Social disparities across the continuum of colorectal cancer: a systematic review

Residential Segregation and Colorectal Cancer Screening in the United States, 2010 to 2018

BACKGROUND

Residential segregation limits the access to resources, primarily because of disinvestment. This study evaluated the association between residential segregation and colorectal cancer screening in the United States and whether findings differed by race and ethnicity.

METHODS

Restricted National Health Interview Survey data (2010-2018) were used to ascertain colorectal cancer screening adherence per US Preventive Services Task Force recommendations. Residential segregation was operationalized using the Index of Concentration at the Extremes (ICE), based on income, race, and ethnicity information obtained from the 2014 to 2018 American Community Survey estimates for counties. Multivariable logistic regression models with robust variance estimators accounting for within-county correlation were used. Analyses were stratified by race and ethnicity and weighted to represent the US population.

RESULTS

In this cross-sectional study (n = 44,690), participants residing in less advantaged counties had lower colorectal cancer screening adherence than those residing in the most advantaged counties [Q1 vs. Q5, OR (95% confidence interval): ICE income, 0.77 (0.70-0.86); ICE race, 0.86 (0.77-0.96); ICE race + income, 0.75 (0.67-0.84)]. In analyses stratified by race and ethnicity, we observed that overall findings were mostly driven by White people and estimates were less precise with no clear gradients among racial and ethnic minoritized groups. Among Black participants, colorectal cancer screening did not vary across quintiles of economic segregation.

CONCLUSIONS

Residential segregation was associated with colorectal cancer screening.

IMPACT

Interventions aimed at improving colorectal cancer screening uptake in the United States should address structural barriers present in areas with higher concentrations of low-income minoritized racial and ethnic groups and how features of residential segregation might differentially affect racial and ethnic groups.

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.

Incidence of Stomach, Liver, and Colorectal Cancers by Geography and Social Vulnerability Among American Indian and Alaska Native Populations, 2010-2019

Social determinants of health and associated systems, policies, and practices are important drivers of health disparities. American Indian and Alaska Native (AI/AN) populations in the United States have elevated incidence rates of stomach, liver, and colorectal cancers compared with other racial/ethnic groups. In this study, we examined incidence rates of 3 types of gastrointestinal cancer among non-Hispanic AI/AN (NH-AI/AN) and non-Hispanic White (NHW) populations by geographic region and Social Vulnerability Index (SVI) score. Incident cases diagnosed during 2010-2019 were identified from population-based cancer registries linked with the Indian Health Service patient registration databases. Age-adjusted incidence rates (per 100,000 population) for stomach, liver, and colorectal cancers were compared within NH-AI/AN populations and between the NH-AI/AN and NHW populations by SVI score. Rates were higher among NH-AI/AN populations in moderate- and high-SVI-score counties in Alaska, the Southern Plains, and the East than in low-SVI counties. Incidence rates among NH-AI/AN populations were elevated when compared with NHW populations by SVI category. Results indicated that higher social vulnerability may drive elevated cancer incidence among NH-AI/AN populations. Additionally, disparities between NH-AI/AN and NHW populations persist even when accounting for SVI. Exploring social vulnerability can aid in designing more effective interventions to address root causes of cancer disparities among AI/AN populations.

Primary Prevention of Cancer: A Multilevel Approach to Behavioral Risk Factor Reduction in Racially and Ethnically Minoritized Groups

ABSTRACT

Cancer continues to be the second most common cause of death in the United States. Racially and ethnically minoritized populations continue to experience disparities in cancer prevention compared with majority populations. Multilevel interventions-from policy, communities, health care institutions, clinical teams, families, and individuals-may be uniquely suited to reducing health disparities through behavioral risk factor modification in these populations. The aim of this article is to provide a brief overview of the evidence for primary prevention among racially and ethnically minoritized subpopulations in the United States. We focus on the epidemiology of tobacco use, obesity, diet and physical activity, alcohol use, sun exposure, and smoking, as well as increasing uptake of the Human Papillomavirus Vaccine (HPV), as mutable behavioral risk factors. We describe interventions at the policy level, including raising excise taxes on tobacco products; within communities and with community partners, for safe greenways and parks, and local healthful food; health care institutions, with reminder systems for HPV vaccinations; among clinicians, by screening for alcohol use and providing tailored weight reduction approaches; families, with HPV education; and among individuals, routinely using sun protection. A multilevel approach to primary prevention of cancer can modify many of the risk factors in racially and ethnically minoritized populations for whom cancer is already a burden.

An integrated interpreting service normalizes access to care for culturally and linguistically diverse (CALD) patients with colorectal cancer

AIM

To compare access to the initial management and overall survival with colorectal cancer for limited English proficient (LEP) patients compared with patients from an English background.

METHODS

All newly diagnosed patients from 2017 with colorectal cancer from a single health service with a highly multicultural catchment area and a well-developed and integrated translation and language support (TALS) department were recruited. Time from referral to: biopsy, date seen by a surgeon, oncologist, discussion at a multidisciplinary meeting (MDM), and day of commencement of the first treatment modality, and overall survival were analyzed.

RESULTS

One hundred sixty-two patients were analyzed, including 57 LEP patients from 22 countries of birth. Interpreters were present at 687/782 appointments with LEP patients. There were no differences in demographics or cancer staging. There were no differences between English background and LEP patients with regard to times from referral to biopsy (1 vs. 0 days), specialist review (surgical: 4 vs. 6 days, oncological: 45 vs. 57 days), MDM discussion (23 vs. 15 days), or commencement of treatment (32 vs. 28.5 days). There were no differences in treatment for colorectal cancer, although a higher rate of stomas was noted in LEP patients. There was no difference in overall survival between groups.

CONCLUSION

Time to critical initial checkpoints and overall survival were similar in LEP and English background patients with colorectal cancer. An integrated TALS department may abrogate the language and cultural barriers that are known to disadvantage LEP patients and may contribute to normalizing care for the culturally and linguistically diverse community.

Long-term benefits for lower socioeconomic groups by improving bowel screening participation in South Australia: A modelling study

INTRODUCTION

The gap in bowel cancer screening participation rates between the lowest socioeconomic position (SEP) groups and the highest in Australia is widening. This study estimates the long-term health impacts and healthcare costs at current colorectal cancer (CRC) screening participation rates by SEP in South Australia (SA).

METHODS

A Markov microsimulation model for each socioeconomic quintile in SA estimated health outcomes over the lifetime of a population aged 50-74 years (total n = 513,000). The model simulated the development of CRC, considering participation rates in the National Bowel Cancer Screening Program and estimated numbers of cases of CRC, CRC deaths, adenomas detected, mean costs of screening and treatment, and quality adjusted life years. Screened status, stage of diagnosis and survival were obtained for patients diagnosed with CRC in 2006-2013 using data linked to the SA Cancer Registry.

RESULTS

We predict 10915 cases of CRC (95%CI: 8017─13812) in the lowest quintile (Q1), 17% more than the highest quintile (Q5) and 3265 CRC deaths (95%CI: 2120─4410) in Q1, 24% more than Q5. Average costs per person, were 29% higher in Q1 at $11997 ($8754─$15240) compared to Q5 $9281 ($6555─$12007). When substituting Q1 screening and diagnostic testing rates with Q5's, 17% more colonoscopies occur and adenomas and cancers detected increase by 102% in Q1.

