Multiple myeloma incidence, mortality, and survival differences at the intersection of sex, age, and race/ethnicity: A comparison between Puerto Rico and the United States SEER population

BACKGROUND

Multiple myeloma (MM) survival has increased during the last decades due to the introduction of new therapies. We investigated the intersectionality among age, sex, and race/ethnicity to better understand the pattern of MM incidence, mortality, and survival.

METHODS

Puerto Rico (PR) Central Cancer Registry and the United States of America (US) Surveillance, Epidemiology, and End Results (SEER) Program databases were used. We analyzed MM incidence and mortality trends from 2001 to 2019 using Joinpoint regression models to calculate annual percent change (APC). Age-standardized rate ratios (SRR) for incidence and mortality were used to compare PR with US SEER racial/ethnic groups during 2015-2019. Five-year survival analyses were also performed stratified by age and sex.

RESULTS

Regardless of age and race/ethnicity, males had higher MM incidence and mortality rates than females. PR had a higher increase in incidence rates of MM than other ethnic groups, regardless of sex and age (PR APC = 4.3 among males <65, 3.1 among males ≥65, 6.3 among females <65, and 2.6 among females ≥65 years old). No significant change in mortality APCs (p > 0.05) was observed in PR when stratified by age or sex while other groups showed a decrease. Among males < 65 years, PR had significantly higher incidence rates than non-Hispanic Whites (NHW), and US Hispanics (USH). However, among both males and females ≥ 65 years, PR had significantly lower MM mortality rates than NHW, non-Hispanic Blacks (NHB), USH, and US Overall. In terms of survival, PR showed the lowest 5-year overall survival among males < 65 years (54.6%, 95% CI: 47.2-61.5) and males ≥ 65 years (34.5%, 95% CI: 29.2-39.9) but not among females.

CONCLUSION

The incidence of MM in PR increased significantly over the study period, particularly among younger women. Despite the introduction of new therapies, mortality rates in PR have remained stable while other ethnic groups show significant decreases among all intersections of sex and age.

Racial and Ethnic Disparities in Use of Colorectal Cancer Screening Among Adults With Chronic Medical Conditions: BRFSS 2012-2020

Introduction

People with chronic conditions and people with colorectal cancer (CRC) may share common risk factors; thus, CRC screening is important for people with chronic conditions. We examined racial and ethnic differences in the use of CRC screening among people with various numbers of chronic conditions.

Methods

We included data on adult respondents aged 50 to 75 years from the Behavioral Risk Factor Surveillance System in 2012 through 2020. We categorized counts of 9 conditions as 0, 1, 2, 3, and ≥4. We classified self-reported CRC screening status as up to date or not. We used Poisson models to estimate adjusted prevalence ratios (APRs) among the different counts of chronic conditions in 4 racial and ethnic groups: Hispanic adults with limited English proficiency (LEP), Hispanic adults without LEP, non-Hispanic Black adults, and non-Hispanic White adults.

Results

Overall, 66.5% of respondents were up to date with CRC screening. The prevalence of being up to date increased with the number of chronic conditions. We found disparities among racial and ethnic groups. Hispanic respondents with LEP had lower rates than non-Hispanic White adults of being up to date with CRC screening across all counts of chronic conditions (APR for 0 conditions = 0.67; 95% CI, 0.64-0.71; APR for ≥4 conditions = 0.85; 95% CI, 0.79-0.91). Hispanic respondents without LEP with 0, 1, or 2 conditions were less likely than non-Hispanic White respondents to be up to date with CRC screening. We found no significant differences between non-Hispanic Black and non-Hispanic White respondents.

Conclusion

We found disparities among Hispanic BRFSS respondents with LEP, who had lower rates than non-Hispanic White respondents of being up to date with CRC screening, regardless of the number of chronic conditions. Tailored interventions are needed to address these disparities and improve screening rates, particularly among Hispanic people.

Oral Inflammation and Human Papilloma Virus Association among Hispanics

Background

Identifying factors related to persistent human papillomavirus (HPV) infection is essential to reduce the incidence of HPV-related cancers.

Objective

To evaluate whether gingival/periodontal inflammation is associated with oral HPV infection.

Methods

This cross-sectional study (n = 740) uses data from the follow-up visit of the San Juan Overweight Adults Longitudinal Study, which recruited overweight/obese adults aged 40-65 from Puerto Rico. Participants completed a dental examination and two interviews (face-to-face/ACASI) and provided oral rinse samples for HPV detection. Oral inflammation was assessed using two definitions: (1) the number of sites with bleeding on probing (BOP), and (2) the number of teeth with probing pocket depths (PPD) ≥ 4 mm and BOP. Multivariate logistic regression was used to assess the association between oral inflammation and oral HPV.

