Disparities across the breast cancer continuum

Cost of ovarian cancer by the phase of care in the United States

BACKGROUND

Ovarian cancer is associated with delayed diagnosis and poor survival; thus, interest is high in identifying predictive and prognostic biomarkers and novel therapeutic agents. Although the costs of ovarian cancer care are likely to increase as newer, more effective, but more expensive treatment regimens become available, information on the current costs of care for ovarian cancer-across the care continuum from diagnosis to the end of life-are lacking.

OBJECTIVE

This study aimed to estimate real-world mean and median costs of ovarian cancer care within the first 5 years after diagnosis by patients' phase of care, age, race/ethnicity, and geographic region.

STUDY DESIGN

We performed a retrospective cohort study of ovarian cancer patients diagnosed between January 1, 2015 and December 31, 2020. We used claims data from Optum's deidentified Clinformatics Data Mart database, which includes inpatient, outpatient, and prescription claims for commercial insurance and Medicare beneficiaries nationwide. Cost of ovarian cancer care were calculated for the start of care (ie, the first 6 months), continuing care (ie, period between the initial and end-of-life care), and end-of-life care (ie, the last 6 months) phases and reported in 2021 U.S. dollar amounts. Ovarian cancer care costs were stratified by age, race/ethnicity, and geographic region. Due to the skewed nature of cost data, the mean cost data were log-transformed for modeling. Ordinary least-squares regression was conducted on the log costs, adjusting for patient categorical age, race/ethnicity, and geographic region.

RESULTS

A total of 7913 patients were included in the analysis. The mean cost per year for ovarian cancer care was >$200,000 during the start of care, between $26,000 and $88,000 during the continuing care phase, and >$129,000 during the end-of-life care phase. There were statistically significant associations between age and costs during each phase of care. Compared to younger patients, older patients incurred higher costs during the continuing care phase and lower costs during the end-of-life care phase. Geographic differences in the costs of ovarian cancer care were also noted regardless of the phase of care. There were no associations between cost and race/ethnicity in our cohort.

CONCLUSION

Ovarian cancer care costs are substantial and vary by the phase of care, age category, and geographic region. As more effective but expensive treatment options for ovarian cancer become available with potential survival benefit, sustainable interventions to reduce the cost of care for ovarian cancer will be needed throughout the cancer care continuum.

Addressing Breast Cancer Disparities: A Comprehensive Approach to Health Equity

This article addresses the persistent disparities in breast cancer outcomes across different racial, ethnic, and socioeconomic groups despite advancements in diagnosis and treatment. The disparities are rooted in various factors, including access to care, socioeconomic status, and cultural barriers. The article emphasizes the need for targeted interventions, such as expanding insurance coverage, mobile mammography units, and culturally tailored outreach programs to promote health equity. Achieving this requires comprehensive strategies addressing systemic and social determinants of health.

Effectiveness of a Breast Cancer Education Screening and NavigaTion (BEST) Intervention among Hispanic Women

BACKGROUND

In the United States, breast cancer remains one of the most diagnosed cancers among females and remains the second leading cause of cancer death. In addition, breast cancer is most likely diagnosed at an advanced stage among Hispanic females in the United States due to lower mammogram utilization.

AIMS

The objective of this study was to determine the effectiveness of a multilevel, multicomponent community-based breast cancer screening intervention called the Breast Cancer Education Screening and NavigaTion (BEST) program. The primary outcome was the completion of a screening mammogram 4 months post-intervention.

METHOD

We used a pragmatic approach for evaluation, utilizing a quasi-experimental delayed intervention design. We recruited women from the community aged between 50 and 75, uninsured or underinsured, and overdue for screening.

RESULTS

Six hundred participants were recruited (300 intervention and 300 control). Among completers, the screening rate was 97% in the intervention group and 4.4% in the control group (RR = 22.2, 95% CI: 12.5-39.7, p < .001). In multivariable analysis, age ≥ 65 (RR = 1.29, p = .047), perceived benefits (RR = 1.04, p = .026), curability (RR = 1.24, p < .001), subjective norms (RR = 1.14, p = .014), and fatalism (RR = .96, p = .004) remained significantly associated with screening outcome.

CONCLUSION

A multicomponent, bilingual, and culturally tailored intervention effectively facilitated breast cancer screening completion in an underserved population of Hispanic women. Individuals with improved screening outcomes were more likely to have higher positive beliefs. Our study has important implications regarding using multicomponent interventions in increasing breast cancer screening completion in poorly screened populations. It also highlights differences in health belief motivation for breast cancer screening completion.

Navigating the cancer care continuum: A comparative study of Black and White breast cancer patients

Despite improvements in early detection and therapeutic interventions, the mortality rate for Black breast cancer patients is still significantly higher than that of White breast cancer patients. This study seeks to understand differences in the patient experience that lead to this disparity. Semi-structured interviews were conducted to understand the breast cancer treatment process and patient experiences. This study collected health services and timeline data from medical records. Based on these two data sources, the patient's journey in breast cancer treatment was mapped and a thematic analysis was conducted to identify challenges and barriers in the process. The cancer care continuum consists of four stages-diagnosis, surgery, chemotherapy/radiation, and follow-up care. The themes contributing to patient experiences and challenges were identified and compared in each stage for both Black and White patients. Both Black and White participants faced challenges related to financial constraints, treatment changes, lack of autonomy, and insufficient emotional support. However, Black participants additionally faced significant barriers in terms of cultural concordance, effective patient-provider communication, and delay in diagnosis. This study highlights the importance of incorporating effective provider-patient communication, navigation, and emotional support, especially for Black breast cancer patients throughout the cancer care continuum to address healthcare disparities.