CONCLUSION

Inequalities were evident in CRC cases and deaths, as well as adenomas and cancers that could be detected earlier. Implementing programs to increase screening uptake and follow-up tests for lower socioeconomic groups is critical to improve the health of these priority population groups.

Colorectal cancer disparities across the continuum of cancer care: A systematic review and meta-analysis

BACKGROUND

Disparate colorectal cancer outcomes persist in vulnerable populations. We aimed to examine the distribution of research across the colorectal cancer care continuum, and to determine disparities in the utilization of Surgery among Black patients.

METHODS

A systematic review and meta-analysis of colorectal cancer disparities studies was performed. The meta-analysis assessed three utilization measures in Surgery.

RESULTS

Of 1,199 publications, 60% focused on Prevention, Screening, or Diagnosis, 20% on Survivorship, 15% on Treatment, and 1% on End-of-Life Care. A total of 16 studies, including 1,110,674 patients, were applied to three meta-analyses regarding utilization of Surgery. Black patients were less likely to receive surgery, twice as likely to refuse surgery, and less likely to receive laparoscopic surgery, when compared to White patients.

CONCLUSIONS

Since 2011, the majority of research focused on prevention, screening, or diagnosis. Given the observed treatment disparities among Black patients, future efforts to reduce colorectal cancer disparities should include interventions within Surgery.

Implementing a multilevel intervention to accelerate colorectal cancer screening and follow-up in federally qualified health centers using a stepped wedge design: a study protocol

Background

Screening for colorectal cancer (CRC) not only detects disease early when treatment is more effective but also prevents cancer by finding and removing precancerous polyps. Because many of our nation’s most disadvantaged and vulnerable individuals obtain health care at federally qualified health centers, these centers play a significant role in increasing CRC screening among the most vulnerable populations. Furthermore, the full benefits of cancer screenings must include timely and appropriate follow-up of abnormal results. Thus, the purpose of this study is to implement a multilevel intervention to increase rates of CRC screening, follow-up, and referral-to-care in federally qualified health centers, as well as simultaneously to observe and to gather information on the implementation process to improve the adoption, implementation, and sustainment of the intervention. The multilevel intervention will target three different levels of influences: organization, provider, and individual. It will have multiple components, including provider and staff education, provider reminder, provider assessment and feedback, patient reminder, and patient navigation.

Methods

This study is a multilevel, three-phase, stepped wedge cluster randomized trial with four clusters of clinics from four different FQHC systems. In the first phase, there will be a 3-month waiting period during which no intervention components will be implemented. After the 3-month waiting period, we will randomize two clusters to cross from the control to the intervention and the remaining two clusters to follow 3 months later. All clusters will stay at the same phase for 9 months, followed by a 3-month transition period, and then cross over to the next phase.

Discussion

There is a pressing need to reduce disparities in CRC outcomes, especially among racial/ethnic minority populations and among populations who live in poverty. Single-level interventions are often insufficient to lead to sustainable changes. Multilevel interventions, which target two or more levels of changes, are needed to address multilevel contextual influences simultaneously. Multilevel interventions with multiple components will affect not only the desired outcomes but also each other. How to take advantage of multilevel interventions and how to implement such interventions and evaluate their effectiveness are the ultimate goals of this study.

Trial registration

This protocol is registered at clinicaltrials.gov (NCT04514341) on 14 August 2020.

Promoting colorectal cancer screening: a systematic review and meta-analysis of randomised controlled trials of interventions to increase uptake

Colorectal cancer (CRC) represents a global public health concern. CRC screening is associated with significant reductions in CRC incidence and mortality, however, uptake is suboptimal. This systematic review and meta-analysis of randomised controlled trials explored the effectiveness of interventions designed to increase screening uptake, plus the impact of various moderators. Data from 102 studies including 1.94 million participants were analysed. Results showed significant benefit of all interventions combined (OR, 1.49, 95% CI: 1.43, 1.56, p < 0.001). The effects were similar in studies using objective versus self-reported uptake measures and lower in studies judged to be at high risk of bias. Moderator analyses indicated significant effects for aspects of behaviour (effects lower for studies on non-endoscopic procedures), and intervention (effects higher for studies conducted in community settings, in healthcare systems that are not free, and that use reminders, health-professional providers, paper materials supplemented with in-person or phone contact, but avoid remote contact). Interventions that included behaviour change techniques targeting social support (unspecified or practical), instructions or demonstration of the behaviour, and that added objects to the environment produced stronger effects. The way in which findings can inform interventions to improve CRC screening uptake is discussed.

Cervical and colorectal cancer screening prevalence before and after Affordable Care Act Medicaid expansion

Community health centers (CHCs), which serve socioeconomically disadvantaged patients, experienced an increase in insured visits after the 2014 Affordable Care Act (ACA) coverage options began. Yet, little is known about how cancer screening rates changed post-ACA. Therefore, this study assessed changes in the prevalence of cervical and colorectal cancer screening from pre- to post-ACA in expansion and non-expansion states among patients seen in CHCs. Electronic health record data on 624,601 non-pregnant patients aged 21-64 eligible for cervical or colorectal cancer screening between 1/1/2012 and 12/31/2015 from 203 CHCs were analyzed. We assessed changes in prevalence and screening likelihood among patients, by insurance type and race/ethnicity and compared Medicaid expansion and non-expansion states using difference-in-difference methodology. Female patients had 19% increased odds of receiving cervical cancer screening post- relative to pre-ACA in expansion states [adjusted odds ratio (aOR) = 1.19, 95% confidence interval (CI) = 1.09-1.31] and 23% increased odds in non-expansion states (aOR = 1.23, 95% CI = 1.05-1.46): the greatest increase was among uninsured patients in expansion states (aOR = 1.36, 95% CI = 1.16-1.59) and privately-insured patients in non-expansion states (aOR = 1.43, 95% CI = 1.11-1.84). Colorectal cancer screening prevalence increased from 11% to 18% pre- to post-ACA in expansion states and from 13% to 21% in non-expansion states. For most outcomes, the observed changes were not significantly different between expansion and non-expansion states. Despite increased prevalences of cervical and colorectal cancer screening in both expansion and non-expansion states across all race/ethnicity groups, rates remained suboptimal for this population of socioeconomically disadvantaged patients.

Racial-Ethnic Disparities in Late-Stage Colorectal Cancer Among Hispanics and Non-Hispanic Whites of New Mexico

INTRODUCTION

Hispanics in New Mexico are diagnosed with more later-stage colorectal cancer (CRC) than non-Hispanic Whites (NHW). Our study evaluated the interaction of race/ethnicity and risk factors for later-stage III and IV CRC among patients in New Mexico.

METHOD

CRC patients ages 30 to 75 years ( n = 163, 46% Hispanic) completed a survey on key explanatory clinical, lifestyle, preventive health, and demographic variables for CRC risk. Adjusted logistic regression models examined whether these variables differentially contributed to later-stage CRC among NHW versus Hispanics.

RESULTS

Compared with NHW, Hispanics had a higher prevalence of later-stage CRC ( p = .007), diabetes ( p = .006), high alcohol consumption ( p = .002), low education ( p = .003), and CRC diagnosis due to symptoms ( p = .06). Compared with NHW, Hispanics reporting high alcohol consumption (odds ratio [OR] = 7.59; 95% confidence interval [CI] = 1.31-43.92), lower education (OR = 3.5; 95% CI = 1.28-9.65), being nondiabetic (OR = 3.23; 95% CI = 1.46-7.15), or ever smokers (OR = 2.4; 95% CI = 1.03-5.89) were at higher risk for late-stage CRC. Adjusting for CRC screening did not change the direction or intensity of the odds ratios.

