Disparities in Survival and Comorbidity Burden Between Asian and Native Hawaiian and Other Pacific Islander Patients With Cancer

Racial Disparities in 30-day Readmissions after Surgery for Head and Neck Cancer

BACKGROUND

Native Hawaiians and other Pacific Islanders (NHPI) patients with head and neck cancer are often aggregated with Asian individuals despite evidence of heterogeneous health outcomes and mortality. The aim of this study was to determine the association of race with unplanned 30-day hospital readmission rate after head and neck surgery across the five federally recognized racial categories.

METHODS

This retrospective cohort study used a national hospital-based database and included patients ≥18 years old with diagnostically confirmed, nonmetastatic head and neck cancer of any subsite treated surgically between 2004 and 2017. The primary endpoint was unplanned readmission within 30 days of discharge after primary surgery.

RESULTS

A total of 365,834 patients were included who were predominantly White (87%), treated at academic cancer centers (47%), lower income (63%), with early-stage disease (60%), and with thyroid (47%) or oral cavity (23%) cancers. Median follow-up duration was 47 months. Of the 10,717 (3%) readmissions, 5,845 (1.6%) were unplanned. Adjusted for confounders and compared with White patients, NHPI patients had the highest likelihood of unplanned (aOR 2.07, 95%CI 1.16-3.40, p = 0.008) readmissions. Within the NHPI group, patients with lower income (aOR 4.27, 95%CI 1.28-20.4, p = 0.035) and those residing in an urban or rural area (aOR 7.42, 95%CI 1.14-49.5, p = 0.034) were more likely to be readmitted.

CONCLUSIONS

NHPI patients with head and neck cancers experience significantly higher 30-day readmissions following definitive surgical treatment. These results highlight the importance of racial disaggregation in clinical studies.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1282-1287, 2024.

The accuracy of polygenic score models for anthropometric traits and Type II Diabetes in the Native Hawaiian Population

Polygenic scores (PGS) are promising in stratifying individuals based on the genetic susceptibility to complex diseases or traits. However, the accuracy of PGS models, typically trained in European- or East Asian-ancestry populations, tend to perform poorly in other ethnic minority populations, and their accuracies have not been evaluated for Native Hawaiians. Using body mass index, height, and type-2 diabetes as examples of highly polygenic traits, we evaluated the prediction accuracies of PGS models in a large Native Hawaiian sample from the Multiethnic Cohort with up to 5,300 individuals. We evaluated both publicly available PGS models or genome-wide PGS models trained in this study using the largest available GWAS. We found evidence of lowered prediction accuracies for the PGS models in some cases, particularly for height. We also found that using the Native Hawaiian samples as an optimization cohort during training did not consistently improve PGS performance. Moreover, even the best performing PGS models among Native Hawaiians would have lowered prediction accuracy among the subset of individuals most enriched with Polynesian ancestry. Our findings indicate that factors such as admixture histories, sample size and diversity in GWAS can influence PGS performance for complex traits among Native Hawaiian samples. This study provides an initial survey of PGS performance among Native Hawaiians and exposes the current gaps and challenges associated with improving polygenic prediction models for underrepresented minority populations.

Racial and Ethnic Disparity in Preoperative Chemosensitivity and Survival in Patients With Early-Stage Breast Cancer

Importance

It remains unclear what survival benefit is associated with preoperative chemosensitivity after receiving neoadjuvant chemotherapy (NACT) among patients with resectable breast cancer from diverse racial and ethnic backgrounds.

Objective

To investigate racial and ethnic disparities in chemosensitivity and association with survival in patients with early-stage breast cancer.

Design, Setting, and Participants

This retrospective cohort study queried data from the National Cancer Database (NCDB) between calendar years 2010 and 2018. Participants included patients with breast cancer with clinical stage I to III disease treated with NACT. Preoperative chemosensitivity was defined as very sensitive (ypT0N0), sensitive (pathologic TNM stage less than clinical stage, excluding ypT0N0), and refractory (pathologic stage greater than or equal to clinical stage). Data were analyzed in November 2022.

Exposure

Receipt of NACT and clinicopathologic and treatment factors contributing to racial and ethnic disparities in survival.

Main Outcomes and Measures

Overall survival of patients from diverse racial and ethnic backgrounds who received NACT.