Understanding and tackling cancer inequities: What opportunities does intersectionality offer researchers, policymakers, and providers? A scoping review

PROBLEM IDENTIFICATION

We summarised the international evidence relating to the role of intersectionality in patients' lived experience of inequities along the cancer care pathway. We produced guidance to use intersectionality in future research.

LITERATURE SEARCH

We included 42 articles published between 1989 to 2023 that used intersectionality to guide the study and interpretation of inequities in cancer care.

DATA EVALUATION/SYNTHESIS

Articles predominantly comprised North American (n = 37), followed by European (n = 4) and Asian (n = 1) studies. Similar compounding effects of racism, homophobia, and discrimination across countries exacerbated inequities in cancer care experience and cancer outcomes particularly for women of color and sexual/gender minority groups. Professionals' knowledge, attitudes, and behaviors toward minoritised groups affected patient-provider relationships and influenced cancer patients' psychosocial responses.

CONCLUSION

Intersectionality provides a framework to assess the personal, interpersonal, and structural processes through which cancer inequities manifest within and across countries.

The Impact of COVID-19 on Breast Cancer Care: A Qualitative Analysis of Surgeons' Perspectives

INTRODUCTION

While studies have documented delays in breast cancer (BC) care during the COVID-19 pandemic due to healthcare restrictions, there have been no studies on the experiences, and, particularly, the challenges with providing care faced by breast surgeons during this unprecedented time. This paper aims to understand the perspectives of breast surgeons regarding the impact of the COVID-19 pandemic on BC care.

METHODS

We used purposeful and snowball sampling to identify breast surgeons in Ontario, Canada. One-on-one qualitative semi-structured interviews were conducted exploring the impact of the pandemic on BC treatment, psychosocial well-being of patients and providers, and the future state of BC care. Audio-recorded interviews were transcribed verbatim and analyzed using Thematic Analysis.

RESULTS

A total of 10 breast surgeons (5 community and 5 academic) were interviewed. Breast surgeons reported that the pandemic led to increased multidisciplinary collaboration and innovations in delivery of BC surgery (e.g., increased use of regional anesthesia). Multiple surgeons identified that the pandemic created disparities in BC care based geographic location and that existing disparities in care based on ethnicity or marginalization were exacerbated. Last, surgeons identified that virtual care improved, but also created some challenges to how BC care was delivered, with many hoping for this to be continued after the pandemic was over.

CONCLUSIONS

In this study, breast surgeons identified unique challenges and solutions to BC care delivery during the pandemic. Concerns regarding disparities in care based on geographic location and marginalized patients require further study to improve future BC care.

"Should I Prioritize My Cancer or My Diabetes?": Patient-Perceived Barriers to Co-Managing Cancer and Diabetes Mellitus

Among patients with cancer, diabetes mellitus (DM) is a prevalent comorbid condition. With an aging population and an increase in the prevalence of cancer and DM, the number of cancer patients with DM will rise. To date, studies have largely focused on understanding the context of cancer and DM co-management from the perspectives of oncology and primary care providers. To better understand the potential barriers to optimal cancer and DM co-management, we conducted 17 semi-structured interviews with DM patients receiving cancer care at New York-Presbyterian Weill Cornell Medical Center outpatient oncology clinics in New York, NY. In total, 53% patients were female, 35% were non-White, and the mean age was 64.75 (SD 11.10) years. We qualitatively analyzed our data and identified the following nine themes: (1) patients develop DM during or after cancer treatment; (2) patients do not know about the possible interactions between DM and cancer treatment; (3) cancer care is prioritized over DM management; (4) severity of DM symptoms drive patients' DM self-management during cancer care; (5) impact of cancer treatment on quality of life; (6) demands from cancer care make DM management more difficult; (7) patients want individualized treatment plans that integrate DM and cancer co-management; (8) need for greater patient activation; (9) lack of patient-centered educational resources on DM management during cancer care. Owing to these results, our findings highlight the need to increase patient engagement by developing and disseminating patient-centered educational resources on cancer and DM to improve self-management practices and patient outcomes.

Geographic and sociodemographic access to systemic anticancer therapies for secondary breast cancer: a systematic review

BACKGROUND

The review aimed to investigate geographic and sociodemographic factors associated with receipt of systemic anticancer therapies (SACT) for women with secondary (metastatic) breast cancer (SBC).

METHODS

Included studies reported geographic and sociodemographic factors associated with receipt of treatment with SACT for women > 18 years with an SBC diagnosis. Information sources searched were Ovid CINAHL, Ovid MEDLINE, Ovid Embase and Ovid PsychINFO. Assessment of methodological quality was undertaken using the Joanna Briggs Institute method. Findings were synthesised using a narrative synthesis approach.

RESULTS

Nineteen studies published between 2009 and 2023 were included in the review. Overall methodological quality was assessed as low to moderate. Outcomes were reported for treatment receipt and time to treatment. Overall treatment receipt ranged from 4% for immunotherapy treatment in one study to 83% for systemic anticancer therapies (unspecified). Time to treatment ranged from median 54 days to 95 days with 81% of patients who received treatment < 60 days. Younger women, women of White origin, and those women with a higher socioeconomic status had an increased likelihood of timely treatment receipt. Treatment receipt varied by geographical region, and place of care was associated with variation in timely receipt of treatment with women treated at teaching, research and private institutions being more likely to receive treatment in a timely manner.

