The impact of socioeconomic status on survival after cancer in the United States

Comparing PSA Screening Patterns and Their Role as Predictor of Prostate Cancer Diagnosis: Analysis of a Contemporary North American Cohort

INTRODUCTION

PSA screening remains a pivotal tool for early prostate cancer (PCa) detection. International guidelines rely on evidence from three major randomized clinical trials: ERSPC, PLCO, and CAP. We aim to examine the percentage of patients in real-world practice who get PSA screening as defined by each of the aforementioned trials. Moreover, we seek to evaluate if the different PSA screening patterns have a different impact on PCa incidence and its features at diagnosis.

MATERIALS AND METHODS

Our institutional database was queried to identify men aged 55-69 who received at least one PSA test, did not develop PCa or die within 6 years of the initial test, had follow-up within our system at least 6 years after the initial test, and did not have a previous PCa diagnosis. A total of 28,612 patients met our selection criteria. We categorized patients into three distinct PSA screening patterns based on testing frequency (PLCO: 1 PSA test per year for 6 years; ERSPC: 2 or 3 PSA tests over 6 years; CAP: 1 PSA test over 6 years). Our primary outcomes were any PCa incidence and clinically significant PCa (csPCa, defined as ISUP ≥ 3) incidence. Secondary outcome was the rate of cM1 disease. Competing risks cumulative incidence curves were used to depict any PCa and csPCa diagnosis with death before a diagnosis considered a competing risk. Multivariable competing risks regression (CRR) was used to assess the impact of the different screening patterns on any PCa and csPCa incidence, after adjusting for confounding factors.

RESULTS

The most prevalent PSA screening pattern was ERSPC, including 15,530 patients (54.3%), followed by the CAP with 9003 patients (31.5%), and the PLCO with only 4079 patients (14.2%). The median (IQR) follow-up time was 4.8 (1.7-10.8) years. At 10 years, any PCa incidence was 7.4% versus 5.6% versus 2.5% for PLCO versus ERSPC versus CAP, respectively, while for csPCa, the rates were 2.5% versus 2.5% versus 1.2% (both p < 0.001). On multivariable analyses, PLCO and ERSPC patterns were associated with 2.92-fold and 2.31-fold higher risks from 1 year to the next of any PCa diagnosis, respectively, compared to CAP pattern (both p < 0.001). Similarly, patients with PLCO and ERSPC patterns had 2.07-fold and 2.31-fold higher risks, respectively, of csPCa diagnosis compared to CAP pattern (both p < 0.001). In men with PCa diagnosis, the rates of cM1 disease were respectively 1.7% vs 5.6% vs 10.8% for PLCO versus ERSPC versus CAP, respectively (p = 0.0009).

CONCLUSION

We observed that the most common screening pattern in "real-world" clinical practice is close to what ERSPC recommend, and this pattern seems to achieve a reasonable reduction in the risk of advanced PCa, while limiting overdiagnosis.

Legislation on Medical Fertility Preservation: Improved but Insufficient Access to Care in Disadvantaged Neighborhoods

Objective: To assess whether state-level legislation mandating insurance coverage for medical fertility preservation (MFP) was associated with a change in the neighborhood disadvantage of individuals accessing fertility preservation care. Methods: This is a retrospective cohort study of individuals with ovaries seen for MFP consultation from 2017 to 2020 at a large academic medical center. Neighborhood disadvantage, as measured by median area deprivation index (ADI) in those who had MFP consultation and initiated ovarian stimulation for MFP was assessed; insurance type and other demographics were also assessed. Patients who underwent ovarian stimulation in 2017-2018 (pre-legislation) were compared to those who underwent stimulation between 2019 and 2021 (post-legislation). Results: Overall, 427 individuals with ovaries were seen for MFP consultation from 2017 to 2020; 203 of which were seen prior to legislation mandating insurance coverage (2017-2018), and 224 were seen following expansion of legislation (2019-2020). Overall, 278 individuals initiated ovarian stimulation cycles for MFP, 122 pre-legislation and 156 post-legislation. More patients with Medicaid insurance coverage were seen for MFP consultation and initiated stimulation post-legislation than pre-legislation (28 versus 12 for consultation, p = 0.020; 17 versus 3 for stimulation, p = 0.007). The predicted median ADI of patients initiating stimulation was 8 points higher post-legislation, representing increased neighborhood disadvantage, though this difference did not reach statistical significance (p = 0.053). After adjusting for other sociodemographic factors, the predicted median ADI of patients initiating stimulation was 3.5 points higher post-legislation (p = 0.25). Conclusions: While the implementation of an insurance mandate for MFP increased the median ADI of those initiating stimulation, this difference was not statistically significant. Legislation alone may not be enough to expand access to care to those living in the most disadvantaged areas.

Do differences in secondary treatment explain mortality impact of prostate cancer screening? - A randomized screening trial

BACKGROUND

The European Randomized study of screening for prostate cancer (ERSPC) demonstrated a reduction in prostate cancer (PC) mortality via PSA-based screening. We evaluated whether treatments for castration resistant PC vary between the trial arms within the Finnish section (FinRSPC) of the ERSPC.

METHODS

Clinical data were collected from medical records and national health care databases for all men diagnosed with PC and starting androgen deprivation therapy (ADT) during 1996-2015 at Tampere University Hospital. We evaluated frequencies and durations of treatments for castration resistant PC. Cox regression was used to assess time from ADT initiation to castration resistant PC treatment.

RESULTS

In total, 62 (14.2%) and 116 (15.9%) received at least % cycle of treatment for castration resistant PC in the screening and control-arm, respectively. There were no statistically significant differences in distribution of treatments for castration resistant PC between the study arms at any treatment lines (P-values over 0.05 for first, second and third & later lines of treatment). No difference was found in time to initiation of treatment for castration resistant PC after ADT. (HR: 1.00; 95% [CI], 0.78-1.39; P = 0.998).

CONCLUSIONS

Although limited by small sample size and a single-center scope, our findings suggest the mortality result of the FinRSPC is not attributable to differing treatment for castration-resistant PC between the trial arms.

Addressing Health Disparities in Hematologic Malignancies: from Genes to Outreach

SIGNIFICANCE

This review underscores our shared responsibility to champion multidimensional strategies rooted in basic and translational science, community involvement, and societal responsiveness for a meaningful impact. Unifying themes include the need to enhance collaborative infrastructure to engage laboratory researchers, epidemiologists, data scientists, clinicians, patients, community leaders, and policymakers; patient-level support services; outreach, education, and navigation for patients at the community level; recruitment and retention of underrepresented groups in the healthcare and research workforce; and funding for these efforts.

Advances in the understanding and therapeutic manipulation of cancer immune responsiveness: a Society for Immunotherapy of Cancer (SITC) review

Cancer immunotherapy-including immune checkpoint inhibition (ICI) and adoptive cell therapy (ACT)-has become a standard, potentially curative treatment for a subset of advanced solid and liquid tumors. However, most patients with cancer do not benefit from the rapidly evolving improvements in the understanding of principal mechanisms determining cancer immune responsiveness (CIR); including patient-specific genetically determined and acquired factors, as well as intrinsic cancer cell biology. Though CIR is multifactorial, fundamental concepts are emerging that should be considered for the design of novel therapeutic strategies and related clinical studies. Recent advancements as well as novel approaches to address the limitations of current treatments are discussed here, with a specific focus on ICI and ACT.

Intensity-modulated proton therapy versus volumetric-modulated ARC therapy in patients with nasopharyngeal carcinoma: A long-term, multicenter cohort study

BACKGROUND

Data evaluating the impact of intensity-modulated proton therapy (IMPT) on survival among nasopharyngeal carcinoma (NPC) patients are limited. This study aims to elucidate the survival benefits and toxicity profiles of IMPT compared to modern photon therapy, volumetric-modulated arc therapy (VMAT), over an extended follow-up period.

METHODS

We analyzed data from NPC patients recorded in the Chang Gung Research Database. This analysis focused on individuals who received definitive radiotherapy, either IMPT or VMAT therapy, from 2016 to 2021. Patients with distant metastasis or concurrent other malignancies were excluded. We performed 1:1 matching based on stage, year of diagnosis, and age (± 10 years). Oncological outcomes and toxicities were assessed using Cox proportional hazards modeling. For sensitivity analysis, we employed inverse probability of treatment weighting and additional 1:2 matching.

RESULTS

Out of a 1,202 NPC patients' cohort, 276 were selected from a subset of 294 who received IMPT and matched with an equivalent number of patients receiving VMAT. IMPT was associated with improved oncological outcomes after matching, with an adjusted hazard ratio (aHR) of 0.31 (95% CI: 0.15-0.62) for all-cause mortality and an aHR of 0.58 (95% CI: 0.34-0.99) for disease recurrence. Additionally, IMPT was linked to a reduced incidence of feeding tube placement, with an aHR of 0.31 (95% CI: 0.18-0.55). Competing risk and sensitivity analyses corroborated these trends, though the significance for disease recurrence was not consistent.

CONCLUSION

IMPT was associated with significantly better overall survival outcomes and a lower incidence of dysphagia compared to VMAT in NPC patients. Further randomized trials are needed to confirm these findings.

