreed/agreed that they were treated unfairly because of their race/ethnicity, while 31% (5 of 16) of Black residents and 10% (9 of 94) of Asian residents strongly agreed/agreed (P < .0001). Similarly, Hispanic residents were more likely to strongly agree/agree (24%, 5 of 21) than non-Hispanic residents (7%, 20 of 298) (P = .003). Regarding mentorship, there were no differences by gender or ethnicity. There were differences by race in residents reporting that they had a supportive mentor (P = .022), with 89% (154 of 174) of White residents who strongly agreed/agreed, 88% (14 of 16) of Black residents, and 91% of Asian residents (86 of 94).

CONCLUSIONS

This survey reveals that experiences of support, mentorship, inclusion, and bias vary significantly among radiation oncology residents based on race, ethnicity, and gender. Radiation oncology has opportunity for growth to ensure an equitable experience for all residents.

Proyecto ELEVAR: Evaluating the Latinx Experience With the Health Care System Through Variables on Access and Resources

PURPOSE

Hispanic/Latinx communities encounter disparities in access and availability of appropriate timely health care services, negatively affecting cancer outcomes. Limited data exist on the role of these factors in personal experiences of Hispanic/Latinx with health care systems. We aim to better understand Hispanic/Latinx experience with the health care system, focusing on the impact of the Affordable Care Act (ACA) and applications to clinical practice in patients diagnosed with cancer.

METHODS

Competitively obtained data from 2010 to 2019 Association of American Medical Colleges Consumer Survey of Health Care Access (a US population-based sample of potential health care consumers needing health care at least once in the past year) were retrospectively reviewed. Descriptive statistics and univariate and multivariate comparisons of patterns pre- versus post-ACA were performed for respondents self-identifying as Hispanic/Latinx.

RESULTS

In a total cohort of 53,523 respondents, Hispanic/Latinx comprised 7.5% (n = 4,094). Post-ACA demographics showed a higher proportion of female and an increase in employment, educational attainment, income, and private insurance coverage, with a decrease in uninsured. Adjusted models showed that post-ACA Hispanic/Latinx patients are less likely to use emergency room if sick or needing medical advice (odds ratio [OR] 0.33; P < .001) and more likely to report chronic conditions involving cancer (OR 2.43; P < .001) or being limited in activities because of mental or emotional problems (OR 1.36; P = .005).

CONCLUSION

Although ACA implementation was associated with decreased health care access barriers in Hispanic/Latinx, they continue to experience disparities in chronic health conditions, including cancer, with higher limitations because of emotional or mental health. Ongoing efforts that build upon current strides, toward improved patient satisfaction and overall outcomes, are of paramount importance.

Dónde Están? Latinx/Hispanic Representation in the Oncology Workforce: Present and Future

This manuscript reviews the status of Hispanic/Latinx physicians in oncology, the benefits and challenges to achieving equitable representation, and potential solutions and actions to increase diversity in the oncology workforce. Persons of Hispanic/Latinx origin comprise 18.7% of the population and 16.8% of the adult population in the United States but are only 4.7% of practicing oncologists. The reasons for the lack of representation of Hispanic/Latinx individuals in medicine are multifaceted and include discrimination and biases, exclusionary practices, financial barriers, and lack of role modeling. As a result, patients are deprived the benefits of a representative workforce, such as improved access, enhanced culturally and linguistically competent care, and minimization of health disparities. Solutions included in the manuscript include a description of efforts by ASCO to improve the representativeness of the oncology workforce through its awards programs and educational efforts, especially for Hispanic/Latinx clinicians. The manuscript also outlines individual actions that attending physicians, senior oncologists, oncology leaders, and hospital/cancer center leadership can take to improve the diversity of the oncology workforce and support our Latinx/Hispanic trainees and colleagues. Improving the representativeness of the oncology workforce will require collective action by institutions, medical societies, and individuals. Nevertheless, widespread commitment to creating an inclusive and supported workforce is necessary to ensure the quality of care for minority patients, reduce existing cancer care disparities, and advance innovation in oncology.

Radiation oncology management of stage III and IVA cervical carcinoma

Worldwide, stage III-IVA carcinomas of the uterine cervix comprise a significant proportion of cases at presentation, and have a higher rate of recurrence and worse overall survival. This review will discuss the epidemiology, prevention strategies, clinical presentation, and treatment recommendations for stage III-IVA cervical cancer. The focus will be on the role of radiation therapy, concurrent chemoradiotherapy, and brachytherapy, including the potential benefits and anticipated toxicities. The unique challenges and considerations of fistula formation and approaches to management will be highlighted, and follow-up care and future directions discussed. As low and middle income countries bear the highest burden of advanced stage carcinoma of the uterine cervix, this review will address the unique needs of global communities.