CONCLUSIONS

Treatment receipt varied depending upon type of SACT. A number of factors were associated with treatment receipt. Barriers included older age, non-White race, lower socioeconomic status, significant comorbidities, hospital setting and geographical location. Findings should however be interpreted with caution given the limitations in overall methodological quality of included studies and significant heterogeneity in measures of exposure and outcome. Generalisability was limited due to included study populations. Findings have practical implications for the development and piloting of targeted interventions to address specific barriers in a socioculturally sensitive manner. Addressing geographical variation and place of care may require intervention at a commissioning policy level. Further qualitative research is required to understand the experience and of women and clinicians.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020196490.

Barriers and facilitators for breast cancer early diagnosis in an indigenous community in Mexico: voices of otomí women

BACKGROUND

Literature on barriers and facilitators for early detection of Breast Cancer (BC) among indigenous women is very scarce. This study aimed to identify barriers and facilitators for BC early diagnosis as perceived by women of the otomí ethnic group in Mexico.

METHODS

We performed an exploratory qualitative study. Data was collected in 2021 through three focus group interviews with 19 otomí women. The interview transcripts were analyzed using the constant comparison method and guided by a conceptual framework that integrates the Social Ecological Model (SEM), the Health Belief Model and the Institute of Medicine's Healthcare Quality Framework.

RESULTS

Barriers and facilitators were identified at several levels of the SEM. Among the main barriers reported by the study participants were: beliefs about illness, cancer stigma, cultural gender norms, access barriers to medical care, and mistreatment and discrimination by health care personnel. Our participants perceived as facilitators: information provided by doctors, social support, perceived severity of the disease and perceived benefits of seeking care for breast symptoms.

CONCLUSIONS

Healthcare policies need to be responsive to the particular barriers faced by indigenous women in order to improve their participation in early detection and early help-seeking of care for breast symptoms. Measures to prevent and eradicate all forms of discrimination in healthcare are required to improve the quality of healthcare provided and the trust of the indigenous population in healthcare practitioners.

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.

Clinical characteristics, racial inequities, and outcomes in patients with breast cancer and COVID-19: A COVID-19 and cancer consortium (CCC19) cohort study

Background

Limited information is available for patients with breast cancer (BC) and coronavirus disease 2019 (COVID-19), especially among underrepresented racial/ethnic populations.

Methods

This is a COVID-19 and Cancer Consortium (CCC19) registry-based retrospective cohort study of females with active or history of BC and laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection diagnosed between March 2020 and June 2021 in the US. Primary outcome was COVID-19 severity measured on a five-level ordinal scale, including none of the following complications, hospitalization, intensive care unit admission, mechanical ventilation, and all-cause mortality. Multivariable ordinal logistic regression model identified characteristics associated with COVID-19 severity.

Results

1383 female patient records with BC and COVID-19 were included in the analysis, the median age was 61 years, and median follow-up was 90 days. Multivariable analysis revealed higher odds of COVID-19 severity for older age (aOR per decade, 1.48 [95% CI, 1.32-1.67]); Black patients (aOR 1.74; 95 CI 1.24-2.45), Asian Americans and Pacific Islander patients (aOR 3.40; 95 CI 1.70-6.79) and Other (aOR 2.97; 95 CI 1.71-5.17) racial/ethnic groups; worse ECOG performance status (ECOG PS ≥2: aOR, 7.78 [95% CI, 4.83-12.5]); pre-existing cardiovascular (aOR, 2.26 [95% CI, 1.63-3.15])/pulmonary comorbidities (aOR, 1.65 [95% CI, 1.20-2.29]); diabetes mellitus (aOR, 2.25 [95% CI, 1.66-3.04]); and active and progressing cancer (aOR, 12.5 [95% CI, 6.89-22.6]). Hispanic ethnicity, timing, and type of anti-cancer therapy modalities were not significantly associated with worse COVID-19 outcomes. The total all-cause mortality and hospitalization rate for the entire cohort was 9% and 37%, respectively however, it varied according to the BC disease status.

Conclusions

Using one of the largest registries on cancer and COVID-19, we identified patient and BC-related factors associated with worse COVID-19 outcomes. After adjusting for baseline characteristics, underrepresented racial/ethnic patients experienced worse outcomes compared to non-Hispanic White patients.

Funding

This study was partly supported by National Cancer Institute grant number P30 CA068485 to Tianyi Sun, Sanjay Mishra, Benjamin French, Jeremy L Warner; P30-CA046592 to Christopher R Friese; P30 CA023100 for Rana R McKay; P30-CA054174 for Pankil K Shah and Dimpy P Shah; KL2 TR002646 for Pankil Shah and the American Cancer Society and Hope Foundation for Cancer Research (MRSG-16-152-01-CCE) and P30-CA054174 for Dimpy P Shah. REDCap is developed and supported by Vanderbilt Institute for Clinical and Translational Research grant support (UL1 TR000445 from NCATS/NIH). The funding sources had no role in the writing of the manuscript or the decision to submit it for publication.