Analysing Inequalities in Colorectal Cancer Screening Using an Individual Socioeconomic Status Index

Background/Objectives: An individual socioeconomic status index (ISESI) was used to analyse inequalities in participation and colonoscopy acceptance in the Valencia Region Colorectal Cancer Screening Programme (VR-CRCSP). Methods: This is a cross-sectional study of men and women aged 50-69 who had been invited to participate in the VR-CRCSP as of February 2020 (N = 1,066,763). The variables included in the ISESI were nationality, employment status, disability, healthcare coverage, risk of vulnerability, and family size. The ISESI was categorised into quartiles (Qs), with Q4 corresponding to the lowest socioeconomic status (SES). Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using mixed logistic regression models. Results: The results showed that Q2 (OR = 1.30, CI = 1.28-1.33) and Q3 (OR = 1.07, CI = 1.05-1.09) are more likely to participate in the CRCSP than Q1 (the highest SES), and that Q4 (OR = 0.77, CI = 0.76-0.78) is less likely to participate than Q1. In addition, Q2 (OR = 2.03, CI = 1.78-2.32), Q3 (OR = 1.90, CI = 1.67-2.16), and Q4 (OR = 1.55, CI = 1.36-1.76) are more likely to accept a colonoscopy than Q1. The following socioeconomic characteristics were related to both non-participation and colonoscopy refusal: not Spanish, disabled, no family unit, at risk of social vulnerability, and private mutual health insurance. Conclusions: Inequalities were observed in VR-CRCSP participation and colonoscopy acceptance.

Impact of Socioeconomic Deprivation on Care Quality and Surgical Outcomes for Early-Stage Non-Small Cell Lung Cancer in United States Veterans

Background: Socioeconomic deprivation has been associated with higher lung cancer risk and mortality in non-Veteran populations. However, the impact of socioeconomic deprivation on outcomes for non-small cell lung cancer (NSCLC) in an integrated and equal-access healthcare system, such as the Veterans Health Administration (VHA), remains unclear. Hence, we investigated the impact of area-level socioeconomic deprivation on access to care and postoperative outcomes for early-stage NSCLC in United States Veterans. Methods: We conducted a retrospective cohort study of patients with clinical stage I NSCLC receiving surgical treatment in the VHA between 1 October 2006 and 30 September 2016. A total of 9704 Veterans were included in the study and assigned an area deprivation index (ADI) score, a measure of socioeconomic deprivation incorporating multiple poverty, education, housing, and employment indicators. We used multivariable analyses to evaluate the relationship between ADI and postoperative outcomes as well as adherence to guideline-concordant care quality measures (QMs) for stage I NSCLC in the preoperative (positron emission tomography [PET] imaging, appropriate smoking management, pulmonary function testing [PFT], and timely surgery [≤12 weeks after diagnosis]) and postoperative periods (appropriate surveillance imaging, smoking management, and oncology referral). Results: Compared to Veterans with low socioeconomic deprivation (ADI ≤ 50), those residing in areas with high socioeconomic deprivation (ADI > 75) were less likely to have timely surgery (multivariable-adjusted odds ratio [aOR] 0.832, 95% confidence interval [CI] 0.732-0.945) and receive PET imaging (aOR 0.592, 95% CI 0.502-0.698) and PFT (aOR 0.816, 95% CI 0.694-0.959) prior to surgery. In the postoperative period, Veterans with high socioeconomic deprivation had an increased risk of 30-day readmission (aOR 1.380, 95% CI 1.103-1.726) and decreased odds of meeting all postoperative care QMs (aOR 0.856, 95% CI 0.750-0.978) compared to those with low socioeconomic deprivation. There was no association between ADI and overall survival (adjusted hazard ratio [aHR] 0.984, 95% CI 0.911-1.062) or cumulative incidence of cancer recurrence (aHR 1.047, 95% CI 0.930-1.179). Conclusions: Our results suggest that Veterans with high socioeconomic deprivation have suboptimal adherence to care QMs for stage I NSCLC yet do not have inferior long-term outcomes after curative-intent resection. Collectively, these findings demonstrate the efficacy of an integrated, equal-access healthcare system in mitigating disparities in lung cancer survival that are frequently present in other populations. Future VHA policies should continue to target increasing adherence to QMs and reducing postoperative readmission for socioeconomically disadvantaged Veterans with early-stage NSCLC.

Disparities in Receipt of Adjuvant Immunotherapy among Stage III Melanoma Patients

OBJECTIVE

Melanoma survival has greatly improved with the advent of immunotherapy, but unequal access to these medications may exist due to nonmedical patient factors such as insurance status, educational background, and geographic proximity to treatment.

METHODS

We used the National Cancer Database to assess patients with nonmetastatic cutaneous melanoma who underwent surgical resection and sentinel lymph node biopsy (SLNB) with tumor involvement from 2015 to 2020. We evaluated rates of adjuvant immunotherapy among this patient population based on patient, tumor, and facility variables, including insurance status, socioeconomic status, pathologic stage (IIIA-IIID), and treatment facility type and volume.

RESULTS

Adjuvant immunotherapy was associated with improved survival for stage III melanoma, with a slight increase in 5-year OS for stage IIIA (87.9% vs. 85.9%, P=0.044) and a higher increase in stages IIIB-D disease (70.3% vs. 59.6%, P<0.001). Receipt of adjuvant immunotherapy was less likely for patients who were older, low socioeconomic status, or uninsured. Low-volume and community cancer centers had higher rates of adjuvant immunotherapy overall for all stage III patients, whereas high-volume and academic centers used adjuvant immunotherapy much less often for stage IIIA patients compared with those in stages IIIB-D.

CONCLUSIONS

Our results demonstrate inconsistent use of adjuvant immunotherapy among patients with stage III melanoma despite a significant association with improved survival. Notably, there was a lower use of adjuvant immunotherapy in patients of lower SES and those treated at high-volume centers. Equity in access to novel standards of care represents an opportunity to improve outcomes for patients with melanoma.

The influence of socioeconomic disadvantage on short- and long-term outcomes after oesophagectomy for cancer: an Australian multicentre study

BACKGROUND

Socioeconomic status (SES) affects outcomes following surgery for various cancers. There are currently no Australian studies that examine the role of socioeconomic disadvantage on outcomes following oesophagectomy for cancer. This study assessed whether SES was associated with short-term perioperative morbidity, long-term survival, and oncological outcomes following oesophagectomy across three tertiary oesophageal cancer centres in Australia.

METHODS

A retrospective cohort study was performed comprising all patients who underwent oesophagectomy for cancer across three Australian centres. Patients were stratified into SES groups using the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD). Outcomes measured included perioperative complication rates, overall survival, and disease-free survival.

RESULTS

The study cohort was 462 patients, 205 in the lower SES and 257 in the higher SES groups. The lower SES group presented with more advanced oesophageal cancer stage, a higher rate of T3 (52.6% versus 42.7%, P = 0.038) and N2 disease (19.6% versus 10.5%, P = 0.006), and had a higher rate of readmission within 30 days (11.2% versus 5.4%, P = 0.023). There was no difference in overall survival or disease-free survival between groups.

CONCLUSION

Lower socioeconomic status was associated with more advanced stage and increased risk of early, unplanned readmission following oesophagectomy, but was not associated with a difference in overall or disease-free survival.

Neuropsychological assessment, intervention, and best practices for women with non-Central nervous system cancer: A scoping review of current standards

Objective: Existing literature has sought to characterize the broad cognitive impact of non-central nervous system cancer and its treatment, including chemotherapy, radiation, surgery, and hormonal regulation. However, despite the frequency of women that are diagnosed with breast and gynecological cancer, there is limited research on the specific cognitive experiences of women undergoing cancer treatment. Presently, the current literature lacks concise guidance for neuropsychologists to support the cognitive health of women facing cancer, despite the acknowledged impact of cancer interventions and chronic illness on cognitive outcomes. Method: Applying scoping review criteria outlined by Peters et al. (2015) and adhering to Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) guidelines, we conducted a comprehensive examination of literature spanning multiple databases (Google Scholar, PubMed, PsychINFO) with a focus on the cognitive impact of cancer treatment on women. Conclusions: Women are subject to unique treatment-related outcomes due to the impact of hormonal alterations, differences in metabolization of certain chemotherapies, and psychosocial risk factors. Despite the known impact of cancer intervention, chronic illness, and cancer-related sequelae on cognitive outcomes, the current literature does not parsimoniously outline best practices for neuropsychologists to promote the health of women experiencing cancer. The current paper (1) provides an overview of the cognitive implications of cancer treatment with an intentional focus on cancers that are more prevalent in women versus men, (2) addresses the characteristics of this impact for women undergoing cancer intervention(s), and (3) provides possible intervention and treatment strategies for mental health providers and neuropsychologists.

The association between neighborhood socioeconomic status and the risk of incidence and mortality of colorectal cancer: A systematic review and meta-analysis of 1,678,582 participants

OBJECTIVES

We conducted a systematic review and meta-analysis to evaluate the association between neighborhood socioeconomic status (n-SES) and the risk of incidence and mortality in colorectal cancer (CRC).

SETTING

A comprehensive literature search was performed using PubMed/MEDLINE, ISI Web of Science and Scopus without any limitation until October 11, 2023. Inclusion criteria consisted of observational studies in adult subjects (≥18 years) which provided data on the association between n-SES and CRC-related incidence and mortality. Relative risk (RR) and 95 % confidence interval (CI) were pooled by employing a random-effects model. We employed validated methods to assess study quality and publication bias, utilizing the Newcastle-Ottawa Scale for quality evaluation, subgroup analysis to find possible sources of heterogeneity, Egger's regression asymmetry and Begg's rank correlation tests for bias detection and sensitivity analysis.

RESULTS

Finally, 24 studies (21 cohorts and 3 cross-sectional studies) from seven different countries with 1678,582 participants were included. The analysis suggested that a significant association between lower n-SES and an increased incidence of CRC (RR=1.11; 95 % CI: 1.08, 1.14; I2=64.4 %; p<0.001; n=46). The analysis also indicated a significant association between lower n-SES and an increased risk of mortality of CRC (RR=1.21; 95 % CI: 1.16, 1.26; I2=76.4 %; p<0.001; n=23). Furthermore, subgroup analysis revealed that there was a significant association between lower n-SES and an increased risk of incidence of CRC in colon location (RR=1.06; 95 % CI: 1.02, 1.10; I2=0.0 %; p=0.001; n=8), but not rectal location. In addition, subgroup analysis for covariates adjustment suggested that body mass index, smoking, physical activity, alcohol intake, or sex adjustment may influence the relationship between n-SES and the risk of incidence and mortality in CRC.