The impact of COVID-19 on the well-being and cognition of older adults living in the United States and Latin America

BACKGROUND

In the COVID-19 pandemic, older adults from vulnerable ethnoracial groups are at high risk of infection, hospitalization, and death. We aimed to explore the pandemic's impact on the well-being and cognition of older adults living in the United States (US), Argentina, Chile, Mexico, and Peru.

METHODS

1,608 (646 White, 852 Latino, 77 Black, 33 Asian; 72% female) individuals from the US and four Latin American countries aged ≥ 55 years completed an online survey regarding well-being and cognition during the pandemic between May and September 2020. Outcome variables (pandemic impact, discrimination, loneliness, purpose of life, subjective cognitive concerns) were compared across four US ethnoracial groups and older adults living in Argentina, Chile, Mexico, and Peru.

FINDINGS

Mean age for all participants was 66.7 (SD = 7.7) years and mean education was 15.4 (SD = 2.7) years. Compared to Whites, Latinos living in the US reported greater economic impact (p < .001, ηp 2  = 0.031); while Blacks reported experiencing discrimination more often (p < .001, ηp 2  = 0.050). Blacks and Latinos reported more positive coping (p < .001, ηp 2  = 0.040). Compared to Latinos living in the US, Latinos in Chile, Mexico, and Peru reported greater pandemic impact, Latinos in Mexico and Peru reported more positive coping, Latinos in Argentina, Mexico, and Peru had greater economic impact, and Latinos in Argentina, Chile, and Peru reported less discrimination.

INTERPRETATION

The COVID-19 pandemic has differentially impacted the well-being of older ethnically diverse individuals in the US and Latin America. Future studies should examine how mediators like income and coping skills modify the pandemic's impact.

FUNDING

Massachusetts General Hospital Department of Psychiatry.

Vitamin retention during the canning of swordfish (Xiphias gladius) with different filling media

Swordfish (Xiphias gladius) is an economically and nutritionally important fish. The aims of this study were to determine the effects of the various steps of the canning process and of different filling media (olive oil, corn oil, sunflower oil, and high oleic sunflower oil) on the fat- and water-soluble vitamin contents of swordfish. An HPLC-based method was used for this purpose. The canning process led to loss of some vitamins, particularly of vitamin D₃ . Loss of this vitamin mainly occurred during storage and although important (89.34% to 91.36%), canned swordfish can be considered a good source of vitamin D₃ , providing between 50% and 64% of the RDI. The frying process also caused significant loss of vitamin B₉ (73.7%). However, the vitamin E content increased due to contributions from the frying and filling oils. The canned swordfish packed in olive oil had lower vitamin A (107.35 µg/100 g) and E (1.58 mg/100 g) contents than the fish packed in sunflower oil (193.28 µg/100 g and 2.28 mg/100 g, respectively). The swordfish packed in sunflower oil also had the highest B₂ (0.036 mg/100 g) content. The swordfish packed in corn oil had the lowest vitamin A (80.17 µg/100 g) and B₂ (0.012 mg/100 g) contents, while the samples packed in high oleic sunflower oil had the lowest contents of vitamins B₉ (0.14 µg/100 g) and B₁₂ (2.37 mg/100 g). PRACTICAL APPLICATION: Swordfish (Xiphias gladius) is consumed worldwide and is economically very important in the seafood industry. The canning process caused losses of some vitamins, particularly of vitamins D₃ and B₉ ; however, the vitamin E content increased due to the frying and filling oils. The study findings may contribute to increasing knowledge about how processing, storage and the filling medium influence the composition of canned fish.

A Paradigm Shift in Radiation Oncology Training

The coronavirus disease 2019 pandemic has been intertwined with the movement for racial justice in the United States and has highlighted and risks aggravating educational and workforce disparities within radiation oncology. We discuss wide-ranging changes within radiation oncology training that are essential to developing and maintaining diversity, including utilization of competency-based educational models that allow for streamlining of training and examinations; responsiveness to the needs of residents and medical students of different gender, racial/ethnic, and socioeconomic groups; and technological integration to increase educational efficiency and decrease barriers.