CONCLUSION

The ethnicity-risk factor interactions, identified for late-stage CRC, highlight significant factors for targeted intervention strategies aimed at reducing the burden of later-stage CRC among Hispanics in New Mexico with broad applicability to other Hispanic populations.

Health Volunteerism and Improved Cancer Health for Latina and African American Women and Their Social Networks: Potential Mechanisms

Health volunteerism has been associated with positive health outcomes for volunteers and the communities they serve. This work suggests that there may be an added value to providing underserved populations with information and skills to be agents of change. The current study is a first step toward testing this hypothesis. The purpose is to identify how volunteerism may result in improved cancer health among Latina and African American women volunteers. A purposive sample of 40 Latina and African American female adults who had participated in cancer volunteerism in the past 5 years was recruited by community advocates and flyers distributed throughout community venues in San Diego, CA. This qualitative study included semi-structured focus groups. Participants indicated that volunteerism not only improved their health but also the health of their family and friends. Such perceptions aligned with the high rates of self-report lifetime cancer screening rates among age-eligible patients (e.g., 83-93 % breast; 90-93 % cervical; 79-92 % colorectal). Identified mechanisms included exposure to evidence-based information, health-protective social norms and support, and pressure to be a healthy role model. Our findings suggest that train-the-trainer and volunteer-driven interventions may have unintended health-protective effects for participating staff, especially Latina and African American women.

Fundamental causes of accelerated declines in colorectal cancer mortality: Modeling multiple ways that disadvantage influences mortality risk

BACKGROUND

Improvements in colorectal cancer (CRC) mortality reflect the distribution of effective preventions. Social inequalities often generate unequal diffusion of medical interventions, resulting in disparate outcomes while preventions are being disseminated throughout the population. This study used a novel method to examine whether Race (Black versus White) and SES influenced when rates of CRC mortality started to decline, and how rapidly they did so.

METHOD

Mortality counts from 1968-2010 were derived from death certificates of U.S. residents aged 25 + years. Individuals' race, age, county of residence, and sex were collected from death certificates. County-level SES was measured using the decennial U.S. census. Layered joinpoint regression was used to model CRC mortality trends over time. Acceleration in rates of historical decline were used to indicate preventability within counties.

RESULTS

Black race was associated with a 4.1-year delay in colonoscopy-attributable declines in CRC mortality and each standard deviation unit change in SES with a 5.7-year delay in such mortality. Following the onset of a decline, colonoscopy-attributable mortality change was slower by 0.5% among Blacks, and 2.0%/standard deviation in SES. Modifying the rapidity of colonoscopy uptake could have averted 12-14,000 and 83-86,000 deaths among Blacks and residents of lower SES counties, respectively.

CONCLUSIONS

Successful interventions do not uniformly benefit the U.S.

POPULATION

This study highlighted the notable impact that substantial delays in the provision of interventions, and in the relative rapidity of dissemination, and estimated the extent to which there was a preventable loss of life concentrated amongst the most disadvantaged. A more egalitarian delivery of life-saving interventions could drastically reduce mortality by improving effectiveness of interventions while also addressing inequalities in health.

Is the clinicopathological pattern of colorectal carcinoma similar in the state and private healthcare systems of South Africa? Analysis of a Durban colorectal cancer database

Previous state hospital-based local studies suggest varying population-based clinicopathological patterns of colorectal cancer (CRC). Patients diagnosed with CRC in the state and private sector hospitals in Durban, South Africa over a 12-month period (January-December 2009) form the basis of our study. Of 491 patients (172 state and 319 private sector patients), 258 were men. State patients were younger than private patients. Anatomical site distribution was similar in both groups with minor variations. Stage IV disease was more common in state patients. State patients were younger, presented with advanced disease and had a lower resection rate. Black patients were the youngest, presented with advanced disease and had the lowest resection rate.

Association of Financial Strain With Symptom Burden and Quality of Life for Patients With Lung or Colorectal Cancer

PURPOSE

To measure the association between patient financial strain and symptom burden and quality of life (QOL) for patients with new diagnoses of lung or colorectal cancer.

PATIENTS AND METHODS

Patients participating in the Cancer Care Outcomes Research and Surveillance study were interviewed about their financial reserves, QOL, and symptom burden at 4 months of diagnosis and, for survivors, at 12 months of diagnosis. We assessed the association of patient-reported financial reserves with patient-reported outcomes including the Brief Pain Inventory, symptom burden on the basis of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30, and QOL on the basis of the EuroQoL-5 Dimension scale. Multivariable linear regression models were fit for each outcome and cancer type, adjusting for age, race/ethnicity, sex, income, insurance, stage at diagnosis, and comorbidity.

RESULTS

Among patients with lung and colorectal cancer, 40% and 33%, respectively, reported limited financial reserves (≤ 2 months). Relative to patients with more than 12 months of financial reserves, those with limited financial reserves reported significantly increased pain (adjusted mean difference, 5.03 [95% CI, 3.29 to 7.22] and 3.45 [95% CI, 1.25 to 5.66], respectively, for lung and colorectal), greater symptom burden (5.25 [95% CI, 3.29 to .22] and 5.31 [95% CI, 3.58 to 7.04]), and poorer QOL (4.70 [95% CI, 2.82 to 6.58] and 5.22 [95% CI, 3.61 to 6.82]). With decreasing financial reserves, a clear dose-response relationship was present across all measures of well-being. These associations were also manifest for survivors reporting outcomes again at 1 year and persisted after adjustment for stage, comorbidity, insurance, and other clinical attributes.

CONCLUSION

Patients with cancer and limited financial reserves are more likely to have higher symptom burden and decreased QOL. Assessment of financial reserves may help identify patients who need intensive support.

Sociodemographic disparities in survival from colorectal cancer in South Australia: a population-wide data linkage study

BACKGROUND

Inequalities in survival from colorectal cancer (CRC) across socioeconomic groups and by area of residence have been described in various health care settings. Few population-wide datasets which include clinical and treatment information are available in Australia to investigate disparities. This study examines socio-demographic differences in survival for CRC patients in South Australia (SA), using a population-wide database derived via linkage of administrative and surveillance datasets.

METHODS

The study population comprised all cases of CRC diagnosed in 2003-2008 among SA residents aged 50-79 yrs in the SA Central Cancer Registry. Measures of socioeconomic status (area level), geographical remoteness, clinical characteristics, comorbid conditions, treatments and outcomes were derived through record linkage of central cancer registry, hospital-based clinical registries, hospital separations, and radiotherapy services data sources. Socio-demographic disparities in CRC survival were examined using competing risk regression analysis.

RESULTS

Four thousand six hundred and forty one eligible cases were followed for an average of 4.7 yrs, during which time 1525 died from CRC and 416 died from other causes. Results of competing risk regression indicated higher risk of CRC death with higher grade (HR high v low =2.25, 95% CI 1.32-3.84), later stage (HR C v A = 7.74, 95% CI 5.75-10.4), severe comorbidity (HR severe v none =1.21, 95% CI 1.02-1.44) and receiving radiotherapy (HR = 1.41, 95% CI 1.18-1.68). Patients from the most socioeconomically advantaged areas had significantly better outcomes than those from the least advantaged areas (HR =0.75, 95% 0.62-0.91). Patients residing in remote locations had significantly worse outcomes than metropolitan residents, though this was only evident for stages A-C (HR = 1.35, 95 % CI 1.01-1.80). These disparities were not explained by differences in stage at diagnosis between socioeconomic groups or area of residence. Nor were they explained by differences in patient factors, other tumour characteristics, comorbidity, or treatment modalities.