Results

This study included 103 605 patients (median age, 53 [IQR, 44-62] years, 99.5% [n = 103 060] women, and 68.7% [n = 71 203] White race). Among them, breast cancer was refractory in 43.2% (n = 44 796), sensitive in 34.4% (n = 35 638), and very sensitive in 22.4% (n = 23 171) of patients. In the hormone receptor-positive ERBB2 negative (formerly HER2 negative) group, patients had more refractory disease regardless of race or ethnicity (all races and ethnicities refractory: 54%-59%; P < .001). Among ERBB2 positive disease, Black patients had a lower percentage of very sensitive disease (32% vs 37%-40%; P < .001) and among triple-negative breast cancer, more refractory disease was seen among Black patients compared with other races and ethnicities (38% vs 30%-35%; P < .001). In refractory (hazard ratio [HR], 1.53; 95% CI, 1.47-1.60; P < .001) and sensitive (HR, 1.25; 95% CI, 1.17-1.33; P < .001) disease, Black patients had a higher mortality risk compared with White patients in the overall cohort. Asian patients had a lower mortality risk compared with White patients in refractory (HR, 0.71; 95% CI, 0.63-0.80; P < .001), sensitive (HR, 0.58; 95% CI, 0.49-0.69; P < .001), and very sensitive (HR, 0.60; 95% CI, 0.43-0.82; P < .001) disease groups in the overall cohort.

Conclusions and Relevance

In this cohort study, Black patients had a higher mortality risk compared with White patients among those with residual disease after NACT. This highlights the need for personalized treatment strategies for Black patients to help them attain pathologic complete response.

Diversity in Cancer Care: Current Challenges and Potential Solutions to Achieving Equity in Clinical Trial Participation

ABSTRACT

Access to and participation in cancer clinical trials determine whether such data are applicable, feasible, and generalizable among populations. The lack of inclusion of low-income and marginalized populations limits generalizability of the critical data guiding novel therapeutics and interventions used globally. Such lack of cancer clinical trial equity is troubling, considering that the populations frequently excluded from these trials are those with disproportionately higher cancer morbidity and mortality rates. There is an urgency to increase representation of marginalized populations to ensure that effective treatments are developed and equitably applied. Efforts to ameliorate these clinical trial inclusion disparities are met with a slew of multifactorial and multilevel challenges. We aim to review these challenges at the patient, clinician, system, and policy levels. We also highlight and propose solutions to inform future efforts to achieve cancer health equity.

Hula as a physical activity and social support intervention for sustained activity in female breast and gynecologic cancer survivors

Background

Physical activity improves health and psychosocial functioning for people who have been diagnosed with cancer. Native Hawaiians face disparities for some cancers, including breast cancer. Delivering culturally grounded interventions has the potential to improve enjoyment and adherence to the intervention. We sought to test the adherence and impact of a 6 month randomized wait-list controlled trial of hula.

Methods

In this randomized wait-list controlled design people who had been diagnosed with breast or gynecologic cancers were invited to participate with other cancer survivors in a group based setting. Participants were randomized to begin hula immediately or after six months. Attendance was collected and heart-rate measured three times per session. In addition, demographic data, self-report psychosocial data, and biological data (findings will be reported elsewhere) were collected at three time points: baseline, 6 months, and 12 months. The study included six months of hula, twice per week, 60 min each session. In addition, participants committed to practice 60 min per week at home.

Results

Participants in the study (n = 42) attended, on average, 72% of the sessions. Significant increase in moderate physical activity (d = 0.50, p = 0.03) was observed in the intervention versus control group. For the measures of intra-individual changes pre-and post-intervention, an increase in total physical activity were seen in the intervention group (d = 0.69, p = 0.003), daily caloric intake decreased (d = -0.62, p = 0.007), and a reduction in waist circumference (d = -0.89, p = 0.0002) that was sustained six months after completion of the intervention. Psychosocially, cognitive functioning significantly declined from baseline to 12 months (d = -0.50, p = 0.03), with role functioning improving (d = 0.55, p = 0.02), social constraints increasing (d = 0.49, p = 0.03), and financial difficulties improving (d = -0.55, p = 0.02).

Conclusion

Sustainable physical activity is crucial to improve both the survival and quality of life of cancer survivors. Culturally grounded interventions, such as hula have the potential to increase the maintenance of physical activity. In addition, they create a support group where the benefits of people who have all experienced cancer can gather and garner those benefits of social support, too. This study was registered as a clinical trial through the National Cancer Institute (NCT02351479).