Clinical trial number

CCC19 registry is registered on ClinicalTrials.gov, NCT04354701.

Overcoming barriers: Modelling the effect of potential future changes of organized breast cancer screening in Italy

OBJECTIVES

Organized breast cancer screening may not achieve its full potential due to organizational and cultural barriers. In Italy, two identified barriers were low attendance in Southern Italy and, in Italy as a whole, underscreening and overscreening in parts of the eligible population. The objective of this study was to identify potential changes to overcome these barriers and to quantify their costs and effects.

METHODS

To assess the impact of potential measures to improve breast cancer screening in Italy, we performed an evaluation of costs and effects for increasing adherence for Southern Italy and harmonizing screening intervals (biennial screening) for the whole of Italy, using an online tool (EU-TOPIA evaluation tool) based on the MIcrosimulation SCreening ANalysis (MISCAN) model.

RESULTS

Increasing adherence in Southern Italy through investing in mobile screening units has an acceptable cost-effectiveness ratio of €9531 per quality-adjusted life year gained. Harmonizing the screening interval by investing in measures to reduce opportunistic screening and simultaneously investing in mobile screening units to reduce underscreening is predicted to gain 1% fewer life-years, while saving 19% of total screening costs compared to the current situation.

CONCLUSIONS

Increasing adherence in Southern Italy and harmonizing the screening interval could result in substantial improvements at acceptable costs, or in the same benefits at lower costs. This example illustrates a systematic approach that can be easily applied to other European countries, as the online tools can be used by stakeholders to quantify effects and costs of a broad range of specific barriers, and ways to overcome them.

Gender, Racial and Ethnic Differences in Pathologic Response Following Neoadjuvant Chemotherapy for Bladder Cancer Patients

OBJECTIVE

To evaluate trends and racial variations of pathologic complete response (CR) in patients with muscle-invasive bladder cancer undergoing cystectomy.

MATERIALS AND METHODS

The National Cancer Database was queried for patients with non-metastatic muscle-invasive bladder cancer who underwent neoadjuvant chemotherapy and surgery. The primary endpoints, CR and mortality, were evaluated using the Cochran-Armitage test, multivariable regression, and Kaplan-Meier analyses.

RESULTS

The cohort comprised 9955 patients. Non-Hispanic Black (NHB) patients were younger (P < .001), had a higher clinical tumor (P < .001), and had higher clinical node (P = .029) stages at presentation. CR for non-Hispanic White (NHW), NHB, and Hispanic patients were 12.6%, 10.1%, and 11.8%, respectively (P = .030). There was a significant increase in CR trends for NHW patients (P < .001) and increases in NHB (P = .311) and Hispanic patients (P = .236). On multivariable analysis, NHW females had lower odds of achieving CR (odds ratio: 0.83, 95% CI: 0.71-0.97); however, NHB males (hazard ratio: 1.21, 1.01-1.44) and NHB females (hazard ratio: 1.25, 1.03-1.53) had higher overall mortality in adjusted analysis. Survival differences were not observed in patients who achieved CR, regardless of racial background; however, for those with residual disease, the 2-year survival probabilities were 60.7%, 62.5%, and 51.1% for NHW, HW, and NHB patients, respectively (log-rank P = .010).

CONCLUSION

Our findings revealed differences in chemotherapy response based on gender and race or ethnicity. The CR trends for all racial or ethnic groups increased over time. However, Black patients were found to have worse survival, particularly when residual disease was present. Clinical studies with more underrepresented minorities are needed to verify biological differences in response to neoadjuvant chemotherapy.

Social and racial inequalities in diabetes and cancer in the United States

Background

Cancer and diabetes are among the leading causes of morbidity and mortality worldwide. Several studies have reported diabetes as a risk factor for developing cancer, a relationship that may be explained by associated factors shared with both diseases such as age, sex, body weight, smoking, and alcohol consumption. Social factors referred to as social determinants of health (SDOH) were shown to be associated with the risk of developing cancer and diabetes. Despite that diabetes and social factors were identified as significant determinants of cancer, no studies examined their combined effect on the risk of developing cancer. In this study, we aim at filling this gap in the literature by triangulating the association between diabetes, indices of SDOH, and the risk of developing cancer.

Methods

We have conducted a quantitative study using data from the Behavioral Risk Factor Surveillance System (BRFSS), whereby information was collected nationally from residents in the United States (US) with respect to their health-related risk behaviors, chronic health conditions, and the use of preventive services. Data analysis using weighted regressions was conducted on 389,158 study participants.

Results

Our findings indicated that diabetes is a risk factor that increases the likelihood of cancer by 13% (OR 1.13; 95%CI: 1.05-1.21). People of White race had higher odds for cancer compared to African Americans (OR 0.44; 95%CI: 0.39-0.49), Asians (OR 0.27; 95%CI: 0.20-0.38), and other races (OR 0.56; 95%CI: 0.46-0.69). The indices of SDOH that were positively associated with having cancer encompassed unemployment (OR 1.78; 95%CI: 1.59-1.99), retirement (OR 1.54; 95%CI: 1.43-1.67), higher income levels with ORs ranging between 1.16-1.38, college education (OR 1.10; 95%CI: 1.02-1.18), college graduates (OR 1.31; 95%CI: 1.21-1.40), and healthcare coverage (OR 1.44; 95%CI: 1.22-1.71). On the other hand, the indices of SDOH that were protective against having cancer were comprised of renting a home (OR 0.86; 95%CI: 0.79-0.93) and never married (OR 0.73; 95%CI: 0.65-0.81).