Results

Nearly three-quarters (72%) of participants were female, and 68% had 50 years or older. Participants with HPV had a higher mean number of sites with BOP (15.5 vs. 10.1) and teeth with PPD ≥ 4 mm and BOP (8.5 vs. 3.2) than participants without HPV (p < 0.05). After adjusting for sex, age, income, and the number of oral sex partners, the odds of having an oral HPV infection increased by 3% (95% confidence interval (CI): 1.00-1.06) for any additional sites with BOP and 5% (95% CI: 1.02-1.09) for any other teeth with PPD ≥ 4 mm and BOP.

Conclusions

We found that oral inflammation was associated with oral HPV infection among adults in Puerto Rico. Future studies need to further investigate the underlying mechanisms.

Breast, cervical, and colorectal cancer screening test use in the US territories of Guam, Puerto Rico, and the US Virgin Islands

BACKGROUND

The United States Preventive Services Task Force (USPSTF) recommends breast, cervical, and colorectal cancer screening among eligible adults, but information on screening use in the US territories is limited.

METHODS

To estimate the proportion of adults up-to-date with breast, cervical, and colorectal cancer screening based on USPSTF recommendations, we analyzed Behavioral Risk Factor Surveillance System data from 2016, 2018, and 2020 for the 50 US states and DC (US) and US territories of Guam and Puerto Rico and from 2016 for the US Virgin Islands. Age-standardized weighted proportions for up-to-date cancer screening were examined overall and by select characteristics for each jurisdiction.

RESULTS

Overall, 67.2% (95% CI: 60.6-73.3) of women aged 50-74 years in the US Virgin Islands, 74.8% (70.9-78.3) in Guam, 83.4% (81.7-84.9) in Puerto Rico, and 78.3% (77.9-78.6) in the US were up-to-date with breast cancer screening. For cervical cancer screening, 71.1% (67.6-74.3) of women aged 21-65 years in Guam, 81.3% (74.6-86.5) in the US Virgin Islands, 83.0% (81.7-84.3) in Puerto Rico, and 84.5% (84.3-84.8) in the US were up-to-date. For colorectal cancer screening, 45.2% (40.0-50.5) of adults aged 50-75 years in the US Virgin Islands, 47.3% (43.6-51.0) in Guam, 61.2% (59.5-62.8) in Puerto Rico, and 69.0% (68.7-69.3) in the US were up-to-date. Adults without health care coverage reported low test use for all three cancers in all jurisdictions. In most jurisdictions, test use was lower among adults with less than a high school degree and an annual household income of < $25,000.

CONCLUSION

Cancer screening test use varied between the US territories, highlighting the importance of understanding and addressing territory-specific barriers. Test use was lower among groups without health care coverage and with lower income and education levels, suggesting the need for targeted evidence-based interventions.

Multi-trajectory models of serum biomarkers among patients with monoclonal gammopathy of undetermined significance

Understanding the progression of monoclonal gammopathy of undetermined significance (MGUS) to multiple myeloma (MM) is needed to identify patients who would benefit from closer clinical surveillance. Given that two of the defining criteria of MM are renal failure and anemia, we described the trajectories of creatinine (Cr) and hemoglobin (Hgb) over time in patients with a diagnosis of MGUS. Patients diagnosed with MGUS (n = 424) were identified by a previously validated case-finding algorithm using health claims and electronic health record data (2007-2015) and followed through 2018. Group-based trajectory modeling identified patients with distinct laboratory value trajectories of Cr (mg/dl) and Hgb (g/dl). Most patients were non-Hispanic White (97.6%) with a mean age of 75 years at MGUS diagnosis. Three multi-trajectory groups were identified: (1) Normal Cr/Hgb (n = 225; 53.1%)-stable serum Cr levels and decreasing, normal Hgb levels; (2) Normal Cr/lower-normal Hgb group (n = 188; 44.3%)-stable, slightly elevated levels of Cr and decreasing levels of Hgb; and (3) High Cr/borderline Hgb group (n = 11; 2.6%)-increased Cr levels and stable low levels of Hgb. Patients with MGUS in Group 2 were older than patients in other groups, and patients in group 3 had more comorbidities than participants in all other groups. Few patients developed MM during the study period. We were able to identify distinct biomarker trajectories in patients with MGUS over time. Future research should investigate how these trajectories may be related to the risk of progression to MM, including M-protein levels.