Improving Diversity and Inclusion in the Post-Coronavirus Disease 2019 Era Through a Radiation Oncology Intensive Shadowing Experience (RISE)

Purpose

In response to the coronavirus disease 2019 pandemic, current Association of American Medical Colleges guidelines discourage away rotations, posing significant challenges for attracting students to radiation oncology (RO). This is particularly concerning for medical students underrepresented in medicine (UIM) due to the potential of widening existing disparities in applicant and workforce composition. To proactively address this, we created a Radiation Oncology Intensive Shadowing Experience (RISE) to expose UIM students to the field of RO.

Methods and Materials

Key stakeholders within the residency program, including both UIM faculty and residents with experience in health disparities and medical education, designed a 1-week virtual RISE intended for fourth year UIM students recruited through established national organizations serving UIM medical students. A 1-week disease-specific curriculum was developed using 4 components: (1) foundational exposure to RO, (2) didactic teaching, (3) mentorship opportunities, and (4) a capstone experience. Mentorship was continuously weaved through the experience by attendings, peer resident mentors, and a UIM resident panel to optimize exposure.

Results

RISE was successfully initiated at 2 academic medical centers with 12 UIM students enrolled through August. Anonymized pre- and postclerkship surveys were developed for students, residents, and faculty involved in RISE to evaluate participants’ satisfaction, resident and attending time burden, and perceptions of program effectiveness.

Conclusions

We created a unique virtual RO shadowing experience for UIM students to address a critical gap in exposure to RO, heightened by the corona virus disease 2019 pandemic, with the goal of improving diversity, equity, and inclusion in our field.

Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy: results from the CLIMHET study group

BACKGROUND

Laparoscopic right hemicolectomy (LRHC) is increasingly performed for the treatment of right colon disease. Nevertheless, standardization of the surgical technique regarding the performance of intracorporeal (IC) or extracorporeal (EC) anastomosis is lacking. The purpose of this study was to compare short-term postoperative outcomes in patients who had laparoscopic right colectomy either with IC or EC.

METHODS

This was a retrospective, non-randomized and multicenter study conducted from January 2005 to December 2015 on the CLIMHET study group cohort from five tertiary centers in France. Data were collected for all patients with LRHC to compare patient characteristics, intraoperative data and postoperative outcomes in terms of medical and surgical complications, duration of hospitalization and mortality. A multivariate analysis was performed to compare the results in the two groups.

RESULTS

Of the 597 patients undergoing LRHC, 150 had IC and 447 had EC. The incidence of medical complications (cardiac, vascular, and pulmonary complications) was lower in the IC group than in the EC group (13 vs 20%, p = 0.049). This difference remained significant in multivariate analysis after adjusting to field characteristics and patient histories (p = 0.009). Additionally, a shorter hospital stay (7 vs 8 days, p = 0.003) was observed in the IC group as compared to the EC group. This difference remained significant in favor of the IC group in multivariate analysis (p = 0.029). There was no difference between the groups as regards: surgical complications (p = 0.76), time of mobilization (p = 0.93), reintervention rate (p = 1) and 90-day mortality (p = 0.47).

CONCLUSIONS

Our results show that IC anastomosis in LRHC is associated with fewer medical complications and shorter hospital stays compared to EC anastomosis.

The impact of quantitative CT-based tumor volumetric features on the outcomes of patients with limited stage small cell lung cancer

INTRODUCTION

Limited stage small cell lung cancer (LS-SCLC) has a poor prognosis. Additional prognostic markers are needed for risk-stratification and treatment intensification. This study compares quantitative CT-based volumetric tumor measurements versus International Association for the Study of Lung Cancer (IASLC) TNM staging to predict outcomes.

MATERIALS & METHODS

A cohort of 105 patients diagnosed with LS-SCLC and treated with chemoradiation (CRT) from 2000 to 2013 were analyzed retrospectively. Patients were staged by the Union for International Cancer Control (UICC) TNM Classification, 8th edition. Tumor volumes and diameters were extracted from radiation planning CT imaging. Univariable and multivariable models were used to analyze relationships between CT features and overall survival (OS), locoregional recurrence (LRR), in-field LRR, any progression, and distant metastasis (DM).

RESULTS

Median follow-up was 21.3 months. Two-year outcomes were as follows: 38% LRR, 31% in-field LRR, 52% DM, 62% any progression, and 47% OS (median survival 16.5 months). On univariable analysis, UICC T-stage and N-stage were not associated with any clinical outcome. UICC overall stage was only statistically associated with in-field LRR. One imaging feature (3D maximum tumor diameter) was found to be significantly associated with LRR (HR 1.10, p = 0.003), in-field LRR (HR 1.10, p = 0.007), DM (HR 1.10, p = 0.02), any progression (HR 1.10, p = 0.008), and OS (HR 1.10, p = 0.03). On multivariable analysis, this feature remained significantly associated with all outcomes.