Conclusion

This study offers a novel social dimension for the association between diabetes and cancer that could guide setting strategies for addressing social inequities in disease prevention and access to healthcare.

The social vulnerability index as a risk stratification tool for health disparity research in cancer patients: a scoping review

PURPOSE

The social vulnerability index (SVI), developed by the Centers for Disease Control and Prevention, is a novel composite measure encompassing multiple variables that correspond to key social determinants of health. The objective of this review was to investigate innovative applications of the SVI to oncology research and to employ the framework of the cancer care continuum to elucidate further research opportunities.

METHODS

A systematic search for relevant articles was performed in five databases from inception to 13 May 2022. Included studies applied the SVI to analyze outcomes in cancer patients. Study characteristics, patent populations, data sources, and outcomes were extracted from each article. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

In total, 31 studies were included. Along the cancer care continuum, five applied the SVI to examine geographic disparities in potentially cancer-causing exposures; seven in cancer diagnosis; fourteen in cancer treatment; nine in treatment recovery; one in survivorship care; and two in end-of-life care. Fifteen examined disparities in mortality.

CONCLUSION

In highlighting place-based disparities in patient outcomes, the SVI represents a promising tool for future oncology research. As a reliable geocoded dataset, the SVI may inform the development and implementation of targeted interventions to prevent cancer morbidity and mortality at the neighborhood level.

A scoping review of natural language processing of radiology reports in breast cancer

Various natural language processing (NLP) algorithms have been applied in the literature to analyze radiology reports pertaining to the diagnosis and subsequent care of cancer patients. Applications of this technology include cohort selection for clinical trials, population of large-scale data registries, and quality improvement in radiology workflows including mammography screening. This scoping review is the first to examine such applications in the specific context of breast cancer. Out of 210 identified articles initially, 44 met our inclusion criteria for this review. Extracted data elements included both clinical and technical details of studies that developed or evaluated NLP algorithms applied to free-text radiology reports of breast cancer. Our review illustrates an emphasis on applications in diagnostic and screening processes over treatment or therapeutic applications and describes growth in deep learning and transfer learning approaches in recent years, although rule-based approaches continue to be useful. Furthermore, we observe increased efforts in code and software sharing but not with data sharing.

Clinical Characteristics, Racial Inequities, and Outcomes in Patients with Breast Cancer and COVID-19: A COVID-19 and Cancer Consortium (CCC19) Cohort Study

Background

Limited information is available for patients with breast cancer (BC) and coronavirus disease 2019 (COVID-19), especially among underrepresented racial/ethnic populations.

Methods

This is a COVID-19 and Cancer Consortium (CCC19) registry-based retrospective cohort study of females with active or history of BC and laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection diagnosed between March 2020 and June 2021 in the US. Primary outcome was COVID-19 severity measured on a five-level ordinal scale, including none of the following complications, hospitalization, intensive care unit admission, mechanical ventilation, and all-cause mortality. Multivariable ordinal logistic regression model identified characteristics associated with COVID-19 severity.

Results

1,383 female patient records with BC and COVID-19 were included in the analysis, the median age was 61 years, and median follow-up was 90 days. Multivariable analysis revealed higher odds of COVID-19 severity for older age (aOR per decade, 1.48 [95% CI, 1.32 - 1.67]); Black patients (aOR 1.74; 95 CI 1.24-2.45), Asian Americans and Pacific Islander patients (aOR 3.40; 95 CI 1.70 - 6.79) and Other (aOR 2.97; 95 CI 1.71-5.17) racial/ethnic groups; worse ECOG performance status (ECOG PS ≥2: aOR, 7.78 [95% CI, 4.83 - 12.5]); pre-existing cardiovascular (aOR, 2.26 [95% CI, 1.63 - 3.15])/pulmonary comorbidities (aOR, 1.65 [95% CI, 1.20 - 2.29]); diabetes mellitus (aOR, 2.25 [95% CI, 1.66 - 3.04]); and active and progressing cancer (aOR, 12.5 [95% CI, 6.89 - 22.6]). Hispanic ethnicity, timing and type of anti-cancer therapy modalities were not significantly associated with worse COVID-19 outcomes. The total all-cause mortality and hospitalization rate for the entire cohort was 9% and 37%, respectively however, it varied according to the BC disease status.

Conclusions

Using one of the largest registries on cancer and COVID-19, we identified patient and BC related factors associated with worse COVID-19 outcomes. After adjusting for baseline characteristics, underrepresented racial/ethnic patients experienced worse outcomes compared to Non-Hispanic White patients.

Reporting on Race and Racial Disparities in Breast Cancer: The Neglect of Racism as a Driver of Inequitable Care

OBJECTIVE

This study reviews the surgical literature on racial disparities in breast cancer mortality, specifically evaluating the inclusion, justification, and discussion of race and ethnicity as a driver of disparities.

SUMMARY OF BACKGROUND DATA

The volume of research on racial disparities has increased over the past 2 decades, but we hypothesize that there is considerable variation in how race is contextualized, defined, and captured in the disparities literature, leading to its questionable validity and relevance as a covariate. Recent guidelines for reporting have been suggested, but not yet applied.