CONCLUSIONS

Socio-economic and regional disparities in survival following CRC are evident in SA, despite having a universal health care system. Of particular concern is the poorer survival for patients from remote areas with potentially curable CRC. Reasons for these disparities require further exploration to identify factors that can be addressed to improve outcomes.

Cumulative social risk exposure and risk of cancer mortality in adulthood

Background

Adults in the United States (U.S) can be simultaneously exposed to more than one social risk factor over their lifetime. However, cancer epidemiology tends to focus on single social risk factors at a time. We examined the prospective association between cumulative social risk exposure and deaths from cancer in a nationally representative sample of U.S. adults.

Methods

The study included 8745 adults (aged ≥ 40 years) in the NHANES Survey III Mortality Study over a median follow-up of 13.5 years (1988-1994 enrollment dates and 1988 through 2006 for mortality data). Social risk factors (low family income, low education level, minority race, and single-living status) were summed to create a cumulative social risk score (0 to ≥3). We used Cox proportional hazard models to estimate age- and sex-adjusted hazard ratios (HRs) and 95 % confidence intervals (95 % CI) for the association between cumulative social risk with deaths from all-cancers combined, tobacco-related cancers, and screening-detectable cancers.

Results

Deaths from all-cancers combined (P for trend = 0.001), tobacco-related cancers (P for trend = <0.001), and lung cancer (P for trend = 0.01) increased with an increasing number of social risk factors. As compared with adults with no social risk factors, those exposed to ≥3 social risk factors were at increased risk of deaths from all-cancers combined (HR = 1.8, 95 % CI = 1.3-2.4), tobacco-related cancers (HR = 2.6, 95 % CI: 1.6-4.0), and lung cancer (HR = 2.3, 95 % CI = 1.3-4.1).

Conclusions

U.S. adults confronted by higher amounts of cumulative social risk appear to have increased mortality from all-cancers combined, tobacco-related cancers, and lung cancer. An enhanced understanding of the cumulative effect of social risk factors may be important for targeting interventions to address social disparities in cancer mortality.

Characterization of the Hispanic or latino population in health research: a systematic review

The size and diversity of the Hispanic population in the United States has dramatically increased, with vast implications for health research. We conducted a systematic review of the characterization of the Hispanic population in health research and described its implications. Relevant studies were identified by searches of PubMed, Embase Scopus, and Science/Social Sciences Citation Index from 2000 to 2011. 131 articles met criteria. 56% of the articles reported only "Hispanic" or "Latino" as the characteristic of the Hispanic research population while no other characteristics were reported. 29% of the articles reported language, 27% detailed country of origin and 2% provided the breakdown of race. There is great inconsistency in reported characteristics of Hispanics in health research. The lack of detailed characterization of this population ultimately creates roadblocks in translating evidence into practice when providing care to the large and increasingly diverse Hispanic population in the US.

The Relationship Between Perceived Racism/Discrimination and Health Among Black American Women: a Review of the Literature from 2003 to 2013

OBJECTIVES

The purpose of this paper was to systematically review the literature investigating the relationship between perceived racism/discrimination and health among black American women.

METHODS

Searches for empirical studies published from January 2003 to December 2013 were conducted using PubMed and PsycInfo. Articles were assessed for possible inclusion using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 framework. In addition, the Agency for Healthcare Research and Quality (AHRQ) system for rating the strength of scientific evidence was used to assess the quality of studies included in the review.

RESULTS

Nineteen studies met criteria for review. There was mixed evidence for general relationships between perceived racism/discrimination and health. Consistent evidence was found for the relationship between adverse birth outcomes, illness incidence, and cancer or tumor risk and perceived racism/discrimination. Inconsistent findings were found for the relationship between perceived racism/discrimination and heart disease risk factors. There was no evidence to support the relationship between perceived racism/discrimination and high blood pressure.

CONCLUSIONS

There is mixed evidence to support the association between perceived racism/discrimination and overall objective health outcomes among black American women. The strongest relationship was seen between perceived racism/discrimination and adverse birth outcomes. Better understanding of the relationship between health and racism/discrimination can aid in identifying race-based risk factors developing primary prevention strategies. Future studies should aim to investigate the role of perceived racism/discrimination as a specific chronic stressor within discrete pathogenesis models.

Associations between patient-provider communication and socio-cultural factors in prostate cancer patients: a cross-sectional evaluation of racial differences

OBJECTIVE

To examine the association between socio-cultural factors and patient-provider communication and related racial differences.

METHODS

Data analysis included 1854 men with prostate cancer from a population-based study. Participants completed an assessment of communication variables, physician trust, perceived racism, religious beliefs, traditional health beliefs, and health literacy. A multi-group structural equation modeling approach was used to address the research aims.

RESULTS

Compared with African Americans, Caucasian Americans had significantly greater mean scores of interpersonal treatment (p<0.01), prostate cancer communication (p<0.001), and physician trust (p<0.001), but lower mean scores of religious beliefs, traditional health beliefs, and perceived racism (all p values <0.001). For both African and Caucasian Americans, better patient-provider communication was associated with more physician trust, less perceived racism, greater religious beliefs (all p-values <0.01), and at least high school education (p<0.05).

CONCLUSION

Socio-cultural factors are associated with patient-provider communication among men with cancer. No evidence supported associations differed by race.

PRACTICE IMPLICATION

To facilitate patient-provider communication during prostate cancer care, providers need to be aware of patient education levels, engage in behaviors that enhance trust, treat patients equally, respect religious beliefs, and reduce the difficulty level of the information.

Gender and social disparities in esophagus cancer incidence in Iran, 2003-2009: a time trend province-level study

BACKGROUND

Esophagus cancer (EC) is among the five most common cancers in both sexes in Iran, with an incidence rate well above world average. Social rank (SR) of individuals and regions are well-known independent predictors of EC incidence. The aim of current study was to assess gender and social disparities in EC incidence across Iran's provinces through 2003-2009.

MATERIALS AND METHODS

Data on distribution of population at province level were obtained from the Statistical Centre of Iran. Age-standardized incidence rates of EC were gathered from the National Cancer Registry. The Human Development Index (HDI) was used to assess the province social rank. Rate ratios and Kunst and Mackenbach relative indices of inequality (RIIKM) were used to assess gender and social inequalities, respectively. Annual percentage change (APC) was calculated using joinpoint regression.

RESULTS

EC incidence rate increased 4.6% and 6.5% per year among females and males, respectively. There were no gender disparities in EC incidence over the study period. There were substantial social disparities in favor of better-off provinces in Iran. These social disparities were generally the same between males and females and were stable over the study period.

CONCLUSIONS

The results showed an inverse association between the provinces' social rank and EC incidence rate in Iran. In addition, I found that, in contrast with international trends, women are at the same risk of EC as men in Iran. Further investigations are needed to explain these disparities in EC incidence across the provinces.