CONCLUSION

Lower n-SES was found to be a contributing factor to increased incidence and mortality rates associated with CRC, highlighting the substantial negative impacts of lower n-SES on cancer susceptibility and health outcomes.

Racial and ethnic disparities in mortality among World Trade Center Health Registry enrollees with post-9/11 cancer

INTRODUCTION

There are well-documented racial and ethnic disparities in mortality after cancer in the general population, but less is known about whether disparities also exist in disaster-exposed populations.

METHODS

We conducted a longitudinal cohort study of 4341 enrollees in the World Trade Center Health Registry (WTCHR) with a first-ever primary invasive cancer diagnosis after 9/11/2001 and followed through 2020. We examined associations of race and ethnicity with all-cause mortality risk and cause-specific mortality risk using multivariable Cox proportional hazards regression models and Fine and Gray's proportional sub-distribution hazards models, respectively. Models were adjusted for baseline characteristics and tumor characteristics. We also examined models further adjusted for socioeconomic status (SES), and we used inverse odds weighting to formally test for mediation by SES.

RESULTS

Compared to non-Hispanic White enrollees with cancer, non-Hispanic Blacks had higher risks for all-cause mortality (adjusted hazard ratio (aHR) = 1.20, 95% CI = 1.02-1.41) and non-cancer mortality (aHR = 1.48, 95% CI = 1.09-2.01) in the full model. In the model without SES, Hispanic enrollees with cancer had higher risks for all-cause mortality (aHR = 1.32, 95% CI = 1.09-1.60) and cancer mortality (aHR = 1.31, 95% CI = 1.05-1.64) compared to non-Hispanic Whites; these associations became not statistically significant in the full model. In the inverse odds weighting analysis, SES explained 24% and 29% of the disparity in all-cause mortality risk observed in non-Hispanic Blacks and Hispanics, respectively, compared to non-Hispanic Whites.

CONCLUSION

This study found that there are racial and ethnic disparities in mortality after cancer in the WTCHR. Additional studies are needed to further explore the factors mediating these disparities.

The Impact of Socioeconomic Status on the Incidence and Stage of Melanoma in China: A Single-Center Observational Study

BACKGROUND

The role of high socioeconomic status (SES) as an established risk factor for melanoma has been well documented in Western countries and regions. However, research on the association between melanoma and SES in China remains limited. This study aimed to investigate the association between SES and melanoma incidence and stage in China.

METHODS

Five measures of SES were accessed, including education level, ethnic background, per capita household income, occupation, and medical insurance coverage. A scoring system based on the Kuppuswamy Socio-Economic Scale was used to create a quantitative assessment of SES. To improve clarity and precision, we refined the language in the original text. Clinical stage at diagnosis was classified according to the Chinese Society Oncology Melanoma Guidelines.

RESULTS

A total of 122 patients with pathologic melanoma were enrolled in this study from January 2013 to December 2017. Of these patients, 58 (48%) were male and 64 (52%) were female, with a mean age of 59.23 ± 9.91 years. Patients in the age groups of 45-59 and 60-73 had a higher incidence of melanoma compared to other age groups. Acral lentiginous melanoma was the most commonly observed subtype, accounting for 48% of cases. Patients with a low level of education (middle school and below) and a low level of monthly household income (<3000 CNY) had a higher risk of developing melanoma, as did those who were unemployed. Interestingly, a higher proportion of melanoma diagnoses were made in patients with medical insurance than those without. However, no significant differences in melanoma staging were found based on education level ( P = 0.153), monthly household income ( P = 0.507), occupation ( P = 0.687), or insurance status ( P = 0.537). According to the Kuppuswamy Socio-Economic Scale, there were 0 in upper class, 50 in upper middle class, 44 in lower middle class, 28 in upper lower class, 0 in lower class. The mean K-score was 13.85. No statistically significant interaction was observed between K-score and tumor stage.

CONCLUSIONS

Patients with lower SES have a higher risk of developing melanoma. However, no significant differences were found in melanoma staging based on SES.

Socioeconomic Disparities in Six Common Cancer Survival Rates in South Korea: Population-Wide Retrospective Cohort Study

Background

In South Korea, the cancer incidence rate has increased by 56.5% from 2001 to 2021. Nevertheless, the 5-year cancer survival rate from 2017 to 2021 increased by 17.9% compared with that from 2001 to 2005. Cancer survival rates tend to decline with lower socioeconomic status, and variations exist in the survival rates among different cancer types. Analyzing socioeconomic patterns in the survival of patients with cancer can help identify high-risk groups and ensure that they benefit from interventions.

Objective

The aim of this study was to analyze differences in survival rates among patients diagnosed with six types of cancer-stomach, colorectal, liver, breast, cervical, and lung cancers-based on socioeconomic status using Korean nationwide data.

Methods

This study used the Korea Central Cancer Registry database linked to the National Health Information Database to follow up with patients diagnosed with cancer between 2014 and 2018 until December 31, 2021. Kaplan-Meier curves stratified by income status were generated, and log-rank tests were conducted for each cancer type to assess statistical significance. Hazard ratios with 95% CIs for any cause of overall survival were calculated using Cox proportional hazards regression models with the time since diagnosis.

Results

The survival rates for the six different types of cancer were as follows: stomach cancer, 69.6% (96,404/138,462); colorectal cancer, 66.6% (83,406/125,156); liver cancer, 33.7% (23,860/70,712); lung cancer, 30.4% (33,203/109,116); breast cancer, 91.5% (90,730/99,159); and cervical cancer, 78% (12,930/16,580). When comparing the medical aid group to the highest income group, the hazard ratios were 1.72 (95% CI 1.66-1.79) for stomach cancer, 1.60 (95% CI 1.54-1.56) for colorectal cancer, 1.51 (95% CI 1.45-1.56) for liver cancer, 1.56 (95% CI 1.51-1.59) for lung cancer, 2.19 (95% CI 2.01-2.38) for breast cancer, and 1.65 (95% CI 1.46-1.87) for cervical cancer. A higher deprivation index and advanced diagnostic stage were associated with an increased risk of mortality.

Conclusions

Socioeconomic status significantly mediates disparities in cancer survival in several cancer types. This effect is particularly pronounced in less fatal cancers such as breast cancer. Therefore, considering the type of cancer and socioeconomic factors, social and medical interventions such as early cancer detection and appropriate treatment are necessary for vulnerable populations.

Study on the additional financial burden of breast cancer disease on cancer patients and their families. Financial toxicity in cancer

Introduction

Breast cancer is among the most frequently diagnosed cancers worldwide, with 2.3 million new cases reported annually. The condition causes a social and economic impact known as financial toxicity of cancer. The study aims to explore the extra expenses borne by patients and their families on being diagnosed with breast cancer.

Methodology

An observational, descriptive, cross-sectional study was conducted. The data was collected between November 2021 and March 2022 at the Medical Oncology Service in Complejo Asistencial Universitario de Salamanca, Spain. The variables under investigation were additional economic costs, physical disability (as measured by the Barthel Index), instrumental activities of daily living (as measured by the Lawton-Brody Scale), and caregiver burden (measured using the ZARIT scale).

Results

The final sample size was N = 107. The study yielded the following outcomes: the median age was 55 years old and the majority of participants were female, with a proportion of 99.1%. The incidence rates for stage I and II were 31.8 and 35.5%, respectively. The median Barthel score was 100 points, while the Lawton and Brody score were 8 points and the ECOG score was 2 points. The analysis of primary caregiver burden resulted in a median ZARIT score of 15 points. The expenses related solely to the cancer diagnosis totaled 1511.22 euros per year (316.82 euros for pharmaceuticals; 487.85 euros for orthopedic equipment; 140.19 euros for home help; and 566.36 euros for housing adaptation or transfer to a hospital). The average annual income before diagnosis was 19962.62 euros. However, after being diagnosed with breast cancer, there is a significant income decrease of 15.91%, resulting in a reduced average annual income of 16785.98 euros. Additionally, a significant correlation was found between total expenditure and the level of dependency (p = 0.032) and functional status (p = 0.045).

Conclusion

These findings indicate that breast cancer patients experience a considerable economic burden, which worsens as their functional status deteriorates. Therefore, we believe policies should be implemented to help control this economic deterioration resulting from a serious health condition.

Comparison of outcomes for Hispanic and non-Hispanic patients with advanced renal cell carcinoma in the International Metastatic Renal Cell Carcinoma Database

BACKGROUND

Existing data on the impact of Hispanic ethnicity on outcomes for patients with renal cell carcinoma (RCC) is mixed. The authors investigated outcomes of Hispanic and non-Hispanic White (NHW) patients with advanced RCC receiving systemic therapy at large academic cancer centers using the International Metastatic Renal Cell Carcinoma Database (IMDC).

METHODS

Eligible patients included non-Black Hispanic and NHW patients with locally advanced or metastatic RCC initiating systemic therapy. Overall survival (OS) and time to first-line treatment failure (TTF) were calculated using the Kaplan-Meier method. The effect of ethnicity on OS and TTF were estimated by Cox regression hazard ratios (HRs).