METHODS

A rubric was developed to evaluate the reporting of race and/or ethnicity. A systematic review (2010-2020) was performed to identify studies reporting on racial disparities in breast cancer surgery and mortality. We then evaluated these original articles based on key domains of race and/or ethnicity: justification for inclusion, formal definition, methodology used for classification, and type of racism contributing to disparity.

RESULTS

Of the 52 studies assessed, none provided a formal definition for race and/or ethnicity. A justification for the inclusion of race and/or ethnicity was provided in 71% of the studies. Although 81% of studies discussed at least 1 potential driver of observed racial disparities, only 1 study explicitly named racism as a driver of racial disparities.

CONCLUSIONS

Significant improvement in the reporting on racial disparities in breast cancer surgical literature is warranted. A more rigorous framework should be applied by both researchers and publishers in reporting on race, racial health disparities, and racism.

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.

Regional Disparities in the Use and Delivery of Adjuvant Radiation Therapy after Lumpectomy for Breast Cancer in the Medicare Population

Purpose

We examined radiation therapy (RT) use among patients with early-stage breast cancer and analyzed the contribution of patient, cancer, and regional factors to the likelihood of RT receipt across Health Service Areas.

Methods and Materials

We identified 13,176 patients aged 66 to 79 years in the Surveillance, Epidemiology, and End Results (SEER) Program-Medicare database who were diagnosed with lymph node-negative breast cancer in 2007 to 2011 and were treated with breast-conserving surgery. Patients were stratified as being at high risk or low risk for recurrence based on National Comprehensive Cancer Network Guidelines. Receipt of RT was studied with 5 modeling approaches to determine whether RT use and regional variation in its use changed based on the risk level of the cohort. Multivariable mixed-effects logistic regression was performed for each outcome. Choropleth maps were used to describe patterns of RT use.

Results

Among high-risk patients, 70.1% received RT, compared with 72.6% of low-risk patients (P = .002). Among patients receiving RT, 60.9% were classified as high-risk, compared with 63.0% of patients who did not receive RT (P = .002). In multivariable analyses, patients in all rural areas had lower odds of receiving RT compared with the entire cohort (odds ratio [OR], 0.73; P < .001) and had lower odds of being high-risk and receiving RT (OR, 0.69; P < .001). Black patients (OR, 0.73; P = .001) and Asian patients (OR, 0.74; P = .004) had decreased likelihood of receiving RT compared with the entire cohort. The regional interclass correlation coefficient (ICC) for the model predicting receipt of RT among all patients was 0.05 and among low-risk patients was 0.06. The regional ICC dropped to 0.02 for the model predicting being both high-risk and receiving RT among all patients.

Conclusions

We observed regional and racial and ethnic disparities in RT receipt among our cohort. Reassuringly, less regional variability was observed for RT receipt among those at high risk for recurrence. Future work is needed to understand the causes of these regional disparities to better serve patients who may benefit from treatment.

Disparities in the Management of Pediatric Breast Masses

INTRODUCTION

Disparities in surgical management have been documented across a range of disease processes. The objective of this study was to investigate sociodemographic disparities in young females undergoing excision of a breast mass.

METHODS

A retrospective study of females aged 10-21 y who underwent surgery for a breast lesion across eleven pediatric hospitals from 2011 to 2016 was performed. Differences in patient characteristics, workup, management, and pathology by race/ethnicity, insurance status, median neighborhood income, and urbanicity were evaluated with bivariate and multivariable regression analyses.

RESULTS

A total of 454 females were included, with a median age of 16 y interquartile range (IQR: 3). 44% of patients were nonHispanic (NH) Black, 40% were NH White, and 7% were Hispanic. 50% of patients had private insurance, 39% had public insurance, and 9% had other/unknown insurance status. Median neighborhood income was $49,974, and 88% of patients resided in a metropolitan area. NH Whites have 4.5 times the odds of undergoing preoperative fine needle aspiration or core needle biopsy compared to NH Blacks (CI: 2.0, 10.0). No differences in time to surgery from the initial imaging study, size of the lesion, or pathology were observed on multivariable analysis.

CONCLUSIONS

We found no significant differences by race/ethnicity, insurance status, household income, or urbanicity in the time to surgery after the initial imaging study. The only significant disparity noted on multivariable analysis was NH White patients were more likely to undergo preoperative biopsy than were NH Black patients; however, the utility of biopsy in pediatric breast masses is not well established.

Pain management practices for outpatients with breast cancer

Objectives

Methods

Results

Conclusions

•

One in four women office visits for breast cancer received pain medication prescriptions.

•

Among the patients receiving pain medications, one in seven women received opioids.

•

Both patient and provider characteristics contribute to variations in pain management in breast cancer patients.

Social Disparities of Pain and Pain Intensity Among Women Diagnosed With Early Stage Breast Cancer

Background

Breast cancer is one of the most commonly diagnosed cancers among women in the United States and pain is the most common side effect of breast cancer and its treatment. Yet, the relationships between social determinants of pain and pain experience/intensity remain under-investigated. We examined the associations between social determinants of pain both at the individual level and the neighborhood level to understand how social conditions are associated with pain perception among early stage breast cancer patients.