Associations of anthropometric factors with KRAS and BRAF mutation status of primary colorectal cancer in men and women: a cohort study

Obesity is a well-established risk factor for colorectal cancer (CRC), and accumulating evidence suggests a differential influence of sex and anthropometric factors on the molecular carcinogenesis of the disease. The aim of the present study was to investigate the relationship between height, weight, bodyfat percentage, waist- and hip circumference, waist-hip ratio (WHR), body mass index (BMI) and CRC risk according to KRAS and BRAF mutation status of the tumours, with particular reference to potential sex differences. KRAS and BRAF mutations were analysed by pyrosequencing in tumours from 494 incident CRC cases in the Malmö Diet and Cancer Study. Hazard ratios of CRC risk according to anthropometric factors and mutation status were calculated using multivariate Cox regression models. While all anthropometric measures except height were associated with an increased risk of KRAS-mutated tumours, only BMI was associated with an increased risk of KRAS wild type tumours overall. High weight, hip, waist, WHR and BMI were associated with an increased risk of BRAF wild type tumours, but none of the anthropometric factors were associated with risk of BRAF-mutated CRC, neither in the overall nor in the sex-stratified analysis. In men, several anthropometric measures were associated with both KRAS-mutated and KRAS wild type tumours. In women, only a high WHR was significantly associated with an increased risk of KRAS-mutated CRC. A significant interaction was found between sex and BMI with respect to risk of KRAS-mutated tumours. In men, all anthropometric factors except height were associated with an increased risk of BRAF wild type tumours, whereas in women, only bodyfat percentage was associated with an increased risk of BRAF wild type tumours. The results from this prospective cohort study further support an influence of sex and lifestyle factors on different pathways of colorectal carcinogenesis, defined by KRAS and BRAF mutation status of the tumours.

Social disparity in breast and ovarian cancer incidence in iran, 2003-2009: a time trend province-level study

Purpose

This pioneering study aimed to investigate social disparities in breast cancer (BC) and ovarian cancer (OC) incidence rates among women across Iran's provinces from 2003 to 2009.

Methods

Provincial level population distribution data pertaining to women were obtained from the Statistical Centre of Iran. Age-standardized incidence rates of BC and OC were gathered from the National Cancer Registry. Human Development Index was used as the provinces' social rank (SR), and rate ratio and Kunst and Mackenbach relative index of inequality were used to assess social disparities. Annual percentage change (APC) was calculated using joinpoint regression, and Spearman rank correlation was used to examine the association between APC and SR.

Results

It was found that over the study period, annual incidence rates rose by 11.6% and 9.7% for BC and OC, respectively. Social disparities were substantial and stable in favor of provinces with lower SR in Iran, and were more profound for BC than OC. Correlations between APC and SR were small and nonsignificant for both BC and OC.

Conclusion

The results showed that both BC and OC incidence increased in Iran during 2003 to 2009. There were positive associations between BC and OC incidence rates and the provinces' SR. This study's recommendations provide valuable information for health resource allocation pertaining to BC and OC control programs across provinces in Iran.

Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK

Background:

Not recognising a symptom as suspicious is a common reason given by cancer patients for delayed help-seeking; but inevitably this is retrospective. We therefore investigated associations between recognition of warning signs for breast, colorectal and lung cancer and anticipated time to help-seeking for symptoms of each cancer.

Methods:

Computer-assisted telephone interviews were conducted with a population-representative sample (N=6965) of UK adults age ⩾50 years, using the Awareness and Beliefs about Cancer scale. Anticipated time to help-seeking for persistent cough, rectal bleeding and breast changes was categorised as >2 vs ⩽2 weeks. Recognition of persistent cough, unexplained bleeding and unexplained lump as cancer warning signs was assessed (yes/no). Associations between recognition and help-seeking were examined for each symptom controlling for demographics and perceived ease of health-care access.

Results:

For each symptom, the odds of waiting for >2 weeks were significantly increased in those who did not recognise the related warning sign: breast changes: OR=2.45, 95% CI 1.47–4.08; rectal bleeding: OR=1.77, 1.36–2.30; persistent cough: OR=1.30, 1.17–1.46, independent of demographics and health-care access.

Conclusion:

Recognition of warning signs was associated with anticipating faster help-seeking for potential symptoms of cancer. Strategies to improve recognition are likely to facilitate earlier diagnosis.

Evaluation of a patient navigation program to promote colorectal cancer screening in rural Georgia, USA

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer death in the United States. Early detection through recommended screening has been shown to have favorable treatment outcomes, yet screening rates among the medically underserved and uninsured are low, particularly for rural and minority populations. This study evaluated the effectiveness of a patient navigation program that addresses individual and systemic barriers to CRC screening for patients at rural, federally qualified community health centers.

METHODS

This quasi-experimental evaluation compared low-income patients at average risk for CRC (n = 809) from 4 intervention clinics and 9 comparison clinics. We abstracted medical chart data on patient demographics, CRC history and risk factors, and CRC screening referrals and examinations. Outcomes of interest were colonoscopy referral and examination during the study period and being compliant with recommended screening guidelines at the end of the study period. We conducted multilevel logistic analyses to evaluate the program's effectiveness.

RESULTS

Patients at intervention clinics were significantly more likely than patients at comparison clinics to undergo colonoscopy screening (35% versus 7%, odds ratio = 7.9, P < .01) and be guideline-compliant on at least one CRC screening test (43% versus 11%, odds ratio = 5.9, P < .001).

CONCLUSIONS

Patient navigation, delivered through the Community Cancer Screening Program, can be an effective approach to ensure that lifesaving, preventive health screenings are provided to low-income adults in a rural setting.

Association between race, place, and preventive health screenings among men: findings from the exploring health disparities in integrated communities study

African American men consistently report poorer health and have lower participation rates in preventive screening tests than White men. This finding is generally attributed to race differences in access to care, which may be a consequence of the different health care markets in which African American and White men typically live. This proposition is tested by assessing race differences in use of preventive screenings among African American and White men residing within the same health care marketplace. Logistic regression was used to examine the association between race and physical, dental, eye and foot examinations, blood pressure and cholesterol checks, and colon and prostate cancer screenings in men in the Exploring Health Disparities in Integrated Communities in Southwest Baltimore Study. After adjusting for covariates, African American men had greater odds of having had a physical, dental, and eye examination; having had their blood pressure and cholesterol checked; and having been screened for colon and prostate cancer than White men. No race differences in having a foot examination were observed. Contrary to most findings, African American men had a higher participation rate in preventive screenings than White men. This underscores the importance of accounting for social context in public health campaigns targeting preventive screenings in men.

Differences in epidemiologic risk factors for colorectal adenomas and serrated polyps by lesion severity and anatomical site

Using a case-control design, we evaluated differences in risk factors for colorectal polyps according to histological type, anatomical site, and severity. Participants were enrollees in the Group Health Cooperative aged 20-79 years who underwent colonoscopy in Seattle, Washington, between 1998 and 2007 and comprised 628 adenoma cases, 594 serrated polyp cases, 247 cases with both types of polyps, and 1,037 polyp-free controls. Participants completed a structured interview, and polyps were evaluated via standardized pathology review. We used multivariable polytomous logistic regression to compare case groups with controls and with the other case groups. Factors for which the strength of the association varied significantly between adenomas and serrated polyps were sex (P < 0.001), use of estrogen-only postmenopausal hormone therapy (P = 0.01), and smoking status (P < 0.001). For lesion severity, prior endoscopy (P < 0.001) and age (P = 0.05) had significantly stronger associations with advanced adenomas than with nonadvanced adenomas; and higher education was positively correlated with sessile serrated polyps but not with other serrated polyps (P = 0.02). Statistically significant, site-specific associations were observed for current cigarette smoking (P = 0.05 among adenomas and P < 0.001 among serrated polyps), postmenopausal estrogen-only therapy (P = 0.01 among adenomas), and obesity (P = 0.01 among serrated polyps). These findings further illustrate the epidemiologic heterogeneity of colorectal neoplasia and may help elucidate carcinogenic mechanisms for distinct pathways.