Clinical trial registration

Clinicaltrails.gov, NCT02351479.

Cause-specific mortality by county, race, and ethnicity in the USA, 2000-19: a systematic analysis of health disparities

BACKGROUND

Large disparities in mortality exist across racial-ethnic groups and by location in the USA, but the extent to which racial-ethnic disparities vary by location, or how these patterns vary by cause of death, is not well understood. We aimed to estimate age-standardised mortality by racial-ethnic group, county, and cause of death and describe the intersection between racial-ethnic and place-based disparities in mortality in the USA, comparing patterns across health conditions.

METHODS

We applied small-area estimation models to death certificate data from the US National Vital Statistics system and population data from the US National Center for Health Statistics to estimate mortality by age, sex, county, and racial-ethnic group annually from 2000 to 2019 for 19 broad causes of death. Race and ethnicity were categorised as non-Latino and non-Hispanic American Indian or Alaska Native (AIAN), non-Latino and non-Hispanic Asian or Pacific Islander (Asian), non-Latino and non-Hispanic Black (Black), Latino or Hispanic (Latino), and non-Latino and non-Hispanic White (White). We adjusted these mortality rates to correct for misreporting of race and ethnicity on death certificates and generated age-standardised results using direct standardisation to the 2010 US census population.

FINDINGS

From 2000 to 2019, across 3110 US counties, racial-ethnic disparities in age-standardised mortality were noted for all causes of death considered. Mortality was substantially higher in the AIAN population (all-cause mortality 1028·2 [95% uncertainty interval 922·2-1142·3] per 100 000 population in 2019) and Black population (953·5 [947·5-958·8] per 100 000) than in the White population (802·5 [800·3-804·7] per 100 000), but substantially lower in the Asian population (442·3 [429·3-455·0] per 100 000) and Latino population (595·6 [583·7-606·8] per 100 000), and this pattern was found for most causes of death. However, there were exceptions to this pattern, and the exact order among racial-ethnic groups, magnitude of the disparity in both absolute and relative terms, and change over time in this magnitude varied considerably by cause of death. Similarly, substantial geographical variation in mortality was observed for all causes of death, both overall and within each racial-ethnic group. Racial-ethnic disparities observed at the national level reflect widespread disparities at the county level, although the magnitude of these disparities varied widely among counties. Certain patterns of disparity were nearly universal among counties; for example, in 2019, mortality was higher among the AIAN population than the White population in at least 95% of counties for skin and subcutaneous diseases (455 [97·8%] of 465 counties with unmasked estimates) and HIV/AIDS and sexually transmitted infections (458 [98·5%] counties), and mortality was higher among the Black population than the White population in nearly all counties for skin and subcutaneous diseases (1436 [96·6%] of 1486 counties), diabetes and kidney diseases (1473 [99·1%]), maternal and neonatal disorders (1486 [100·0%] counties), and HIV/AIDS and sexually transmitted infections (1486 [100·0%] counties).

INTERPRETATION

Disparities in mortality among racial-ethnic groups are ubiquitous, occurring across locations in the USA and for a wide range of health conditions. There is an urgent need to address the shared structural factors driving these widespread disparities.

FUNDING

National Institute on Minority Health and Health Disparities; National Heart, Lung, and Blood Institute; National Cancer Institute; National Institute on Aging; National Institute of Arthritis and Musculoskeletal and Skin Diseases; Office of Disease Prevention; and Office of Behavioral and Social Sciences Research, US National Institutes of Health.

Advancing Therapies for Asian Americans, Native Hawaiians, and Other Pacific Islanders With Cancer: OCE's Project ASIATICA

Project ASIATICA is a new @FDAOncology initiative focusing on AA & NHPI patients with cancer. @drjennifergao @tamykim27 @realrickpazdur

Health Care Disparities in Pulmonary Arterial Hypertension

The current approach for the management of pulmonary arterial hypertension (PAH) relies on data gathered from clinical trials and large registries. However, there is concern that minorities including Black, Indigenous, and People of Color are underrepresented in these trials and registries, making current data not generalizable to these groups of patients. Hence, it is important to discuss the significance of race/ethnicity and socioeconomic factors in patients with PAH. Here, we review the current knowledge on health care disparities in PAH. We also propose future steps in the global task of assuring justice and equality in access to pulmonary hypertension health care.