Methods

We conducted integrated statistical analysis of 1,191 women with early stage breast cancer treated at a large cancer center in Memphis, Tennessee. Combining electronic health records, patient-reported data and census data regarding residential address at the time of first diagnosis, we evaluated the relationships between social determinants and pain perception. Pain responses were self-reported by a patient as a numerical rating scale score at the patient’s initial diagnosis and follow-up clinical visits. We implemented two sets of statistical analyses of the zero-inflated Poisson model and estimated the associations between neighborhood poverty prevalence and breast cancer pain intensity. After adjustment for demographic characteristics, cancer stage, and chemotherapy, pain perception was significantly associated with poverty and blight level of the neighborhood.

Results

Among women living in the highest-poverty areas, the odds of reporting pain were 2.48 times higher than those in the lowest-poverty area. Women living in the highest-blight area had 5.43 times higher odds of reporting pain than those in the lowest-blight area. Neighborhood-level social determinants were significantly associated with pain intensity among women diagnosed with early-stage breast cancer.

Conclusions

Distressed neighborhood conditions are significantly associated with higher pain perception. Breast cancer patients living in socio-economically disadvantaged neighborhoods and in poor environmental conditions reported higher pain severity compared to patients from less distressed neighborhoods. Therefore, post-diagnosis pain treatment design needs to be tailored to the social determinants of the breast cancer patients.

Socio-economic Inequality of Utilization of Cancer Testing in Europe: A Cross-Sectional Study

There are currently screening programmes for breast, cervical and colorectal cancer in many European countries. However, the uptake of cancer screening in general may vary within and between countries. The aim of this study is to assess the inequalities in testing utilization by socio-economic status and whether the amount of inequality varies across European regions. We conducted an analysis based on cross-sectional data from the second wave of the European Health Interview Survey from 2013 to 2015. We analysed the use of breast, cervical, and colorectal cancer testing by socio-economic position (household income, educational level and employment status), socio-demographic factors, self-perceived health and smoking behaviour, by using multinomial logistic models, and inequality measurement based on the Slope index of inequality (SII) and Relative index of inequality (RII). The results show that the utilization of mammography (Odds Ratio (OR) = 0.55, 95% confidence interval (95%CI):0.50–0.61), cervical smear tests (OR = 0.60, 95%CI:0.56–0.65) and colorectal testing (OR = 0.82, 95%CI:0.78–0.86) was overall less likely among individuals within a low household income compared to a high household income. Also, individuals with a non-EU country of birth, low educational level and being unemployed (or retired) were overall less likely to be tested. The income-based inequality in breast (SII = 0.191;RII = 1.260) and colorectal testing utilization (SII = 0.161;RII = 1.487) was the greatest in Southern Europe. For cervical smears, this inequality was greatest in Eastern Europe (SII = 0.122;RII = 1.195). We concluded that there is considerable inequality in the use of cancer tests in Europe, with inequalities associated with household income, educational level, employment status, and country of birth.

Sociodemographic Characteristics as Predictors of Outcomes in Hepatocellular Carcinoma: A Retrospective Cohort Study

BACKGROUND

Race, gender, insurance status, and income play important roles in predicting health care outcomes. However, the impact of these factors has yet to be fully elucidated in the setting of hepatocellular carcinoma (HCC).

METHODS

We designed a retrospective cohort study utilizing data from the Surveillance, Epidemiology, and End Results (SEER) program to identify patients diagnosed with resectable HCC (N = 28,518). Demographic factors of interest included race (Asian/Pacific Islander [API], African American [AA], Native American/Alaska Native [NA], or White [WH]) and gender (male [M] or female [F]). Insurance classifications included those having Medicare/Private Insurance [ME/PI], Medicaid [MAID], or No Insurance [NI]. Median household income was estimated for all diagnosed with HCC. Endpoints included: (1) overall survival; (2) likelihood of receiving a recommendation for surgery; and (3) specific surgical intervention performed. Multivariate multinomial logistic regression for relative risk ratio (RRR) and Cox regression models were used to identify pertinent associations.

RESULTS

Race, gender, insurance status, and income had statistically significant effects on the likelihood of surgical recommendation and overall survival. API were more likely to receive a recommendation for hepatic resection (RRR = 1.45; 95% CI: 1.31-1.61; Reference Race: AA) and exhibited prolonged overall survival (HR = 0.77; 95% CI: 0.73-0.82; Reference Race: AA) as compared to members of any other ethnic group; there was no difference in these endpoints between AA, NA, or WH individuals. Gender also had a significant effect on survival: Females exhibited superior overall survival (HR = 0.89; 95% CI: 0.85-0.93; Reference Gender: M) as compared to males. Patients who had ME/PI were more likely than those with MAID or NI to receive a surgical recommendation. ME/PI was also associated with superior overall survival. Conclusions: Race, gender, insurance status, and income have measurable effects on HCC management and outcomes. The underlying causes of these disparities warrant further investigation.

Organized Breast and Cervical Cancer Screening: Attendance and Determinants in Southern Italy

Simple Summary

Although the effectiveness of screening in reducing the mortality of breast and cervical cancer in the EU is established, the impact of these cancers continues to be substantial among women. The aims of this study were to evaluate the attendance to breast and cervical cancer screening and the role of related determinants in an area of Southern Italy. Only 49.7% of the sample reported to have undergone mammography in the previous two years, 27.7% within an organized program and 22% as an opportunistic procedure. The attendance to cervical cancer screening interval of three years was reported by 56.1% of women, 16.1% within an organized program and 40% as an opportunistic procedure. A very low attendance was thus detected for both breast and cervical cancer organized screening programs. A strong commitment to the promotion of these programs is urgently needed, also to support their role in the reduction of inequalities of attendance of disadvantaged women.