Gender differences in colon cancer treatment

Abstract Background: Despite women suffering a disproportionate burden of colon cancer mortality, few studies have examined gender differences in evidence-based treatment, especially in poorer states like Alabama.

OBJECTIVE

To describe colon cancer treatment in older patients diagnosed in Alabama by gender.

METHODS

Colon cancer patients 65 years and older diagnosed in 2000-2002 were identified from the Alabama Statewide Cancer Registry (N=1785). Treatment was identified from Medicare claims for 1999-2003. Outcomes were (1) receipt of surgery and adjuvant 5-fluorouracil chemotherapy (5FU) and (2) 5FU treatment duration (0-4, 5-7, and >7 months). Generalized Estimating Equation (GEE) models were used to determine significant gender differences, adjusting for clustering at the reporting hospital level, and controlling for race, age, stage, comorbid conditions, census tract-level socioeconomic variables, and adverse chemotherapy effects (when analyzing 5FU duration).

RESULTS

Overall, 93.9% of the patients received surgery. Of stage II-III patients undergoing surgery, 60.4% stage III and 25.6% stage II patients received 5FU. Compared with men, women were more likely to have surgery (95.5% vs. 92.2%, p=0.003), less likely to have 5FU (38.6% vs. 45.2%, p=0.02), and more likely to have 0-4 months of 5FU (32.9% vs. 24.9%, p=0.05). Gender differences were significant for having chemotherapy (adjusted odds ratio [aOR] 0.78, confidence interval [CI] 0.61-1.00, p=0.049), but not for having 0-4 months of 5FU when adjusting for adverse effects (aOR 1.36, CI 0.95-1.94, p=0.09).

CONCLUSIONS

In Alabama, some gender differences in stage-specific colon cancer treatment are worth further scrutiny.

Influence of health insurance coverage on breast, cervical, and colorectal cancer screening in rural primary care settings

BACKGROUND

The current study was performed to determine, in rural settings, the relation between the type and status of insurance coverage and being up-to-date for breast, cervical, and colorectal cancer screening.

METHODS

Four primary care practices in 2 rural Oregon communities participated. Medical chart reviews that were conducted between October 2008 and August 2009 assessed insurance coverage and up-to-date status for breast, cervical, and colorectal cancer screening. Inclusion criteria involved having at least 1 health care visit within the past 5 years and being aged ≥ 55 years.

RESULTS

The majority of patients were women aged 55 years to 70 years, employed or retired, and who had private health insurance and an average of 2.5 comorbid conditions. The overall percentage of eligible women who were up-to-date for cervical cancer screening was 30%; approximately 27% of women were up-to-date for clinical breast examination, 37% were up-to-date for mammography, and 19% were up-to-date for both mammography and clinical breast examination. Approximately 38% of men and 35% of women were up-to-date for colorectal cancer screening using any test at appropriate screening intervals. In general, having any insurance versus being uninsured was associated with undergoing cancer screening. For each type of screening, patients who had at least 1 health maintenance visit were significantly more likely to be up-to-date compared with those with no health maintenance visits. A significant interaction was found between having health maintenance visits, having any health insurance, and being up-to-date for cancer screening tests.

CONCLUSIONS

Overall, the percentage of patients who were up-to-date for any cancer screening, especially cervical cancer screening, was found to be very low in rural Oregon. Patients with some form of health insurance were more likely to have had a health maintenance visit within the previous 2 years and to be up-to-date for breast, cervical, and/or colorectal cancer screening.

Effects of being uninsured or underinsured and living in extremely poor neighborhoods on colon cancer care and survival in California: historical cohort analysis, 1996-2011

Background

We examined the mediating effects of health insurance on poverty-colon cancer care and survival relationships and the moderating effects of poverty on health insurance-colon cancer care and survival relationships among women and men in California.

Methods

We analyzed registry data for 3,291 women and 3,009 men diagnosed with colon cancer between 1996 and 2000 and followed until 2011 on lymph node investigation, stage at diagnosis, surgery, chemotherapy, wait times and survival. We obtained socioeconomic data for individual residences from the 2000 census to categorize the following neighborhoods: high poverty (30% or more poor), middle poverty (5-29% poor) and low poverty (less than 5% poor). Primary health insurers were Medicaid, Medicare, private or none.

Results

Evidence of mediation was observed for women, but not for men. For women, the apparent effect of poverty disappeared in the presence of payer, and the effects of all forms of health insurance seemed strengthened. All were advantaged on 6-year survival compared to the uninsured: Medicaid (RR = 1.83), Medicare (RR = 1.92) and private (RR = 1.83). Evidence of moderation was also only observed for women. The effects of all forms of health insurance were stronger for women in low poverty neighborhoods: Medicaid (RR = 2.90), Medicare (RR = 2.91) and private (RR = 2.60). For men, only main effects of poverty and payers were observed, the advantaging effect of private insurance being largest. Across colon cancer care processes, Medicare seemed most instrumental for women, private payers for men.

Conclusions

Health insurance substantially mediates the quality of colon cancer care and poverty seems to make the effects of being uninsured or underinsured even worse, especially among women in the United States. These findings are consistent with the theory that more facilitative social and economic capital is available in more affluent neighborhoods, where women with colon cancer may be better able to absorb the indirect and direct, but uncovered, costs of care.

Multilevel interventions and racial/ethnic health disparities

To examine the impact of multilevel interventions (with three or more levels of influence) designed to reduce health disparities, we conducted a systematic review and meta-analysis of interventions for ethnic/racial minorities (all except non-Hispanic whites) that were published between January 2000 and July 2011. The primary aims were to synthesize the findings of studies evaluating multilevel interventions (three or more levels of influence) targeted at ethnic and racial minorities to reduce disparities in their health care and obtain a quantitative estimate of the effect of multilevel interventions on health outcomes among these subgroups. The electronic database PubMed was searched using Medical Subject Heading terms and key words. After initial review of abstracts, 26 published studies were systematically reviewed by at least two independent coders. Those with sufficient data (n = 12) were assessed by meta-analysis and examined for quality using a modified nine-item Physiotherapy Evidence Database coding scheme. The findings from this descriptive review suggest that multilevel interventions have positive effects on several health behavior outcomes, including cancer prevention and screening, as well improving the quality of health-care system processes. The weighted average effect size across studies for all health behavior outcomes reported at the individual participant level (k = 17) was odds ratio (OR) = 1.27 (95% confidence interval [CI] = 1.11 to 1.44); for the outcomes reported by providers or organizations, the weighted average effect size (k = 3) was OR = 2.53 (95% CI = 0.82 to 7.81). Enhanced application of theories to multiple levels of change, novel design approaches, and use of cultural leveraging in intervention design and implementation are proposed for this nascent field.