RESULTS

A total of 1563 patients (181 Hispanic and 1382 NHW) (mostly males [73.8%] with clear cell RCC [81.5%] treated with tyrosine kinase inhibitor [TKI] monotherapy [69.9%]) were included. IMDC risk groups were similar between groups. Hispanic patients were younger at initial diagnosis (median 57 vs. 59 years, p = .015) and less likely to have greater than one metastatic site (60.8% vs. 76.8%, p < .001) or bone metastases (23.8% vs. 33.4%, p = .009). Median OS and TTF was 38.0 months (95% confidence interval [CI], 28.1-59.2) versus 35.7 months (95% CI, 31.9-39.2) and 7.8 months (95% CI, 6.2-9.0) versus 7.5 months (95% CI, 6.9-8.1), respectively, in Hispanic versus NHW patients. In multivariable Cox regression analysis, no statistically significant differences were observed in OS (adjusted hazard ratio [HR], 1.07; 95% CI, 0.86-1.31, p = .56) or TTF (adjusted HR, 1.06; 95% CI, 0.89-1.26, p = .50).

CONCLUSIONS

The authors did not observe statistically significant differences in OS or TTF between Hispanic and NHW patients with advanced RCC. Receiving treatment at tertiary cancer centers may mitigate observed disparities in cancer outcomes.

Trends and disparities in colorectal cancer hospitalizations and outcomes: a 10-year joinpoint trend study

Background

Colorectal cancer (CRC) poses a significant burden on healthcare systems globally. Sociodemographic factors intricately influence CRC epidemiology, yet their impact on inpatient care remains underexplored. This study aimed to assess trends in CRC hospitalization and the effect of sociodemographic factors on outcomes of CRC patients.

Methods

A retrospective longitudinal analysis was conducted using data from the Healthcare Cost and Utilization Project National Inpatient Sample. Trends in CRC admissions were assessed, stratified by sociodemographic variables. Disparities in hospital-associated outcomes were examined. Statistical methods included multivariable regression and joinpoint regression analysis.

Results

The prevalence of CRC hospitalizations uptrended from 760 per 100,000 hospitalizations in 2010 to 841 per 100,000 hospitalizations in 2019 (P trend < 0.001). The mean age decreased from 67 to 66 years (P < 0.001). Male gender and White race were predominant across the study period. Inpatient mortality decreased from 4.5% in 2010 to 4.16% in 2019 (P trend = 0.033). On sex subgroup analysis, men had a significantly higher mortality rate (P = 0.034). Racially, Blacks had the highest mortality rate (P = 0.550) and only Whites showed a significant decline in mortality over the study period (P = 0.003). Hospitalization length decreased while total hospital charges increased.

Conclusion

Our study highlights sociodemographic disparities in CRC outcomes, emphasizing the need for targeted interventions to address inequity in screening, diagnosis, and treatment. Continued research is needed to inform effective healthcare practices in mitigating these disparities and improving survival outcomes.

Impact of lymphovascular invasion on survival in surgically treated upper tract urothelial carcinoma: a nationwide analysis

OBJECTIVES

To assess the prognostic ability of lymphovascular invasion (LVI) in upper tract urothelial carcinoma (UTUC) as a predictor of overall survival (OS) using a large North American cohort.

PATIENTS AND METHODS

Our cohort included 5940 patients with clinical M0 UTUC who underwent a radical nephroureterectomy (RNU), between 2010 and 2016, within the National Cancer Database. The main variable of interest was LVI status, and its interaction with pathological nodal (pN) status. Kaplan-Meier curves were used to depict the OS also stratifying patients on LVI status. Cox regression analysis tested the impact of LVI status on OS after accounting for the available covariates.

RESULTS

The median (interquartile range [IQR]) age at diagnosis was 71 (63-78) years and most patients had pathological T1 stage disease (48.6%). Nodal status was pN0, pN1 and pNx in 45.8%, 6.3% and 47.9%, respectively. Overall, 22.1% had LVI. The median (IQR) follow-up time was 32.6 (16.0-53.3) months. At the 5-year postoperative follow-up, the estimated OS rate was 28% in patients with LVI vs 66% in those without LVI (P < 0.001). When patients were stratified based on nodal status those rates were 32% vs 68% in pN0 patients (P < 0.001), 23% vs 30% in pN1 patients (P = 0.8), and 28% vs 65% in pNx patients (P < 0.001). On multivariable analysis, the presence of LVI was associated with less favourable OS (hazard ratio 1.79, 95% confidence interval 1.60-1.99; P < 0.001).

CONCLUSION

Our study assessed the impact of LVI on OS in patients with UTUC in a large North American nationwide cohort. Our series, as the largest to date, indicate that LVI is associated with less favourable survival outcomes in patients with UTUC after RNU, and this variable could be used in counselling patients about their prognosis and might be a useful tool for future trials to risk-stratify patients.

Group-based trajectory modeling for fear of cancer recurrence in cancer survivors: a systematic review

PURPOSE

We aimed to systematically review studies that used a group-based trajectory modeling approach to explore the categories of fear of cancer recurrence (FCR) trajectories and their predictors in cancer survivors.

METHODS

MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science were searched. Three authors independently reviewed the literature for predefined eligibility criteria. The Joanna Briggs Institute critical appraisal tools for Cohort Studies and the Guidelines for Reporting on Latent Trajectory Studies were used to assess the quality of included studies. A qualitative synthesis of the included studies was performed.

RESULTS

Ninety-eight studies were retrieved after removing duplicates, and 11 studies met the criteria for inclusion. There are four types of FCR trajectories: stable, decreasing, increasing, and stable-then-decreasing-then-increasing. The following factors were considered significant predictors of FCR trajectory category in at least one of the included studies: age, race, income, education, employment, cancer stage, physical symptoms, depression, anxiety, satisfaction with medical care, and selected cognitive and behavioral factors.

CONCLUSIONS

There was considerable heterogeneity among the studies included in study design and FCR trajectory results. Factors that significantly predicted FCR trajectory categories mostly focused on psychological characteristics. The correlation of sociodemographic and disease-related predictors with FCR trajectory categories was not consistent among the included studies.

IMPLICATIONS FOR CANCER SURVIVORS

We suggest that future scholars should incorporate more psychological factors when identifying cancer survivors who persistently maintain a high level of FCR and developing FCR mitigation measures.

Predictors of quality of life of cancer patients: A psycho-oncological study conducted at Tripura, North-East India

BACKGROUND

Cancer is, no doubt, a life-threatening illness, and it has a long-term effect on the physical and mental health of the patients, particularly on their quality of life (QOL). The present article is an attempt to examine the role of socioeconomic factors, illness duration and spirituality on the QOL of cancer patients.

METHODS

The sample consisted of 200 cancer patients (100 men and 100 women patients) belonging to the state of Tripura, a Northeastern state of India. Out of 200 cancer patients, most of them (100, 50%) were suffering from oral cancer, followed by lung and breast cancer. General Information Schedule, Quality of Life Patient/Cancer Survivor Version (developed by Ferrell, Hassey-Dow and Grant), and The Spiritual Experience Index- Revised (developed by Genia) were used for data collection. For analysis of data, independent t-test, analysis of variance, and multiple linear regression were computed. The statistical analysis was carried out using IBM SPSS Version 25.0.

RESULTS

The findings showed no significant difference in QOL scores among the subgroups of cancer patients in socioeconomic and illness factor, except for family income. Further analysis revealed that only spirituality and educational qualification of cancer patients significantly predicted their QOL.

CONCLUSION

The current article can act as a springboard for further studies in this area and provide aid for socioeconomic development while improvising cancer patients' QOL.

The interaction of financial toxicity and social support on social functioning in post-chemotherapy breast cancer patients: a cross-sectional study

PURPOSE

To explore the correlation between financial toxicity, social support, and social functioning in post-chemotherapy breast cancer patients, as well as any possible interaction of financial toxicity and social support on social functioning.

METHODS

Post-chemotherapy breast cancer patients admitted to the thyroid and breast surgery departments of three first-class general hospitals in East China from December 2020 to January 2022 were recruited by convenience sampling for a cross-sectional survey. The survey instruments included the general information form, the comprehensive scores for financial toxicity based on the patient-reported outcome measures (COST-PROM), the social roles and activity participation subscale from the patient-reported outcomes measurement system-breast-chemotherapy (PROMS-B-C) (score range: 8-40), and the social support subscale from PROMS-B-C (score range: 16-80).

RESULTS

The results showed that low social functioning (low score) in post-chemotherapy breast cancer patients was positively correlated with high financial toxicity (low score) as well as poor economic resources (low score) and poor psychosocial responses (low score) (P<0.01) and negatively correlated with low economic expenditures (low score) (P<0.01); high social functioning (high score) was positively correlated with high social support (high score) (P<0.01). The interaction analysis results showed an additive interaction between financial toxicity and social support in social functioning.

CONCLUSION

There was an additive interaction of financial toxicity and social support in the social functioning of post-chemotherapy breast cancer patients. Those patients with high financial toxicity and low social support are the most likely to benefit from relevant intervention measures compared to other breast cancer populations.

Reduced Racial Disparity as a Result of Survival Improvement in Prostate Cancer

Prostate cancer is a cancer type associated with a high level of racial and socioeconomic disparities as reported by many previous studies. However, the changes in these disparities in the past two decades have not been systematically studied. In this study, we investigated the Surveillance Epidemiology End Results (SEER) data for prostate cancer patients diagnosed during 2004-2018. African Americans and Asians showed significantly better and worse cancer-specific survival (CSS), respectively, compared to non-Hispanic white individuals after adjusting for confounding factors such as age and cancer stage. Importantly, the data indicated that racial disparities fluctuated and reached the highest level during 2009-2013, and thereafter, it showed a substantial improvement. Such a change cannot be explained by the improvement in early diagnosis but is mainly driven by the differential improvement in CSS between races. Compared with Asians and non-Hispanic whites, African American patients achieved a more significant survival improvement during 2014-2018, while no significant improvement was observed for Hispanics. In addition, the SEER data showed that high-income patients had significantly longer CSS than low-income patients. Such a socioeconomic disparity was continuously increasing during 2004-2018, which was caused by the increased survival benefits of the high-income patients with respect to the low-income patients. Our study suggests that more efforts and resources should be allocated to improve the treatment of patients with low socioeconomic status.