Granulocyte colony stimulating factor use and adherence to clinical practice guidelines among women with breast cancer living in Puerto Rico: a population-based study

Background

Febrile Neutropenia (FN) is a common and serious condition related to cancer chemotherapy. Human recombinant Granulocyte-Colony Stimulating Factor (G-CSF) prevents and attenuates the severity and duration of FN. We evaluated the use and predictors of G-CSF adherence among women with breast cancer with a high risk of FN in Puerto Rico.

Methods

This retrospective cohort study used the Puerto Rico Central Cancer Registry-Health Insurance Linkage Database. Women with invasive breast cancer diagnosed during 2009-2015 who received selected chemotherapy regimens (n = 816) were included. The risk of FN was categorized as high and low risk based on the chemotherapy regimens according to the National Comprehensive Cancer Network guidelines and literature. Adherence was defined as the use or no use of G-CSF at the start of the first chemotherapy cycle among women with breast cancer based on the risk of developing FN. We used a multivariate logistic model to identify factors associated with G-CSF use in women classified at high risk for FN.

Results

Adherence to G-CSF clinical practice guidelines was low (38.2%) among women with a high risk of FN. Women at high risk of FN with Medicaid (aOR: 0.14; CI 95%: 0.08, 0.24) and Medicare/Medicaid (aOR: 0.33; CI 95%: 0.15, 0.73) were less likely to receive G-CSF than women with private health insurance. Women with regional stage (aOR: 1.82; CI 95%: 1.15, 2.88) were more likely to receive G-CSF than women with localized cancers.

Conclusions

Adherence to clinical practice guidelines was poor among women with a high risk of FN. Furthermore, disparities in the adherence to G-CSF use in terms of health insurance, health region, and cancer stage granted the opportunity to implement strategies to follow the recommended guidelines for using G-CSF as part of cancer treatment.

Sex and educational attainment differences in HPV knowledge and vaccination awareness among unvaccinated-sexually active adults in Puerto Rico

Human papillomavirus (HPV) knowledge and HPV vaccination uptake remain suboptimal. We assessed sex and educational attainment differences in HPV knowledge and vaccine awareness. Data from a cross-sectional study (2018–2021) in Puerto Rico among adults aged 21–49 was analyzed (n = 278). Adequate knowledge was defined as a score of ≥70% of correct responses on a 13-item knowledge scale. Multivariable logistic regression was used to assess the association of sex (men vs. women) and education (high school or less vs. more than high school) categories with adequate HPV knowledge and vaccine awareness. Adequate HPV knowledge was higher among women (53%) and men (46%) with more than high school and was lower among women (46%) and men (27%) with high school or less. For HPV vaccine awareness, similar results were observed. Women (OR = 3.0 ; 95%CI = 1.4–6.2) and men (OR = 2.3 , 95%CI = 1.1–4.8) with more than high school and women with high school or less (OR = 2.3 , 95%CI = 1.0–5.2) were more likely to have adequate HPV vaccine knowledge than men with high-school or less education. Heightened HPV vaccine awareness was also seen among more educated women and men and women with similar lower education when compared to men with ≤ high school. Men and individuals with lower educational attainment were more likely to have inadequate HPV knowledge and vaccine awareness. HPV vaccine-oriented educational interventions should target these high-risk groups.

Oral microbiota and periodontitis severity among Hispanic adults

Background

Periodontitis, one of the most common bacterial infections characterized by chronic inflammation, is also known to be a risk factor for chronic conditions, including cardiovascular disease and cancer. This inflammation is driven by an altered microbiota with an increase in pathogenic bacteria. We evaluated the association between oral microbiota and periodontitis severity in high-risk Hispanics.

Method

This cross-sectional study recruited 134 sexually active participants aged 21 to 49 years old from STI Clinics in Puerto Rico. A periodontal examination, saliva collection, and an interviewer-administered questionnaire were performed. Periodontal severity was categorized as: having no disease, mild, and moderate/severe and BOP and tooth loos was noted. Saliva samples were collected for genomic DNA extraction, downstream 16S rDNA amplification sequencing, and bioinformatics analyses.

Results

The structure, composition, and diversity of bacterial communities differed significantly according to periodontal severity. The richness and overall diversity also differed between participants without periodontitis and participants with some level of periodontal disease. A higher abundance of Prevotella, Veillonella, or Treponema was attributed to periodontal disease and Aggregatibacter to severe bleeding on probing, while Neisseria was found in higher abundance in healthy participants, decreasing its levels with drinking, smoking, and oral sex practices.