Gender differences in colorectal cancer incidence in the United States, 1975-2006

BACKGROUND

Gender differences have been documented among patients diagnosed with colorectal cancer (CRC). It is still not clear, however, how these differences have changed over the past 30 years and if these differences vary by geographic areas. We examined trends in CRC incidence between 1975 and 2006.

METHODS

The study population consisted of 373,956 patients ≥40 years diagnosed with malignant CRC between 1975 and 2006 who resided in one of the nine Surveillance, Epidemiology and End Results (SEER) regions of the United States. Age-adjusted incidence rates over time were reported by gender, race, CRC subsite, stage, and SEER region.

RESULTS

Overall, CRC was diagnosed in roughly equal numbers of men (187,973) and women (185,983). Men had significantly higher age-adjusted CRC incidence rates across all categories of age, race, tumor subsite, stage, and SEER region. Gender differences in CRC age-adjusted incidence rates widened slightly from 1975 to 1988, reached a peak in 1985-1988, and have narrowed over time since 1990. The largest gap and decline in CRC incidence rates between men and women were observed among those ≥80 years (p<0.001), followed by those 70-79 and then 60-69 years. Gender differences in CRC incidence rates for the 40-49 and 50-59 age categories were small and increased only slightly over time (p=0.003).

CONCLUSIONS

Higher CRC age-adjusted incidence among men than among women has persisted over the past 30 years. Although gender differences narrowed in the population ≥60 years, especially from 1990 to 2006, gender gaps, albeit small ones, in those younger than 60 increased over time. Future studies may need to examine the factors associated with these differences and explore ways to narrow the gender gap.

Shrinking, widening, reversing, and stagnating trends in US socioeconomic inequities in cancer mortality for the total, black, and white populations: 1960-2006

OBJECTIVES OF STUDY

To test recent claims that cancer inequities are bound to increase as population health improves.

METHODS

We analyzed 1960-2006 age-standardized US county cancer mortality data, total and site-specific (lung, prostate, colorectal, breast, cervix, stomach), stratified by county income quintile for the US total, black, and white populations.

RESULTS

Between 1960 and 2006, US socioeconomic inequities in cancer mortality variously shrunk, widened, reversed, and stagnated, depending on time period and cancer site. For all cancers combined and most, but not all, sites, absolute, but not relative, socioeconomic gaps were greater for the black compared to white population. Compared to the yearly age-specific mortality rates among whites in the most affluent counties, the percent of excess cancer deaths among whites in the lower four county income quintiles first rose above 0 in 1990 and in 2006 equaled 5.4% (95% CI 4.8, 6.0); among blacks, it rose from 6.0% (95% CI 4.5, 7.4) in 1960 to 24.7% (95% CI 23.9, 25.5) in 1990 and remained at this level through 2006.

CONCLUSIONS

The hypothesis that cancer mortality inequities are bound to increase is refuted by long-term data on total and site-specific cancer mortality stratified by socioeconomic position and race/ethnicity.

Educational level and risk of colorectal cancer in EPIC with specific reference to tumor location

Existing evidence is inconclusive on whether socioeconomic status (SES) and educational inequalities influence colorectal cancer (CRC) risk, and whether low or high SES/educational level is associated with developing CRC. The aim of our study was to investigate the relationship between educational level and CRC. We studied data from 400,510 participants in the EPIC (European Prospective Investigation into Cancer and Nutrition) study, of whom 2,447 developed CRC (colon: 1,551, rectum: 896, mean follow-up 8.3 years). Cox proportional hazard regression analysis stratified by age, gender and center, and adjusted for potential confounders were used to estimate hazard ratios (HR) and 95% confidence intervals (95%CI). Relative indices of inequality (RII) for education were estimated using Cox regression models. We conducted separate analyses for tumor location, gender and geographical region. Compared with participants with college/university education, participants with vocational secondary education or less had a nonsignificantly lower risk of developing CRC. When further stratified for tumor location, adjusted risk estimates for the proximal colon were statistically significant for primary education or less (HR 0.73, 95%CI 0.57-0.94) and for vocational secondary education (HR 0.76, 95%CI 0.58-0.98). The inverse association between low education and CRC risk was particularly found in women and Southern Europe. These associations were statistically significant for CRC, for colon cancer and for proximal colon cancer. In conclusion, CRC risk, especially in the proximal colon, is lower in subjects with a lower educational level compared to those with a higher educational level. This association is most pronounced in women and Southern Europe.

Psychosocial determinants of socioeconomic inequalities in cancer screening participation: a conceptual framework

Cancer screening participation shows a strong, graded association with socioeconomic status (SES) not only in countries such as the United States, where insurance status can be a barrier for lower income groups, but also in the United Kingdom, where the National Health Service provides all health care to residents, including screening, for free. Traditionally, the literature on socioeconomic inequalities has focused on upstream factors, but more proximal (downstream) influences on screening participation also need to be examined, particularly those that address the graded nature of the association rather than focusing specifically on underserved groups. This review offers a framework that links some of the components and corollaries of SES (life stress, educational opportunities, illness experience) to known psychosocial determinants of screening uptake (beliefs about the value of early detection, fatalistic beliefs about cancer, self-efficacy). The aim is to explain why individuals from lower SES backgrounds perceive cancer screening tests as more threatening, more difficult to accomplish, and less beneficial. A better understanding of the mechanisms through which lower SES causes negative attitudes toward screening could facilitate the development of intervention strategies to reduce screening inequalities.

Presence and correlates of racial disparities in adherence to colorectal cancer screening guidelines

OBJECTIVES

We examined the presence and correlates of Black/White racial disparities in adherence to guidelines for colorectal cancer screening (CRCS).

METHODS

The sample included 328 Black and 1827 White patients age 50-75 from 24 VA medical facilities who responded to a mailed survey with phone follow-up (response rate: 73% for Blacks and 89% for Whites). CRCS adherence and race were obtained through surveys and supplemented with administrative data. Logistic regressions estimated the contribution of demographic, health, cognitive, and environmental factors to racial disparities in adherence to CRCS guidelines.

RESULTS

In unadjusted analyses, Blacks had slightly lower rates of adherence to CRCS guidelines than Whites (72% versus 77%, p<0.05). This racial disparity in CRCS adherence was explained by race differences in demographic, health, and environmental factors but not by cognitive factors. Tests for interactions revealed that the association of race with adherence varied significantly across levels of income, education, and marital status. In particular, among those who were married with higher levels of education, CRCS adherence was significantly higher for Whites; whereas among those who were unmarried, with low levels of education, adherence was significantly higher for Blacks.

CONCLUSION

We found that disparities in CRCS are greatly attenuated in the VA system and both Whites and Blacks have substantially higher rates of CRCS than the national average. These results point to the success of the VA at implementing CRCS system-wide. Our findings also suggest additional initiatives may be needed for unmarried low income white men and higher income black men.

Socioeconomic status and changing inequalities in colorectal cancer? A review of the associations with risk, treatment and outcome

BACKGROUND

Upcoming mass screening for colorectal cancer (CRC) makes a review of recent literature on the association with socioeconomic status (SES) relevant, because of marked and contradictory associations with risk, treatment and outcome.

METHODS

The Pubmed database using the MeSH terms 'Neoplasms' or 'Colorectal Neoplasms' and 'Socioeconomic Factors' for articles added between 1995 and 1st October 2009 led to 62 articles.