Women's Health Maintenance Efforts at a Student-Run Free Clinic in South Florida Exceeded National Trends During the COVID-19 Pandemic

The COVID-19 pandemic posed a setback to health maintenance screenings worldwide. These delays have impacted minorities and those of low socioeconomic status in the same way that disparities in cancer screenings have historically trended. Here, we evaluated the performance of a student-run free clinic in maintaining women up-to-date with cancer screenings before, during, and after the pandemic in relation to national trends. We identified all women eligible for screening mammography and cervical cancer screenings between 2018 and 2022 at the clinic (N = 185). Adequate adherence to screening was defined according to the American Cancer Society (ACS) recommendations for breast mammography, and the United States Preventive Services Task Force (USPSTF) guidelines for cervical cancer screenings. For cervical cancer screening, 166 female patients seen between 2018 and 2022 were eligible, and up-to-date proportions were as follows: 81.3% in 2018; 90.9% in 2019; 83.3% in 2020; 93.3% in 2021; 93.8% in 2022. For breast surveillance, 143 women were eligible for screening mammography, and up-to-date proportions were as follows: 66.7% in 2018; 62.5% in 2019; 91.7% in 2020; 73.1% in 2021; 84.1% in 2022. These proportions were higher than or near national averages.In conclusion, adherence remained steady during the pandemic and was not subject to the declines seen nationally. Our clinic represents an effective model for promoting women's health maintenance and tempering the disparities seen among women of low socioeconomic status.

Differential Expression of miRNAs Contributes to Tumor Aggressiveness and Racial Disparity in African American Men with Prostate Cancer

Prostate cancer is the leading cancer in incidence and second leading cause of cancer mortality in US men. African American men have significantly higher incidence and mortality rates from prostate cancer than European American men. Previous studies reported that the disparity in prostate cancer survival or mortality can be explained by different biological backgrounds. microRNAs (miRNAs) regulate gene expression of their cognate mRNAs in many cancers. Therefore, miRNAs may be a potentially promising diagnostic tool. The role of miRNAs in prostate cancer aggressiveness and racial disparity has not been fully established. The goal of this study is to identify miRNAs associated with aggressiveness and racial disparity in prostate cancer. Here we report miRNAs that are associated with tumor status and aggressiveness in prostate cancer using a profiling approach. Further, downregulated miRNAs in African American tissues were confirmed by qRT-PCR. These miRNAs have also been shown to negatively regulate the expression of the androgen receptor in prostate cancer cells. This report provides a novel insight into understanding tumor aggressiveness and racial disparities of prostate cancer.

A Medicare Claims Analysis of Racial and Ethnic Disparities in the Access to Radiation Therapy Services

PURPOSE

Reduced access and utilization of radiation therapy (RT) is a well-documented healthcare disparity observed among racial and ethnic minority groups in the USA and a contributor to the inferior health outcomes observed among Black, Hispanic, and Native American patient groups. What is less understood are the points during the process of care following RT consultation at which patients either fail to complete their prescribed treatment or encounter delays. Identification of those points where significant differences exist among different patient groups may help identify opportunities to close gaps in the access of clinically indicated RT.

METHODS AND MATERIALS

This analysis examines 261,559 RT episodes abstracted from Medicare claims and beneficiary data between 2016 and 2018 to determine rates of treatment initiation following planning and timeliness of treatment completion for different racial groups.

RESULTS

Failure to initiate treatment was observed to be 29.3% relatively greater for Black, Hispanic, and Native American patients than for White and Asian patients. Among episodes for which treatment was initiated, Black and Hispanic patients were observed to require a significantly greater number of calendar days (when adjusted for fraction number) for completion than for White, Asian, and Native American patients.

CONCLUSIONS

There appears to be a patient cohort for which RT disparities may be more marginal in their effects-allowing for access to consultation and treatment prescription but not for treatment initiation or timely completion of treatment-and may therefore permit effective solutions to help address current differences in cancer outcomes.

Relationship between intersectionality and cancer inequalities: a scoping review protocol

INTRODUCTION

Persistent inequalities in cancer care and cancer outcomes exist within and between countries. However, the evidence pertaining to the root causes driving cancer inequalities is mixed. This may be explained by the inadequate attention paid to experiences of patients with cancer living at the intersection of multiple social categories (eg, social class, ethnicity). This is supported by the intersectionality framework. This framework offers an alternative lens through which to analyse and understand how these interlocking systems of oppression uniquely shape the experiences of patients with cancer and drive inequalities. In this protocol, we outline a scoping review that will systematically map what is known about the relationship between intersectionality and inequalities in care experience and cancer outcomes of patients with cancer; and to determine how the intersectionality framework has been applied in studies across the cancer care pathway and across countries.

METHODS AND ANALYSIS

This study will be guided by Arksey and O'Malley's, and Levac et al's frameworks for scoping reviews. We will identify and map the evidence on cancer inequalities and intersectionality from 1989 to present date. Electronic databases (EMBASE, PsychINFO, CINAHL, Medline, Web of Science, ProQuest) and a systematic search strategy using a combination of keywords and Boolean operators AND/OR will be used to identify relevant studies. Screening of eligible papers and data extraction will be conducted by two independent reviewers, and disagreements resolved by discussion with the research team. We will use an iterative process to data charting using a piloted form. Findings will be collated into a narrative report.

ETHICS AND DISSEMINATION

Ethical approval is not required since data used are from publicly available secondary sources. Findings will be disseminated through peer-reviewed journals, conferences and stakeholder meetings. Further, findings will inform the next phases of a multistage research project aimed at understanding inequalities among patients with breast cancer.

Facing problems in radiotherapy for breast cancer patients in Yogyakarta, Indonesia: A cohort retrospective study

BACKGROUND

The aim of this study is to explore problems in radiotherapy for breast cancer patients in Yogyakarta, Indonesia, focusing on overall treatment time (OTT) and completion rate.

METHODS

A retrospective cohort study was conducted based on data from the Insurance Unit at a tertiary hospital in Yogyakarta, Indonesia. The study included all female outpatients with breast cancer who were treated with radiotherapy from January to December 2017 and met the inclusion criteria. The primary outcomes were OTT and completion rate. The secondary outcomes included the number of radiotherapy fractions, radiotherapy doses, number of radiotherapy interruption days, and reasons for radiotherapy interruption. The chi-squared and Mann-Whitney U tests were used to assess the differences in outcomes between two insurance schemes (JKN-PBI (Beneficiaries of Health Insurance Contribution Assistance) and JKN-NON-PBI (Non-Beneficiaries of Health Insurance Contribution Assistance)).

RESULTS

The sample included 285 breast cancer patients (mean age: 53 years). The median OTT was 38 days (IQR: 17-48 days), with 123 (43.2%) patients having prolonged OTT. The completion rate was 57.9%. No significant differences in OTT (44.4% vs. 35.7%, p = 0.445) and completion rate (57.2% vs. 61.9%, p = 0.569) were found between the JKN-NON-PBI and JKN-PBI groups, respectively. In all, the data reported 3,022 interrupted days of radiotherapy across a total of 227 patients. The most common reason for radiotherapy interruption was unknown.

CONCLUSION

There are problems in timely delivery and low completion rate of radiotherapy among breast cancer patients in Indonesia. There are no significant differences in OTT and completion rate between the insurance schemes.

Current practice and recommendations for advancing how human variability and susceptibility are considered in chemical risk assessment

A key element of risk assessment is accounting for the full range of variability in response to environmental exposures. Default dose-response methods typically assume a 10-fold difference in response to chemical exposures between average (healthy) and susceptible humans, despite evidence of wider variability. Experts and authoritative bodies support using advanced techniques to better account for human variability due to factors such as in utero or early life exposure and exposure to multiple environmental, social, and economic stressors.This review describes: 1) sources of human variability and susceptibility in dose-response assessment, 2) existing US frameworks for addressing response variability in risk assessment; 3) key scientific inadequacies necessitating updated methods; 4) improved approaches and opportunities for better use of science; and 5) specific and quantitative recommendations to address evidence and policy needs.Current default adjustment factors do not sufficiently capture human variability in dose-response and thus are inadequate to protect the entire population. Susceptible groups are not appropriately protected under current regulatory guidelines. Emerging tools and data sources that better account for human variability and susceptibility include probabilistic methods, genetically diverse in vivo and in vitro models, and the use of human data to capture underlying risk and/or assess combined effects from chemical and non-chemical stressors.We recommend using updated methods and data to improve consideration of human variability and susceptibility in risk assessment, including the use of increased default human variability factors and separate adjustment factors for capturing age/life stage of development and exposure to multiple chemical and non-chemical stressors. Updated methods would result in greater transparency and protection for susceptible groups, including children, infants, people who are pregnant or nursing, people with disabilities, and those burdened by additional environmental exposures and/or social factors such as poverty and racism.

Analysis of delay in adjuvant chemotherapy in locally advanced rectal cancer

BACKGROUND

Adjuvant chemotherapy (AC) after neoadjuvant chemoradiation and surgical resection has been the standard of care for locally advanced rectal cancer. However, there are no evidence-based guidelines regarding the optimal timing of AC for rectal cancer. The objective of this study was to evaluate the effect of AC timing on overall survival for rectal cancer.

METHODS

The National Cancer Database (NCDB) from 2004 to 2016 was queried for primary clinical stage II or III rectal cancer patients who had undergone neoadjuvant chemoradiation followed by surgery and AC. Patients were grouped based on AC initiation: early ≤ 4 weeks, intermediate 4-8 weeks, and delayed ≥ 8 weeks. The primary outcome was overall survival.

