Concerns About Lung Cancer Among Prisoners

Lung Cancer Screening in the Incarcerated Population Through a Community Imaging Partnership

Limited data exist on cancer screening in carceral facilities. This study evaluates the feasibility and outcomes of a population-based lung cancer screening initiative in a carceral setting. This is a retrospective review of a lung cancer screening event at the Rhode Island Department of Corrections. Sentenced individuals meeting U.S. Preventive Services Task Force age criteria for lung cancer screening were mailed a letter asking about their smoking history. Low-dose computed tomography (LDCT) scans were offered to individuals who responded and met the criteria. Retrospective analyses examined patients' LDCT scoring using the American College of Radiology's Lung CT Screening Reporting and Data System (Lung-RADS v1.1). Among more than 2,000 incarcerated individuals, 282 met the age criteria and 117 (41.5%) replied with interest in screening, of whom 57 (48.7%) verified as eligible. All 57 (100%) received LDCT. Most scans (94.4%) were categorized as Lung-RADS 1 or 2, indicating negative or benign findings. Comparisons with general population estimates showed no significant differences in Lung-RADS scores. The screening identified 21 incidental findings, including aortic aneurysms and severe coronary artery calcification. The implementation of lung cancer screening in a carceral setting was shown to be feasible and accepted by the incarcerated population.

Cancer in English prisons: a mixed-methods study of diagnosis, treatment, care costs and patient and staff experiences

Background

The increasing size of the ageing English prison population means that non-communicable diseases such as cancer are being more commonly diagnosed in this setting. Little research has so far considered the incidence of cancer in the English prison population, the treatment patients receive when they are diagnosed in a prison setting, their care costs and outcomes or their experiences of care compared with those of people diagnosed in the general population. This is the first mixed-methods study that has been designed to investigate these issues in order to inform recommendations for cancer practice, policy and research in English prisons.

Methods

We compared cancer diagnoses made in prison between 1998 and 2017 with those made in the general population using a cohort comparison. We then used a cohort comparison approach to patients' treatment, survival, care experiences and costs of care between 2012 and 2017. We also conducted qualitative interviews with 24 patients diagnosed or treated in prison, and 6 custodial staff, 16 prison health professionals and 9 cancer professionals. Findings were presented to senior prison and cancer stakeholders at a Policy Lab event to agree priority recommendations.

Results

By 2017 cancer incidence in prison had increased from lower levels than in the general population to similar levels. Men in prison developed similar cancers to men outside, while women in prison were more likely than women outside to be diagnosed with preinvasive cervical cancer. In the comparative cohort study patients diagnosed in prison were less likely to undergo curative treatment, particularly surgery, and had a small but significantly increased risk of death. They also had fewer but slightly longer emergency hospital admissions, lower outpatient costs and fewer planned inpatient stays. While secondary care costs were lower for patients in prison, when security escorts costs were added, emergency care and total costs were higher. Control and choice, communication, and care and custody emerged as key issues from the qualitative interviews. People in prison followed a similar diagnostic pathway to those in the general population but experienced barriers arising from lower health literacy, a complex process for booking general practitioner appointments, communication issues between prison staff, surgical, radiotherapy and oncology clinicians and a lack of involvement of their family and friends in their care. These issues were reflected in patient experience survey results routinely collected as part of the annual National Cancer Patient Experience Survey. The four priorities developed and agreed at the Policy Lab event were giving clinical teams a better understanding of the prison system, co-ordinating and promoting national cancer screening programmes, developing 'health champions' in prison and raising health literacy and awareness of cancer symptoms among people in prison.

Limitations

We could not identify patients who had been diagnosed with cancer before entering prison.

Conclusion

Healthcare practices and policies both within prisons and between prisons and NHS hospitals need to be improved in a range of ways if the cancer care received by people in prison is to match that received by the general population.

Future work

Evaluating new policy priorities.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/52/53) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 3. See the NIHR Funding and Awards website for further award information.

Cancer in prison: barriers and enablers to diagnosis and treatment

Background

Approximately 82,000 people are in prison annually in England and Wales. Limited research has investigated cancer in this population and none has explored experiences of imprisoned people with cancer. This study aimed to address this gap.

Methods

We conducted 55 semi-structured, qualitative, audio-recorded interviews with: imprisoned people with cancer (n = 24), custodial staff (n = 6), prison healthcare staff (n = 16) and oncology specialists (n = 9). Data were collected 07/10/2019-20/03/2020. Patients were recruited by prison healthcare staff and interviews were conducted face-to-face. Professionals were recruited via professional networks and interviews were conducted face-to-face or via telephone. Transcribed interviews were analysed using reflexive thematic analysis. We also analysed relevant National Cancer Patient Experience Survey (NCPES) questions for those diagnosed in prison (n = 78) and in the general population (n = 390).