Conclusions

Our findings indicate that dysbiosis occurs as periodontal disease progresses, and both alcohol consumption and smoking habits pose risk factors for oral dysbiosis. These results are of public health and clinical impact, as several bacteria identified could serve in the future as biomarkers for periodontitis and oral cancer risk.

Differences in Hospital, Emergency Room and Outpatient Visits Among Adults With and Without Monoclonal Gammopathy of Undetermined Significance

INTRODUCTION

This study evaluated the impact of receiving a monoclonal gammopathy of undetermined significance (MGUS) diagnosis on healthcare utilization from patients at a community-based multispecialty provider organization.

METHODS

A cohort of patients with MGUS (n = 429) were matched on sex, age, and length of enrollment to a cohort of patients without MGUS (n = 1286). Healthcare utilization was assessed: 1-12 months before, 1 month before and after, and 1-12 months after diagnosis/index date. Multivariable conditional Poisson models compared change in utilization of each service in patients with and without MGUS.

RESULTS

During the 2 months around diagnosis/index date, the rates of emergency room, hospital and outpatient visits were higher for patients with MGUS than patients without MGUS. In the year before MGUS diagnosis, the association was still elevated, although attenuated.

CONCLUSION

Understanding the care of MGUS patients is important given that multiple myeloma patients with a pre-existing MGUS diagnosis may have a better prognosis.

Differences in survival among multiple myeloma patients in the United States SEER population by neighborhood socioeconomic status and race/ethnicity

PURPOSE

We examined the combined influences of race/ethnicity and neighborhood socioeconomic status (SES) on long-term survival among patients with multiple myeloma (MM).

METHODS

Data from the 2000-2015 NCI Surveillance, Epidemiology, and End Results Program (SEER-18) were used. Census tract-level SES index was assessed in tertiles (low, medium, high SES). Competing-risk modeling was used to estimate sub-hazard ratios (SHR) and 95% confidence intervals (CIs) for SES tertile adjusted for sex and age at diagnosis and stratified by race/ethnicity.

RESULTS

Overall, living in a low SES neighborhood was associated with worse MM survival. However, we observed some variation in the association by racial/ethnic group. Living in a low versus a high SES neighborhood was associated with a 35% (95% CI = 1.16-1.57) increase in MM-specific mortality risk among Asian/Pacific Islander cases, a 17% (95% CI = 1.12-1.22) increase among White cases, a 14% (95% CI = 1.04-1.23) increase among Black cases, and a 7% (95% CI = 0.96-1.19) increase among Hispanic cases.

CONCLUSION

These results suggest that the influence of both SES and race/ethnicity should be considered when considering interventions to remedy disparities in MM survival.

Variation in Colorectal Cancer Screening Practices According to Cardiovascular Disease Status and Race/Ethnicity

PURPOSE

To assess current estimates of colorectal cancer (CRC) screening practices in relation to cardiovascular disease (CVD) status and whether this association varies by race/ethnicity.

METHODS

Cross-sectional analysis of the Behavioral Risk Factor Surveillance System data from 2012, 2014, 2016, and 2018 among US adults aged 50-75 years (n = 807,937). Participants' self-reported CRC screening practices were categorized as being up-to-date, not up-to-date, or never screened. Multinomial logistic regression was used to assess whether self-reported prevalent CVD was associated with CRC screening practices after adjusting for several potentially confounding variables; additional analyses were stratified by race/ethnicity.

RESULTS

One-quarter of US adults had never been screened for CRC, while 67.0% reported being up-to-date with CRC screening. The proportion of Hispanics who had never been screened (35.3%) was higher than non-Hispanic Whites (23.5%) and Blacks (20.6%). Adults with CVD were less likely to never have been screened (adjusted odds ratio (aOR), 0.92; 95% confidence interval (CI), 0.88-0.95) or not to be up-to-date (aOR, 0.90; 95% CI, 0.86-0.94) on CRC screening than those without CVD.

CONCLUSION

The presence of CVD is associated with better adherence to CRC screening guidelines. Poor CRC screening utilization in Hispanics should be a priority for further investigation and intervention.

Chlamydia Trachomatis and Human Papillomavirus Serostatus in Puerto Rican Women

OBJECTIVE

There is a high prevalence of human papillomavirus (HPV) infection in Puerto Rico, but little is known about the prevalence of Chlamydia trachomatis (CT) infection in healthy Puerto Rican women. Thus we aimed to evaluate the seroprevalence and association and the association between HPV and CT.