RESULTS

We identified 8722 patients, of which 905 (10.4%) received early AC, 4621 (53.0%) intermediate AC, and 3196 (36.6%) delayed AC. Pathological lymph-node metastasis (ypN +) was positive in 73% of early AC, 74% intermediate AC, and 63% delayed AC (p < 0.05). The 5-year survival probability was 71.1% (95% CI 68-74%) for early AC, 73.2% (95% CI 72-75%) intermediate AC, and 65.8% (95% CI 64-68%) delayed AC (p < 0.001). Using Cox proportional hazard modeling, patients undergoing delayed AC had an associated decreased survival compared to patients receiving early AC (HR 1.18; 95% CI 1.028-1.353, p = 0.018) or intermediate AC (HR 1.28; 95% CI 1.179-1.395, p < 0.01).

CONCLUSIONS

Delay in AC administration may be associated with decreased 5-year survival. Compared to early or intermediate AC, patients in the delayed AC group were observed to have increased risk of death, despite having lower proportions with ypN + disease. Patients with higher socioeconomic and education status were more likely to receive early chemotherapy.

Oncology distress screening within predominately Black Veterans: Outcomes on supportive care utilization, hospitalizations, and mortality

BACKGROUND

We evaluated whether patients' initial screening symptoms were related to subsequent utilization of supportive care services and hospitalizations, and whether patient-level demographics, symptoms, hospitalizations, and supportive care service utilization were associated with mortality in primarily low-income, older, Black Veterans with cancer.

METHODS

This quality improvement project created collaborative clinics to conduct cancer distress screenings and refer to supportive care services at an urban, VA medical center. All patients completed a distress screen with follow-up screening every 3 months. Supportive care utilization, hospitalization rates, and mortality were abstracted through medical records. Poisson regression models and cox proportional hazard models were utilized.

RESULTS

Five hundred and eighty five screened patients were older (m = 72), mostly Black 70% (n = 412), and had advanced cancer 54%. Fifty-eight percent (n = 340) were screened only once with 81% (n = 470) receiving ≥1 supportive care service and 51.5% (n = 297) being hospitalized ≥1 time 18 months following initial screen. Symptom severity was significantly related to number of hospitalizations. Low mood was significantly related to higher supportive services (p < 0.001), but not hospitalizations (p ≥ 0.52). Pain, fatigue, physical function, nutrition, and physical symptoms were significantly associated with more supportive services and hospitalizations (p < 0.01). Twenty percent (n = 168) died; Veterans who were Black, had lower stage cancers, better physical health, and utilized less supportive care services had lower odds of mortality (p ≤ 0.01).

CONCLUSION

Individuals with elevated distress needs and those reporting lower physical function utilized more supportive care services and had higher hospitalization rates. Lower physical function, greater supportive care use, higher stage cancer, and being non-Black were associated with higher odds of death.

Association of financial toxicity with quality of life in testicular cancer survivors

OBJECTIVES

Most testicular cancer (TC) survivors have long-term survival. However, the association between financial toxicity (FT), which is an economic side effect of cancer treatment, and the quality of life (QOL) of TC survivors is still unclear. Thus, the impact of FT on the QOL of TC survivors was examined in a multi-institutional cross-sectional study.

METHODS

We recruited TC survivors from eight high-volume institutions in Japan between January 2018 and March 2019. A total of 562 participants completed the EORTC QLQ-C30, EORTC QLQ-TC26 and the questionnaires on demographics, including annual income. Financial difficulty in the EORTC QLQ-C30 and low income were used to assess financial distress (FD) and financial burden (FB), respectively. FT was defined as FD and FB. The QOL scores were compared, and a multivariate logistic regression analysis for FT was performed.

RESULTS

With severe FD, TC survivors had more treatment side effects, physical limitations, and anxiety concerning employment and future. The TC survivors who reported low income were worried about their jobs and the future. The QOL of the survivors with FT exhibited high impairment, except for sexual activity. In particular, the TC survivors with FT were physically limited and anxious concerning the future. The multivariate logistic regression analysis revealed that four or more chemotherapy cycles were substantial risk factors for FT (4 cycles, odds ratio (OR) = 4.17; ≥5 cycles, OR = 6.96).

CONCLUSIONS

TC survivors who received multi-cycle chemotherapy were prone to experience FT, resulting in a decline in their health-related QOL.

Impact of socioeconomic status on cancer staging, survival in non-small cell lung cancer

Purpose

We performed this study to evaluate the association of socioeconomic status (SES) factors with cancer-specific survival (CSS) of patients with non-small cell lung cancer (NSCLC). We further assessed the predictive value of a novel Tumor Node Metastasis (TNM)-SES staging system, combining the TNM stage with the SES stage.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER) database, we selected 40,378 patients diagnosed with NSCLC from 2012 to 2016. Cox regression method and Harrell's concordance index (C-index) were performed to select the SES factors related to CSS and evaluate the predictive ability of the novel TNM-SES stage. We used Kaplan-Meier curves and a log-rank test to conduct a survival analysis.

Results

We identified four SES factors (marriage, insurance, education, and household income) associated with CSS and constructed the SES stage (SES-1 and SES-2). NSCLC patients with SES-2 stage (low SES) was associated with young adult, black race, male, squamous carcinoma, upper lobe site, and advanced stage. SES-2 stage patients were significantly associated with a dismal prognosis of patients with NSCLC, with a 21.0% increased risk (HR = 1.21, 95%CI (1.18-1.24), p < 0.001). The C-index of our novel TNM-SES stage was 0.732 [95% CI (0.728-0.736)], higher than the traditional TNM stage [0.717, 95% CI (0.715-0.719)], indicating superior predictive value.

Conclusion

Our population-based study indicated that SES was significantly associated with cancer staging and SCC in patients with NSCLC. Our novel TNM-SES staging system showed a superior predictive value to the traditional TNM stage. The impact of SES on patients with NSCLC should receive more concern in clinical management.

The Association between Survivorship Care Plans and Patient-Reported Satisfaction and Confidence with Follow-Up Cancer Care Provided by Primary Care Providers

Survivorship care plans aim to facilitate a smooth transition from tertiary to primary care settings after primary cancer treatment is completed. This study sought to identify the sociodemographic factors associated with receiving a survivorship care plan and examine the relationship between receiving a plan and confidence in follow-up care delivered by primary care providers. A cross-sectional analysis of the Canadian Partnership Against Cancer's Experiences of Cancer Patients in Transition Study was conducted (n = 9970). Separate adjusted multinomial logistic regression models assessed the relationship between survivorship care plans and follow-up care outcomes. Proportion of survivors more likely to receive a survivorship care plan varied by numerous sociodemographic and medical factors, such as cancer type (colorectal and prostate), gender (male), and education (high school or less). In unadjusted and adjusted models, individuals who received a Survivorship Care Plan had significantly higher odds of: having felt their primary care providers were involved; agreeing that their primary care providers understood their needs, knew where to find supports and services, and were able to refer them directly to services; and were confident that their primary care provider could meet their follow-up care needs.

Social vulnerability, medical care access and asthma related emergency department visits and hospitalization: An observational study

BACKGROUND

The Social Vulnerability Index (SVI) is a publicly available dataset to identify communities in greatest need of resources.

OBJECTIVE

To examine the utility of using the county-level SVI as predictors of asthma-related outcomes.

METHODS

We used the American Community Survey-derived SVI and the National Environmental Public Health Tracking Network - Query Tool to retrieve data for all counties with available SVI data and at least one matched outcome of interest. Then, we tested SVI as a predictor for emergency department visits (EDV) and hospitalizations, with investigating disparities in primary care physician (PCP) density and emergency department physicians (EDP) density. Linear and logistic regression models were used.

RESULTS

Compared to counties of the lowest SVI quartile, counties of mid-low, mid-high, and highest SVI quartiles had 1%, 4%, and 5% higher odds of asthma-related EDV per 10,000 population, respectively, and 4%, 21%, and 24% higher odds of asthma-related hospitalization per 10,000 population, respectively. Moreover, the data showed an apparent resources mismatch between the EDP densities per 10,000 populations and the SVI quartiles, and the effect of the county level SVI on the asthma-related EDV and hospitalization is not strongly affected by PCP or EDP densities.

CONCLUSION

The counties with the highest SVI -and the most vulnerable to asthma hazards- have a lower coverage of PCP and EDP. Interventions directed to address persistent social vulnerability would offer the opportunity of primary prevention with less exhaustion for the medical resources.

Influence of geographic access and socioeconomic characteristics on breast cancer outcomes: A systematic review

Socio-economic and geographical inequalities in breast cancer mortality have been widely described in European countries and the United States. To investigate the combined effects of geographic access and socio-economic characteristics on breast cancer outcomes, a systematic review was conducted exploring the relationships between: (i) geographic access to healthcare facilities (oncology services, mammography screening), defined as travel time and/or travel distance; (ii) breast cancer-related outcomes (mammography screening, stage of cancer at diagnosis, type of treatment and rate of mortality); (iii) socioeconomic status (SES) at individuals and residential context levels. In total, n = 25 studies (29 relationships tested) were included in our systematic review. The four main results are: The statistical significance of the relationship between geographic access and breast cancer-related outcomes is heterogeneous: 15 were identified as significant and 14 as non-significant. Women with better geographic access to healthcare facilities had a statistically significant fewer mastectomy (n = 4/6) than women with poorer geographic access. The relationship with the stage of the cancer is more balanced (n = 8/17) and the relationship with cancer screening rate is not observed (n = 1/4). The type of measures of geographic access (distance, time or geographical capacity) does not seem to have any influence on the results. For example, studies which compared two different measures (travel distance and travel time) of geographic access obtained similar results. The relationship between SES characteristics and breast cancer-related outcomes is significant for several variables: at individual level, age and health insurance status; at contextual level, poverty rate and deprivation index. Of the 25 papers included in the review, the large majority (n = 24) tested the independent effect of geographic access. Only one study explored the combined effect of geographic access to breast cancer facilities and SES characteristics by developing stratified models.