Findings

Our findings highlight the complexities of cancer care for imprisoned people. We identified three core themes: control and choice, communication, and care and custody. Whilst people in prison follow a similar diagnostic pathway to those in the community, additional barriers to diagnosis exist including health literacy, the General Practitioner appointment booking system and communication between prison and oncology staff. Tensions between control and choice in prison impacted aspects of cancer care experience such as symptom management and accessing cancer information. NCPES results supported the qualitative findings and showed people in prison reported significantly poorer experiences than in the general population.

Interpretation

Our findings demonstrate the complexity of cancer care in custodial settings, identifying barriers and enablers to equitable cancer care provision and offering insights on how to improve care for this population.

Funding

National Institute for Health and Social Care Research Delivery Research Programme 16/52/53 and Strategic Priorities Fund 2019/20 Research England via University of Surrey.

Incarceration status and cancer mortality: A population-based study

Background

The complex relationship between incarceration and cancer survival has not been thoroughly evaluated. We assessed whether cancer diagnosis during incarceration or the immediate post-release period is associated with higher rates of mortality compared with those never incarcerated.

Methods

We conducted a population-based study using a statewide linkage of tumor registry and correctional system movement data for Connecticut adult residents diagnosed with invasive cancer from 2005 through 2016. The independent variable was place of cancer diagnosis: during incarceration, within 12 months post-release, and never incarcerated. The dependent variables were five-year cancer-related and overall survival rates.

Results

Of the 216,540 adults diagnosed with invasive cancer during the study period, 239 (0.11%) people were diagnosed during incarceration, 479 (0.22%) within 12 months following release, and the remaining were never incarcerated. After accounting for demographics and cancer characteristics, including stage of diagnosis, the risk for cancer-related death at five years was significantly higher among those diagnosed while incarcerated (AHR = 1.39, 95% CI = 1.12–1.73) and those recently released (AHR = 1.82, 95% CI = 1.57–2.10) compared to the never-incarcerated group. The risk for all-cause mortality was also higher for those diagnosed with cancer while incarcerated (AHR = 1.92, 95% CI = 1.63–2.26) and those recently released (AHR = 2.18, 95% CI = 1.94–2.45).

Conclusions and relevance

There is a higher risk of cancer mortality among individuals diagnosed with cancer during incarceration and in the first-year post-release, which is not fully explained by stage of diagnosis. Cancer prevention and treatment efforts should target people who experience incarceration and identify why incarceration is associated with worse outcomes.

Social Determinants of Health in Oncology: Towards a More Personalized and Equitable Delivery of Cancer Care

Social determinants of health (SDOH) are defined as the set of modifiable social and physical risk factors that affect health. It is known that SDOH directly influence the population's overall health, but their effects on patients with cancer are considerably less elucidated. Here, we review the literature describing the effects of SDOH outlined by the Healthy People 2020 framework on patients diagnosed with cancer. We have found that while some SDOH are well-defined in cancer patients, evidence surrounding several variables is scarce. In addition, we have found that many SDOH are associated with disparities at the screening stage, indicating that upstream interventions are necessary before addressing the clinical outcomes themselves. Further investigation is warranted to understand how SDOH affect screenings and outcomes in multiple disciplines of oncology and types of cancers as well as explore how SDOH affect the treatments sought by these vulnerable patients.

Cancer stage at presentation for incarcerated patients at a single urban tertiary care center

Patients who are incarcerated are a vulnerable patient population and may suffer from less access to routine cancer screenings compared to their non-incarcerated counterparts. Therefore, a thorough evaluation of potential differences in cancer diagnosis staging is needed. We sought to examine whether there are differences in cancer stage at initial diagnosis between non-incarcerated and incarcerated patients by pursuing a retrospective chart review from 2010-2017 for all patients who were newly diagnosed with cancer at an urban safety net hospital. Incarceration status was determined by insurance status. Our primary outcome was incarceration status at time of initial cancer diagnosis. Overall, patients who were incarcerated presented at a later cancer stage for all cancer types compared to the non-incarcerated (+.14 T stage, p = .033; +.23 N stage, p < .001). Incarcerated patients were diagnosed at later stages for colorectal (+0.93 T stage, p < .001; +.48 N stage, p < .001), oropharyngeal (+0.37 N stage, p = .003), lung (+0.60 N stage, p = .018), skin (+0.59 N stage, p = 0.014), and screenable cancers (colorectal, prostate, lung) as a whole (+0.23 T stage, p = 0.002; +0.17 N stage, p = 0.008). Incarcerated patients may benefit from more structured screening protocols in order to improve the stage at presentation for certain malignancies.