Racial Disparities among Asian American, Native Hawaiian, and Other Pacific Islander Patients with Cancer Who Refuse Recommended Radiation Therapy or Surgery

Despite radiation therapy (RT) and surgery being the curative treatments, prior work demonstrated that the aggregated Asian American (AA) and Native Hawaiian and Other Pacific Islanders (NHPI) population refuse RT and surgery at a higher rates than other races. Given that AA and NHPI are distinct groups, data disaggregation is necessary to understand racial and ethnic disparities for treatment refusal. We aimed to (1) compare RT and surgery refusal rates between AA and NHPI populations, (2) assess RT and surgery refusal on overall mortality, and (3) determine predictors of refusing RT and surgery using the United States (U.S.) National Cancer Database. Adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) for treatment refusal were calculated using logistic regression. Adjusted hazard ratios (aHR) were calculated for overall survival using Cox proportional hazard models among propensity score-matched groups. The overall rate of RT refusal was 4.8% and surgery refusal was 0.8%. Compared to East AA patients, NHPI patients had the highest risk of both RT refusal (aOR = 1.38, 95%CI = 1.21-1.61) and surgery refusal (aOR = 1.28, 95%CI = 1.00-1.61). RT refusal significantly predicted higher mortality (aHR = 1.17, 95%CI = 1.08-1.27), whereas surgery refusal did not. Predictors of RT and surgery refusal were older patient age, high comorbidity index, and cancer diagnosis between 2011-2017. The results show heterogenous treatment refusal patterns among AA and NHPI populations, suggesting areas for targeted intervention.

Racial Disparities in Brachytherapy Treatment among Women with Cervical and Endometrial Cancer in the United States

Brachytherapy improves clinical outcomes among women diagnosed with cervical and endometrial cancers. Recent evidence demonstrates that declining brachytherapy boosts for women with cervical cancer were associated with higher mortality. In this retrospective cohort study, women diagnosed with endometrial or cervical cancer in the United States between 2004 and 2017 were selected from the National Cancer Database for evaluation. Women ≥18 years of age were included for high intermediate risk (PORTEC-2 and GOG-99 definition) or FIGO Stage II-IVA endometrial cancers and FIGO Stage IA-IVA-non-surgically treated cervical cancers. The aims were to (1) evaluate brachytherapy treatment practice patterns for cervical and endometrial cancers in the United States; (2) calculate rates of brachytherapy treatment by race; and (3) determine factors associated with not receiving brachytherapy. Treatment practice patterns were evaluated over time and by race. Multivariable logistic regression assessed predictors of brachytherapy. The data show increasing rates of brachytherapy for endometrial cancers. Compared to non-Hispanic White women; Native Hawaiian and other Pacific Islander (NHPI) women with endometrial cancer and Black women with cervical cancer were significantly less likely to receive brachytherapy. For both NHPI and Black women, treatment at community cancer centers was associated with a decreased likelihood of brachytherapy. The data suggest racial disparities among Black women with cervical cancer and NHPI women with endometrial cancer and emphasize an unmet need for brachytherapy access within community hospitals.

Cancer Disparities among Pacific Islanders: A Review of Sociocultural Determinants of Health in the Micronesian Region

It is well appreciated that the social determinants of health are intimately related with health outcomes. However, there is a paucity of literature that explores these themes comprehensively for the indigenous people within Micronesia. Certain Micronesia-specific factors, such as transitions from traditional diets, the consumption of betel nut, and exposure to radiation from the nuclear bomb testing in the Marshall Islands, have predisposed certain Micronesian populations to an increased risk of developing a variety of malignancies. Furthermore, severe weather events and rising sea levels attributed to climate change threaten to compromise cancer care resources and displace entire Micronesian populations. The consequences of these risks are expected to increase the strain on the already challenged, disjointed, and burdened healthcare infrastructure in Micronesia, likely leading to more expenses in off-island referrals. A general shortage of Pacific Islander physicians within the workforce reduces the number of patients that can be seen, as well as the quality of culturally competent care that is delivered. In this narrative review, we comprehensively underscore the health disparities and cancer inequities faced by the underserved communities within Micronesia.