Disparities in post-operative surveillance testing for metastatic recurrence among colorectal cancer survivors

PURPOSE

Among colorectal cancer (CRC) survivors, treatment for metastatic recurrence is most effective when malignancies are detected early through surveillance with carcinoembryonic antigen (CEA) level test and computer tomography (CT) imaging. However, utilization of these tests is low, and many survivors fail to meet the recommended guidelines. This population-based study assesses individual- and neighborhood-level factors associated with receipt of CEA and CT surveillance testing.

METHODS

We used the Surveillance, Epidemiology and End Results (SEER)-Medicare data to identify Medicare beneficiaries diagnosed with CRC stages II-III between 2010 and 2013. We conducted multivariate logistic regression to estimate the effect of individual and neighborhood factors on receipt of CEA and CT tests within 18 months post-surgery.

RESULTS

Overall, 78% and 58% of CRC survivors received CEA and CT testing, respectively. We found significant within racial/ethnic differences in receipt of these surveillance tests. Medicare-Medicaid dual coverage was associated with 39% lower odds of receipt of CEA tests among non-Hispanic Whites, and Blacks with dual coverage had almost two times the odds of receiving CEA tests compared to Blacks without dual coverage.

CONCLUSIONS

Although this study did not find significant differences in receipt of initial CEA and CT surveillance testing across racial/ethnic groups, the assessment of the factors that measure access to care suggests differences in access to these procedures within racial/ethnic groups.

IMPLICATIONS FOR CANCER SURVIVORS

Our findings have implications for developing targeted interventions focused on promoting surveillance for the early detection of metastatic recurrence among colorectal cancer survivors and improve their health outcomes.

Ethnic and socioeconomic disparities in survival of children and adolescents with CNS tumors in Southern Israel

Background

This study sought to evaluate survival of pediatric and adolescent patients with central nervous system (CNS) cancer in southern Israel, outline disparities between ethnic and socioeconomic groups (Bedouin Arabs compared to Jews) and evaluate the role of socioeconomic status (SES) in ethnic disparities.

Methods

A retrospective study was conducted among 91 patients aged one to 20 years, who were diagnosed with CNS tumors between 2001 and 2017, and followed-up through 2020. Ethnic differences in survival were measured by age, sex, stage, histology and SES. One and 3-year survival rates were calculated. Multivariable regression analysis was used to estimate adjusted ethnic differences in survival rates.

Results

Ethnic differences in survival existed within all studied variables. All Bedouin patients lived in low SES settlements (All Bedouin settlement in Southern Israel are ranked in lower socioeconomic deciles). Twenty-eight patients had medulloblastoma. Seven (25%) presented with leptomeningeal disease or distant metastases. Medulloblastoma molecular subgroups were not assessed for logistic reasons. Three-year overall survival of Bedouins was 50% compared to 92.3% for Jews. Adjusted risk of death at 3 years was significantly higher for Bedouin patients (aHR 3.36, 95% CI 1.41–7.98, P = .006).

Conclusions

We conclude that Bedouin children with CNS tumors have significantly lower survival rates compared to Jewish children, and SES seems to play a major part in these disparities. Factors influencing these disparities should be addressed and public health interventions to eliminate these disparities should be developed.

Systematic review of neighborhood socioeconomic indices studied across the cancer control continuum

BACKGROUND

There is extensive interest in understanding how neighborhood socioeconomic status (nSES) may affect cancer incidence or survival. However, variability regarding items included and approaches used to form a composite nSES index presents challenges in summarizing overall associations with cancer. Given recent calls for standardized measures of neighborhood sociodemographic effects in cancer disparity research, the objective of this systematic review was to identify and compare existing nSES indices studied across the cancer continuum (incidence, screening, diagnosis, treatment, survival/mortality) and summarize associations by race/ethnicity and cancer site to inform future cancer disparity studies.

METHODS

Using PRISMA guidelines, peer-reviewed articles published between 2010 and 2019 containing keywords related to nSES and cancer were identified in PubMed.

RESULTS

Twenty-four nSES indices were identified from 75 studies. In general, findings indicated a significant association between nSES and cancer outcomes (n = 64/75 studies; 85.33%), with 42/64 (65.63%) adjusting for highly-correlated individual SES factors (e.g., education). However, the direction of association differed by cancer site, race/ethnicity, and nSES index.

CONCLUSIONS

This review highlights several methodologic and conceptual issues surrounding nSES measurement and potential associations with cancer disparities. Recommendations pertaining to the selection of nSES measures are provided, which may help inform disparity-related disease processes and improve the identification of vulnerable populations in need of intervention.

Impact on Breast Cancer Survival by Surgical Facility Type Secondary to the ACOSOG Z0011 Trial

BACKGROUND

Studies have reported differences between age, socioeconomic status, treatment facility, and tumor burden based on survival outcomes for breast cancer (BC). The goal of this study is to evaluate BC survival and mortality outcomes by facility type. To examine likely influence of evidence-based practices, these groups were then sub stratified by pre- and post-Z0011 trial.

METHODS

This is a population-based study using the National Cancer Database of Commission on Cancer (CoC) designated centers. Intergroup comparisons of demographics were performed using chi-square test. Kaplan-Meier curve and Cox Hazard Ratios were used to evaluate survival differences. Multivariable regression methods were used to evaluate risk-adjusted 30- and 90-day mortality among BC patients. A difference-in-difference (DiD) analysis was used to evaluate the change of treatment over time pre- and post-Z0011 trial.

RESULTS

Median survival was highest among comprehensive community facilities at 63.2 months and integrated community facilities at 62.7 months, while the lowest for community and academic facilities at 60.6 months and 61 months. Academic facilities had the lowest 30- and 90-day mortality. Community centers saw the largest improvement in overall mortality post-Z0011 trial. The benefit after the Z0011 trial was evident among community centers at the 90-day mortality period as their decrease in mortality (-1.7%) was significantly lower than the decrease of mortality among academic centers (-1.3%), P-value = .01.

CONCLUSION

While the Z0011 trial had a positive influence in both community and academic facilities, community programs benefited the most. Z0011 trial showed the most change in practice for the community centers.

Socioeconomic status and its relation with breast cancer recurrence and survival in young women in the Netherlands

BACKGROUND

Associations between socioeconomic status (SES) and breast cancer survival are most pronounced in young patients. We further investigated the relation between SES, subsequent recurrent events and mortality in breast cancer patients < 40 years. Using detailed data on all recurrences that occur between date of diagnosis of the primary tumor and last observation, we provide a unique insight in the prognosis of young breast cancer patients according to SES.

METHODS

All women < 40 years diagnosed with primary operated stage I-III breast cancer in 2005 were selected from the nationwide population-based Netherlands Cancer Registry. Data on all recurrences within 10 years from primary tumor diagnosis were collected directly from patient files. Recurrence patterns and absolute risks of recurrence, contralateral breast cancer (CBC) and mortality - accounting for competing risks - were analysed according to SES. Relationships between SES, recurrence patterns and excess mortality were estimated using a multivariable joint model, wherein the association between recurrent events and excess mortality (expected mortality derived from the general population) was included.

RESULTS

We included 525 patients. The 10-year recurrence risk was lowest in high SES (18.1%), highest in low SES (29.8%). Death and CBC as first events were rare. In high, medium and low SES 13.2%, 15.3% and 19.1% died following a recurrence. Low SES patients had shorter median time intervals between diagnosis, first recurrence and 10-year mortality (2.6 and 2.7 years, respectively) compared to high SES (3.5 and 3.3 years, respectively). In multivariable joint modeling, high SES was significantly related to lower recurrence rates over 10-year follow-up, compared to low SES. A strong association between the recurrent event process and excess mortality was found.

CONCLUSIONS

High SES is associated with lower recurrence risks, less subsequent events and better prognosis after recurrence over 10 years than low SES. Breast cancer risk factors, adjuvant treatment adherence and treatment of recurrence may possibly play a role in this association.

The Role of Safety-Net Hospitals in Reducing Disparities in Breast Cancer Care

Advances in breast cancer screening and systemic therapies have been credited with profound improvements in breast cancer outcomes; indeed, 5-year relative survival rate approaches 91% in the USA (U.S. National Institutes of Health NCI. SEER Training Modules, Breast). While breast cancer mortality has been declining, oncologic outcomes have not improved equally among all races and ethnicities. Many factors have been implicated in breast cancer disparities; chief among them is limited access to care which contributes to lower rates of timely screening mammography and, once diagnosed with breast cancer, lower rates of receipt of guideline concordant care (Wu, Lund, Kimmick GG et al. in J Clin Oncol 30(2):142-150, 2012). Hospitals with a safety-net mission, such as the essential hospitals, historically have been dedicated to providing high-quality care to all populations and have eagerly embraced the role of caring for the most vulnerable and working to eliminate health disparities. In this article, we review landmark articles that have evaluated the role safety-net hospitals have played in providing equitable breast cancer care including to those patients who face significant social and economic challenges.

Racial and socioeconomic disparities in breast cancer diagnosis and mortality in Pennsylvania

PURPOSE

Many studies have demonstrated disparities in breast cancer (BC) incidence and mortality among Black women. We hypothesized that in Pennsylvania (PA), a large economically diverse state, BC diagnosis and mortality would be similar among races when stratified by a municipality's median income.

METHODS

We collected the frequencies of BC diagnosis and mortality for years 2011-2015 from the Pennsylvania Cancer Registry and demographics from the 2010 US Census. We analyzed BC diagnoses and mortalities after stratifying by median income, municipality size, and race with univariable and multivariable logistic regression models.