RESULTS

Low SES groups exhibited a higher incidence compared with high SES groups in the US and Canada (range risk ratio (RR) 1.0-1.5), but mostly lower in Europe (RR 0.3-0.9). Treatment, survival and mortality all showed less favourable results for people with a lower socioeconomic status: Patients with a low SES received less often (neo)adjuvant therapy (RR ranging from 0.4 to 0.99), had worse survival rates (hazard ratio (HR) 1.3-1.8) and exhibited generally the highest mortality rates up to 1.6 for colon cancer in Europe and up to 3.1 for rectal cancer.

CONCLUSIONS

A quite consistent trend was observed favouring individuals with a high SES compared to those with a low SES that still remains in terms of treatment, survival and thus also mortality. We did not find evidence that the low/high SES gradients for treatment chosen and outcome are decreasing. To meet increasing inequalities in mortality from CRC in Europe for people with a low SES and to make mass screening successful, a high participation rate needs to be realised of low SES people in the soon starting screening program.

Association of area socioeconomic status and breast, cervical, and colorectal cancer screening: a systematic review

BACKGROUND

Although numerous studies have examined the association of area socioeconomic status (SES) and cancer screening after controlling for individual SES, findings have been inconsistent. A systematic review of existing studies is timely to identify conceptual and methodologic limitations and to provide a basis for future research directions and policy.

OBJECTIVE

The objectives were to (a) describe the study designs, constructs, methods, and measures; (b) describe the independent association of area SES and cancer screening; and (c) identify neglected areas of research.

METHODS

We searched six electronic databases and manually searched cited and citing articles. Eligible studies were published before 2008 in peer-reviewed journals in English, represented primary data on individuals ages > or = 18 years from developed countries, and measured the association of area and individual SES with breast, cervical, or colorectal cancer screening.

RESULTS

Of 19 eligible studies, most measured breast cancer screening. Studies varied widely in research design, definitions, and measures of SES, cancer screening behaviors, and covariates. Eight employed multilevel logistic regression, whereas the remainder analyzed data with standard single-level logistic regression. The majority measured one or two indicators of area and individual SES; common indicators at both levels were poverty, income, and education. There was no consistent pattern in the association between area SES and cancer screening.

DISCUSSION

The gaps and conceptual and methodologic heterogeneity in the literature to date limit definitive conclusions about an underlying association between area SES and cancer screening. We identify five areas of research deserving greater attention in the literature.

Healthcare access, socioeconomic factors and late-stage cancer diagnosis: an exploratory spatial analysis and public policy implication

Patients diagnosed with late-stage cancer have lower survival rates than those with early-stage cancer. This paper examines possible associations between several risk factors and late-stage diagnosis for four types of cancer in Illinois: breast cancer, prostate cancer, colorectal cancer, and lung cancer. Potential risk factors are composed of spatial factors and nonspatial factors. The spatial factors include accessibility to primary healthcare and distance or travel time to the nearest cancer screening facility. A set of demographic and socioeconomic variables are consolidated into three nonspatial factors by factor analysis. The Bayesian model with convolution priors is utilised to analyse the relationship between the above risk factors and each type of late-stage cancer while controlling for spatial autocorrelation. The results for breast cancer suggest that people living in neighbourhoods with socioeconomic disadvantages and cultural barriers are more likely to be diagnosed at a late stage. In regard to prostate cancer, people in regions with low socioeconomic status are also more likely to be diagnosed at a late stage. Diagnosis of late-stage colorectal or lung cancer is not significantly associated with any of the abovementioned risk factors. The results have important implications in public policy.

Socioeconomic deprivation adversely affects survival of patients with rectal cancer

Background

The aim was to examine the influence of socioeconomic deprivation on stage at presentation, perioperative mortality, permanent stoma rates and overall survival in patients with rectal cancer.

Methods

Data on patient demographics, mode and stage of presentation, and short- and longer-term outcomes were extracted from a database of patients with rectal cancer. Comparisons were made after stratification into quintiles of socioeconomic deprivation.

Results

In total 486 patients were identified. Fewer patients from the most deprived group than from the least deprived group underwent resectional surgery (79·2 versus 93 per cent; P = 0·005). Permanent stoma rates among patients who had surgery were 40·8 and 30 per cent respectively (P = 0·110). The overall 5-year survival rate was 32·8 per cent for the most deprived compared with 64·0 per cent for the least deprived patients (P &lt; 0·001). Respective rates for those who underwent resectional surgery were 49·9 and 72 per cent (P = 0·030).

Conclusion

In rectal cancer, socioeconomic deprivation appears to be associated with poorer outcomes and survival. This has important implications for healthcare planning.

Socioeconomic inequalities in cancer survival in New Zealand: the role of extent of disease at diagnosis

We examined socioeconomic inequalities in cancer survival in New Zealand among 132,006 people ages 15 to 99 years who had a cancer registered (1994-2003) and were followed up to 2004. Relative survival rates (RSR) were calculated using deprivation-specific life tables. A census-based measure of socioeconomic position (New Zealand deprivation based on the 1996 census) based on residence at the time of cancer registration was used. All RSRs were age-standardized, and further standardization was used to investigate the effect of extent of disease at diagnosis on survival. Weighted linear regression was used to estimate the deprivation gap (slope index of inequality) between the most and least deprived cases. Socioeconomic inequalities in cancer survival were evident for all of the major cancer sites, with the deprivation gap being particularly high for prostate (-0.15), kidney and uterus (both -0.14), bladder (-0.12), colorectum (-0.10), and brain (+0.10). Accounting for extent of disease explained some of the inequalities in survival from breast and colorectal cancer and melanoma and all of the deprivation gaps in survival of cervical cancer; however, it did not affect RSRs for cancers of the kidney, uterus, and brain. No substantial differences between the total compared with the non-Māori population were found, indicating that the findings were not due to confounding by ethnicity. In summary, socioeconomic disparities in survival were consistent for nearly all cancer sites, persisted in ethnic-specific analyses, and were only partially explained by differential extent of disease at diagnosis. Further investigation of reasons for persisting inequalities is required.

Influence of patient-provider communication on colorectal cancer screening

BACKGROUND

Screening reduces incidence and mortality from colorectal cancer (CRC). Despite improved access, screening is suboptimal and disparate among minority groups. Quality of patient-provider communication may impact CRC screening.

OBJECTIVES

We examined the relationship between patient-provider communication and socioeconomic variables on the receipt of CRC screening using data from the Medical Expenditure Panel Survey.

SUBJECTS

All persons age 50 years or older (N = 8488).

MEASURES

Dependent measures were receipt of CRC screening, fecal occult blood testing, and colonoscopy or sigmoidoscopy. Independent variables included demographic characteristics, patient language, and patient-provider communication measures from the Consumer Assessment of Health Plan survey.

RESULTS

Patients who felt they had sufficient time with their healthcare provider were more likely to be screened for CRC. Receiving adequate explanation of healthcare needs from provider was a significant predictor of fecal occult blood testing screening. In addition, persons with less than a high school education, the uninsured, or those with low income were associated with reduced likelihood of receiving CRC screening. Asians and Hispanics had a significantly reduced likelihood of receiving screening in comparison with whites; however, after adjusting for language, no significant differences for race or ethnicity were observed.

CONCLUSIONS

Adequate time with a healthcare provider and receiving sufficient explanation of the healthcare processes by providers may improve screening rates. Patient-provider communication may be improved by addressing language needs of non-English speaking patients. Overall improved communication may increase CRC screening rates in underserved populations.