A National Cancer Disparities Analysis of Predictors for Radiation Therapy Refusal by Race

PURPOSE

Radiation therapy (RT) refusal by patients with cancer is infrequent but is significant because it portends poor outcomes. No prior study has evaluated all five federally defined racial categories with respects to RT refusal. Here we use a large nationally representative population with cancer to determine: 1) which race of patients refuse RT the most and 2) predictive factors for RT refusal by race.

MATERIALS/METHODS

A retrospective study included patients ≥18 years old with diagnostically confirmed cancer between 2004-2017, using the National Cancer Database. All patients included were offered RT for first course treatment. Multivariable logistic regression assessed RT refusal (adjusted odds ratio [aOR]) with 95% confidence intervals (95%CI). Analyses were adjusted for patient factors (age, rurality, income, education, and comorbidities) and cancer characteristics (stage, cancer type, facility type, year of diagnosis, and region). Median overall survival was calculated using the Kaplan-Meier method.

RESULTS

Of 11,609,044 patients, 2,759,753 patients were included and recommended for RT by the treating physician. Median follow-up was 50 months. RT was refused by 139,383 patients (5.0%), varying by race: 416 NHPI (7.2%), 489 AIAN (5.8%), 118,186 Non-Hispanic White (5.0%), 17,427 Black (4.8%), and 2,865 Asian (4.8%) patients. The rates of annual RT refusal were increasing, especially among NHPI patients. The populations with the highest likelihood of refusing RT were NHPI (aOR=1.53, 95%CI=1.36-1.71), AIAN (aOR=1.24, 95%CI=1.12-1.37), and Black (aOR=1.11, 95%CI=1.09-1.14) patients, compared to Non-Hispanic White patients. Older age and higher comorbidity burden predicted RT refusal across all races. Median overall survival was 81 months and 144 months for patients who refused RT and received RT, respectively.

CONCLUSIONS

Indigenous and Black patients are more likely to refuse RT, which may contribute to inferior cancer outcomes. Understanding NHPI and AIAN patient perspectives and perceptions may elucidate interventions to mitigate these disparities.

Genetic alterations in CREBRF influence prostate cancer survival and impact prostate tissue homeostasis in mice

BACKGROUND

Risk factors for prostate cancer include age, environment, race and ethnicity. Genetic variants in cyclic-adenosine-monophosphate-response-element-binding protein 3 regulatory factor (CREBRF) gene are frequently observed in Pacific Islanders, a population with elevated prostate cancer incidence. CREBRF has been shown to play a role in other cancers, however its function in prostate homeostasis and tumorigenesis has not been previously explored. We determined the incidence of CREBRF alterations in publicly available databases and examined the impact of CREBRF deletion on the murine prostate in order to determine whether CREBRF impacts prostate physiology or pathophysiology.

METHODS

Alterations in CREBRF were identified in prostate cancer patients via in silico analysis of several publicly available datasets through cBioPortal. Male Crebrf knockout and wild-type littermate mice were generated and examined for prostate defects at 4 months of age. Immunohistochemical staining of murine prostate sections was used to determine the impact of Crebrf knockout on proliferation, apoptosis, inflammation and blood vessel density in the prostate. Serum adipokine levels were measured using a Luminex Multiplex Assay.

RESULTS

CREBRF alterations were identified in up to 4.05% of prostate tumors and the mutations identified were categorized as likely damaging. Median survival of prostate cancer patients with genetic alterations in CREBRF was 41.23 months, compared to 131 months for patients without these changes. In the murine model, the prostates of Crebrf knockout mice had reduced epithelial proliferation and increased TUNEL⁺ apoptotic cells. Circulating adipokines PAI-1 and MCP-1 were also altered in Crebrf knockout mice compared to age-matched controls.

CONCLUSIONS

Prostate cancer patients with genetic alterations in CREBRF had a significantly decreased overall survival suggesting that wild type CREBRF may play a role in limiting prostate tumorigenesis and progression. The murine knockout model demonstrated that CREBRF could modulate proliferation and apoptosis and macrophage density in the prostate. Serum levels of adipokines PAI-1 and MCP-1 were also altered and may contribute to the phenotypic changes observed in the prostates of Crebrf knockout mice. Future studies focused on populations susceptible to CREBRF mutations and mechanistic studies will be required to fully elucidate the potential role of CREBRF in prostate tumorigenesis.