RESULTS

In this cohort, of 5,353,875 women there were 54,038 BC diagnoses (1.01% diagnosis rate) and 9,828 BC mortalities (0.18% mortality rate). Unadjusted diagnosis rate was highest among white women (1.06%) but Black women had a higher age-adjusted diagnosis rate (1.06%) than white women (1.02%). Race, age and income were all significantly associated with BC diagnosis, but there were no differences in BC diagnosis between white and Black women across all levels of income in the multivariable model. BC mortality was highest in Black women, a difference which persisted when adjusted for age. Black women 35 years and older had a higher mortality rate in all income quartiles.

CONCLUSION

We found that in PA, age, race and income are all associated with BC diagnosis and mortality with noteworthy disparities for Black women. Continued surveillance of differences in both breast cancer diagnosis and mortality, and targeted interventions related to education, screening and treatment may help to eliminate these socioeconomic and racial disparities.

The Impact of Socioeconomic Status on Staging, Prognosis in Hepatocellular Carcinoma

Purpose

We conducted this large population-based study to evaluate the impact of socioeconomic status (SES) factors on cancer-specific survival (CSS) of patients with hepatocellular carcinoma (HCC). We further assessed the value of a novel TNM-SES staging system, which incorporated these SES factors with TNM stage on staging and prognosis.

Methods

A total of 13,791 patients diagnosed with HCC from 2012 to 2016 were retrieved from one large population database. Cox proportional hazards regression model and Harrell’s concordance index (C-index) were used to identify the SES factors associated with CSS and analyze the prognostic value of TNM-SES stage. Kaplan–Meier curves and Log rank test were performed to evaluate CSS.

Results

Four SES factors (marital status, insurance status, education, household income) were identified as the prognostic factors associated with CSS. The SES-2 (lower SES) stage was significantly correlated to unfavorable CSS of the patients with HCC, with a 32.0% increased risk (HR = 1.32, 95% CI (1.26–1.39), P < 0.001), after adjusting for several confounders. The C-index of the TNM-SES stage was 0.735 (95% CI (0.729–0.741)) which was higher than that of the TNM stage (0.718, 95% CI (0.712–0.724)), indicating a high accuracy of prognostic prediction.

Conclusion

Our comprehensive study revealed that SES was significantly associated with prognosis of patients with HCC after adjusting several confounders. The novel TNM-SES staging system which combined TNM stage and SES stage had more superior predictive value than the traditional TNM stage. Disparity on SES should receive more attention for patients with HCC in clinical management.

Socioeconomic Status and Inflammation in Women with Early-stage Breast Cancer: Mediation by Body Mass Index

BACKGROUND

Breast cancer is the most common cancer among women in the US, and women of low socioeconomic status (SES) show markedly poorer outcomes than those of high SES. SES may influence health through inflammation, although links between SES and inflammatory biomarkers have not been investigated in women with breast cancer. This study tested the hypothesis that breast cancer patients of lower SES would show higher levels of inflammation than those of higher SES. BMI was examined as a mediator of this association.

METHODS

Women recently diagnosed with early-stage breast cancer (N = 194) were recruited before neoadjuvant or adjuvant therapy. Participants completed questionnaires and provided blood samples for immune assessment. SES was indexed by participants' self-reported education and annual household income, BMI was determined by height and weight measurements, and blood was assayed for inflammatory biomarkers linked with cancer outcomes: IL-6, CRP, TNF-α, and sTNF-RII. General linear models tested associations between SES and inflammation, and mediation models examined indirect effects through BMI.

RESULTS

Consistent with hypotheses, education status was associated with CRP, (F(2,185) = 4.72, p = 0.001), and sTNF-RII, (F(2,185) = 4.19, p = 0.02), such that lower education was associated with higher levels of both biomarkers. Further, BMI mediated the associations between education and CRP, (95% CIs [-0.62, -0.11; -0.76, -0.21]), sTNF-RII, (95% CIs [-0.09, -0.01; -0.10, -0.02]), and IL-6, (95% CIs [-0.32, -0.05; -0.38, -0.09]). Annual household income was not significantly associated with inflammation (ps > 0.25), and indirect effects on inflammation through BMI were not significant.

CONCLUSIONS

Lower education was associated with higher levels of inflammation in this sample, which may presage poor breast cancer-related and clinical outcomes. SES should inform the development of interventions targeting BMI and inflammation in breast cancer.

Health care use in response to health shocks: Does socio-economic status matter?

We investigate how utilization of primary care, specialist care, and emergency department (ED) care (and the mix across the three) changes in response to a change in health need. We determine whether any changes in utilization are impacted by socio-economic status. The use of a unique Australian data set that consists of a large survey linked to multiple years of detailed administrative records enables us to better control for individual heterogeneity and allows us to exploit changes in health that are related to the onset of two health shocks: a new diagnosis of diabetes and heart disease. We extend the analysis by also examining changes to patient out-of-pocket costs. We find significant differences in the mix between primary and specialist care use according to income and type of health shock but no evidence of using ED as a substitute for other care. Our results indicate that low- and high-income patients navigate very different pathways for their care following the onset of diabetes and to a lesser extent heart disease. These pathways appear to be chosen on the basis of ability to pay, rather than the most effective or efficient bundle of care delivered through a combination of GP and specialist care.

Trends in breast cancer incidence rates by race/ethnicity: Patterns by stage, socioeconomic position, and geography in the United States, 1999-2017

BACKGROUND

The incidence rate of breast cancer has been increasing over time across race/ethnicity in the United States. It is unclear whether these trends differ among stage, poverty, and geography subgroups.

METHODS

Using data from the North American Association of Central Cancer Registries, this study estimated trends in age-adjusted breast cancer incidence rates among women aged 50 to 84 years from 1999 to 2017 by race/ethnicity (non-Hispanic Black, non-Hispanic White, and Hispanic) and across subgroups (stage, county-level poverty, county urban/rural status, and geographic region [West, Midwest, South, and Northeast]).

RESULTS

From 2004 to 2017, breast cancer incidence rates increased across race/ethnicity and subgroups, with the greatest average annual percent increases observed for non-Hispanic Black women, overall (0.9%) and those living in lower poverty areas (0.8%), rural areas (1.2%), and all regions except the West (0.8%-1.0%). Stronger increases among non-Hispanic Black women were observed for local-stage disease and for some subgroups of distant-stage disease. Non-Hispanic Black women had the smallest decrease in regional-stage disease across most subgroups. Similarly, Hispanic women had the strongest increases in some subgroups, including areas with higher poverty (0.6%-1.2%) and in the West (0.8%), for local- and distant-stage disease.

CONCLUSIONS

These trends highlight concerns for an increasing burden of breast cancer among subpopulations, with some already experiencing disparate breast cancer mortality rates, and they highlight the need for targeted breast cancer prevention and efforts to reduce mortality disparities in areas with increasing incidence.

The growing trend for no primary surgery in colorectal cancer

AIM

In colorectal cancer (CRC), surgery of the primary site is commonly curative. Our aim was to determine estimates of 'no surgery' for primary CRC while identifying common reasons for no surgery.

METHOD

We identified all patients with a diagnosis of colorectal adenocarcinoma from the National Cancer Database between January 2004 and December 2016. Then, we identified patients who did not undergo surgery on the primary tumour and their demographic, tumour and institutional characteristics. Kaplan-Meier and logistic regression analyses were used to evaluate specific factors associated with overall survival as related to no surgery and recommendations against operative management.

RESULTS

A total of 1,208,878 patients with CRC were identified, 14.5% of whom had no surgery of the primary cancer. No surgery was more common in rectal cancer than in colon cancer. Despite a steady incidence of CRC diagnoses, the likelihood of no surgery grew by 170% over the study period. Metastatic disease was noted in 53.7% of the no surgery cohort. Nine per cent of the no surgery patient cohort received a recommendation against surgery despite the absence of metastatic disease, 7.5% refused surgery and only 2% underwent palliative surgery. On multivariable analysis, patients who were not recommended to have surgery were more likely to be older, uninsured, comorbid and receive care at a single hospital. The no surgery patients had significantly lower overall survival.

CONCLUSION

A substantial proportion of patients with CRC do not have surgery. Interventions aimed at expanding access and promoting second opinions at other cancer hospitals might reduce the growing rate of no surgery in CRC.

The impact of poverty and deprivation at the end of life: a critical review

This critical review interrogates what we know about how poverty and deprivation impact people at the end of life and what more we need to uncover. While we know that people in economically resource-rich countries who experience poverty and deprivation over the life course are likely to die younger, with increased co-morbidities, palliative care researchers are beginning to establish a full picture of the disproportionate impact of poverty on how, when and where we die. This is something the Covid-19 pandemic has further illustrated. Our article uses a critical social science lens to investigate an eclectic range of literature addressing health inequities and is focused on poverty and deprivation at the end of life. Our aim was to see if we could shed new light on the myriad ways in which experiences of poverty shape the end of people's lives. We start by exploring the definitions and language of poverty while acknowledging the multiple intersecting identities that produce privilege. We then discuss poverty and deprivation as a context for the nature of palliative care need and overall end-of-life circumstances. In particular, we explore: total pain; choice at the end of life; access to palliative care; and family caregiving. Overall, we argue that in addressing the effects of poverty and deprivation on end-of-life experiences, there is a need to recognise not just socio-economic injustice but also cultural and symbolic injustice. Too often, a deficit-based approach is adopted which both 'Others' those living with poverty and renders invisible the strategies and resilience they develop to support themselves, their families and communities. We conclude with some recommendations for future research, highlighting in particular the need to amplify the voices of people with lived experience of poverty regarding palliative and end-of-life care.