CONCLUSION

For LS-SCLC, quantitative CT-based volumetric tumor measurements were significantly associated with outcomes after CRT and may be better predictors of outcome than TNM stage.

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center

BACKGROUND

Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality.

RESULTS

Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race.

CONCLUSIONS

Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.

Conservative management of low-risk prostate cancer among young versus older men in the United States: Trends and outcomes from a novel national database

BACKGROUND

Management for men aged ≤55 years with low-risk prostate cancer (LRPC) is debated given quality-of-life implications with definitive treatment versus the potential missed opportunity for cure with conservative management. The objective of this study was to define rates of conservative management for LRPC and associated short-term outcomes in young versus older men in the United States.

METHODS

The nonpublic Surveillance, Epidemiology, and End Results Prostate with Active Surveillance/Watchful Waiting (AS/WW) Database identified 50,302 men who were diagnosed with LRPC from 2010 through 2015. AS/WW rates in the United States were stratified by age (≤55 vs ≥56 years). Prostate cancer-specific mortality and overall mortality were defined by initial management type (AS/WW vs definitive treatment [referent]) and age.

RESULTS

AS/WW utilization increased from 8.61% (2010) to 34.56% (2015) among men aged ≤55 years (P for trend <0.001) and from 15.99% to 43.81% among men aged ≥56 years (P for trend <.001). Among patients who had ≤2 positive biopsy cores, AS/WW rates increased from 12.90% to 48.78% for men aged ≤55 years and from 21.85% to 58.01% for men aged ≥56 years. Among patients who had ≥3 positive biopsy cores, AS/WW rates increased from 3.89% to 22.45% for men aged ≤55 years and from 10.05% to 28.49% for men aged ≥56 years (all P for trend <.001). Five-year prostate cancer-specific mortality rates were <0.30% across age and initial management type subgroups.

CONCLUSIONS

AS/WW rates quadrupled for patients aged ≤55 years from 2010 to 2015, with favorable short-term outcomes. These findings demonstrate the short-term safety and increasing acceptance of AS/WW for both younger and older patients. However, there are still higher absolute rates of AS/WW in older patients (P < .001), suggesting some national ambivalence toward AS/WW in younger patients.

Deep Learning Predicts Lung Cancer Treatment Response from Serial Medical Imaging

PURPOSE

Tumors are continuously evolving biological systems, and medical imaging is uniquely positioned to monitor changes throughout treatment. Although qualitatively tracking lesions over space and time may be trivial, the development of clinically relevant, automated radiomics methods that incorporate serial imaging data is far more challenging. In this study, we evaluated deep learning networks for predicting clinical outcomes through analyzing time series CT images of patients with locally advanced non-small cell lung cancer (NSCLC).Experimental Design: Dataset A consists of 179 patients with stage III NSCLC treated with definitive chemoradiation, with pretreatment and posttreatment CT images at 1, 3, and 6 months follow-up (581 scans). Models were developed using transfer learning of convolutional neural networks (CNN) with recurrent neural networks (RNN), using single seed-point tumor localization. Pathologic response validation was performed on dataset B, comprising 89 patients with NSCLC treated with chemoradiation and surgery (178 scans).

RESULTS

Deep learning models using time series scans were significantly predictive of survival and cancer-specific outcomes (progression, distant metastases, and local-regional recurrence). Model performance was enhanced with each additional follow-up scan into the CNN model (e.g., 2-year overall survival: AUC = 0.74, P < 0.05). The models stratified patients into low and high mortality risk groups, which were significantly associated with overall survival [HR = 6.16; 95% confidence interval (CI), 2.17-17.44; P < 0.001]. The model also significantly predicted pathologic response in dataset B (P = 0.016).

CONCLUSIONS

We demonstrate that deep learning can integrate imaging scans at multiple timepoints to improve clinical outcome predictions. AI-based noninvasive radiomics biomarkers can have a significant impact in the clinic given their low cost and minimal requirements for human input.

Use of Active Surveillance or Watchful Waiting for Low-Risk Prostate Cancer and Management Trends Across Risk Groups in the United States, 2010-2015

This cancer epidemiology study uses SEER data to examine US trends in use of active surveillance, watchful waiting, radiotherapy, and surgical management of localized prostate cancer among men with low-, intermediate-, and high-risk disease treated between 2010 and 2015.