METHODS

This was a secondary data analysis from a cross-sectional, populationbased, study of HPV infection in women aged 16-64 years in Puerto Rico (2010-2013). Enzyme-linked immunosorbent assays (ELISA) were used to detect serum antibodies to CT and HPV. Logistic regression models were used to estimate the odds ratio (OR) for the association between HPV and CT serostatus.

RESULTS

The study included 524 women; mean age was 42 years. Overall, 97 (18.5%) women were CT-seropositive, 251 (47.0%) were HPV seropositive, and 57 (10.9%) had antibodies for both CT and HPV. Women who were CT-seropositive were more likely (p<0.05) to also be seropositive to any HPV type (ORadjusted: 1.7, IC 95% =1.1, 2.6), HPV 16/18 (ORadjusted: 1.6, IC 95% =1.0, 2.6) and HPV 6/11 (ORadjusted: 1.6, IC 95% =1.1, 2.6) than those CT-seronegative, after adjusting for possible confounding factors.

CONCLUSION

Given the association between CT and HPV seropositivity, longitudinal studies to evaluate whether CT infection influences HPV incidence and persistence in this group are warranted.

Trends in cause of death among patients with multiple myeloma in Puerto Rico and the United States SEER population, 1987-2013

Multiple myeloma (MM) survival has improved due to recent developments in MM treatment. As a result, other co-morbid conditions may be of increasing importance to MM patients' long-term survival. This study examines trends in common causes of death among patients with MM in Puerto Rico, and in the US Surveillance, Epidemiology, and End Results (SEER) population. We analyzed the primary cause of death among incident MM cases recorded in the Puerto Rico Central Cancer Registry (n = 3,018) and the US SEER Program (n = 67,733) between 1987 and 2013. We calculated the cumulative incidence of death due to the eight most common causes and analyzed temporal trends in mortality rates using joinpoint regression. Analyses of SEER were also stratified by Hispanic ethnicity. MM accounted for approximately 72% of all reported deaths among persons diagnosed with MM in Puerto Rico and in SEER. In both populations, the proportion of patients who died from MM decreased with increasing time since diagnosis. Age-standardized temporal trends showed a decreased MM-specific mortality rate among US SEER (annual percent change [APC] = -5.0) and Puerto Rican (APC = -1.8) patients during the study period, and particularly after 2003 in non-Hispanic SEER patients. Temporal decline in non-MM causes of death was also observed among US SEER (APC = -2.1) and Puerto Rican (APC = -0.1) populations. MM-specific mortality decreased, yet remained the predominant cause of death for individuals diagnosed with MM over a 26-year period. The most pronounced decreases in MM-specific death occurred after 2003, which suggests a possible influence of more recently developed MM therapies.

Abstract A32: Trends in cause of death among Puerto Rican and United States multiple myeloma patients

Background/objective: Multiple myeloma (MM) is an incurable, yet treatable, cancer of plasma cells. Due to recent improvements in treatment, people diagnosed with MM have been living longer, and other comorbid conditions may be of increasing importance. This study examines temporal trends in specific causes of death among MM patients in Puerto Rico (PR) and the United States (U.S.).

Methods: We analyzed primary cause of death among all incident MM cancer cases recorded in the Puerto Rico Central Cancer Registry (PRCCR) (n=3,018) and the US Surveillance, Epidemiology, and End Results Program (SEER) (n=67,733) between 1987-2013, overall and by follow-up time, age, and sex. We calculated the cumulative incidence of death due to seven selected causes and analyzed age-adjusted mortality trends by MM and other causes using joinpoint regression.

Results: MM accounted for 71.7% and 71.3% of all reported deaths in PR and the U.S., respectively, among people diagnosed with MM. In PR, the proportion of patients who died from MM decreased with increasing follow-up time since diagnosis (72.3% of deaths with ≤2 years vs 65.6% with &gt;5 years of follow-up) and the proportion of patients who died from circulatory (4.6% vs 9.0%) and respiratory system (3.7% vs 5.0%) diseases increased slightly. A similar trend of decreasing MM deaths with follow-up time was observed in the U.S. (73.2% of deaths with ≤2 years vs 66.5% with &gt;5 years of follow-up). Joinpoint regression showed a decreasing trend in MM mortality in the U.S. and PR.

Conclusion: In both PR and the U.S., people diagnosed with MM are still more likely to die from MM than from another cause. However, a decrease in MM mortality is evident, particularly in more recent years, but this decrease is lower in Puerto Rico.

Citation Format: Maira A. Castañeda-Avila, Karen J. Ortiz-Ortiz, Carlos R. Torres-Cintrón, Mara M. Epstein. Trends in cause of death among Puerto Rican and United States multiple myeloma patients [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A32.