Abstract

The aims of this study were to evaluate the attendance to breast and cervical cancer screening and the related determinants in a low attendance area. A cross-sectional study was conducted among mothers of students attending secondary schools and university courses in Campania region, Southern Italy. Only 49.7% of the eligible women reported to have undergone mammography in the previous two years. Unemployed women, unsatisfied about their health status, with a family history of breast cancer, and having visited a physician in the previous 12 months were significantly more likely to have undergone mammography in the previous two years within an organized screening program. The attendance to cervical cancer screening in the interval of three years was reported to be 56.1% of women. Having a lower than graduation degree, being smokers, and having visited a physician in the previous 12 months were significant predictors of having had a Pap-smear in the previous three years in an organized screening program. In this study a very low attendance was found to both breast and cervical cancer organized screening programs. A strong commitment to their promotion is urgently needed, also to reduce inequalities of attendance of disadvantaged women.

Associated Factors and Survival Outcomes for Breast Conserving Surgery versus Mastectomy among New Zealand Women with Early-Stage Breast Cancer

This study aimed to investigate type of loco-regional treatment received, associated treatment factors and mortality outcomes in New Zealand women with early-stage breast cancer who were eligible for breast conserving surgery (BCS). This is a retrospective analysis of prospectively collected data from the Auckland and Waikato Breast Cancer Registers and involves 6972 women who were diagnosed with early-stage primary breast cancer (I-IIIa) between 1 January 2000 and 31 July 2015, were eligible for BCS and had received one of four loco-regional treatments: breast conserving surgery (BCS), BCS followed by radiotherapy (BCS + RT), mastectomy (MTX) or MTX followed by radiotherapy (MTX + RT), as their primary cancer treatment. About 66.1% of women received BCS + RT, 8.4% received BCS only, 21.6% received MTX alone and 3.9% received MTX + RT. Logistic regression analysis was used to identify demographic and clinical factors associated with the receipt of the BCS + RT (standard treatment). Differences in the uptake of BCS + RT were present across patient demographic and clinical factors. BCS + RT was less likely amongst patients who were older (75+ years old), were of Asian ethnicity, resided in impoverished areas or areas within the Auckland region and were treated in a public healthcare facility. Additionally, BCS + RT was less likely among patients diagnosed symptomatically, diagnosed during 2000–2004, had an unknown tumour grade, negative/unknown oestrogen and progesterone receptor status or tumour sizes ≥ 20 mm, ≤50 mm and had nodal involvement. Competing risk regression analysis was undertaken to estimate the breast cancer-specific mortality associated with each of the four loco-regional treatments received. Over a median follow-up of 8.8 years, women who received MTX alone had a higher risk of breast cancer-specific mortality (adjusted hazard ratio: 1.38, 95% confidence interval (CI): 1.05–1.82) compared to women who received BCS + RT. MTX + RT and BCS alone did not have any statistically different risk of mortality when compared to BCS + RT. Further inquiry is needed as to any advantages BCS + RT may have over MTX alternatives.

Outcomes of Hormone-Receptor Positive, HER2-Negative Breast Cancers by Race and Tumor Biological Features

Background

Black women have higher hormone receptor positive (HR+) breast cancer mortality than White women. Early recurrence rates differ by race, but little is known about genomic predictors of early recurrence among HR+ women.

Methods

Using data from the Carolina Breast Cancer Study (phase III, 2008-2013), we estimated associations between race and recurrence among nonmetastatic HR+/HER2-negative tumors, overall and by PAM50 Risk of Recurrence score, PAM50 intrinsic subtype, and tumor grade using survival curves and Cox models standardized for age and stage. Relative frequency differences (RFD) were estimated using multivariable linear regression. To assess intervention opportunities, we evaluated treatment patterns by race among patients with high-risk disease.

Results

Black women had higher recurrence risk relative to White women (crude hazard ratio = 1.81, 95% confidence interval [CI] = 1.34 to 2.46), which remained elevated after standardizing for clinical covariates (hazard ratio = 1.42, 95% CI = 1.05 to 1.93). Racial disparities were most pronounced among those with high PAM50 Risk of Recurrence score (5-year standardized recurrence risk = 18.9%, 95% CI = 8.6% to 29.1% in Black women vs 12.5%, 95% CI = 2.0% to 23.0% in White women) and high grade (5-year standardized recurrence risk = 16.6%, 95% CI = 11.7% to 21.5% in Black women vs 12.0%, 95% CI = 7.3% to 16.7% in White women). However, Black women with high-grade tumors were statistically significantly less likely to initiate endocrine therapy (RFD = -8.3%, 95% CI = -15.9% to -0.6%) and experienced treatment delay more often than White women (RFD = +9.0%, 95% CI = 0.3% to 17.8%).

Conclusions

Differences in recurrence by race appear greatest among women with aggressive tumors and may be influenced by treatment differences. Efforts to identify causes of variation in cancer treatment are critical to reducing outcome disparities.

Can Regionalization of Care Reduce Socioeconomic Disparities in Breast Cancer Survival?

BACKGROUND

Breast cancer patients of low socioeconomic status (SES) have worse survival than more affluent women and are also more likely to undergo surgery in low-volume facilities. Since breast cancer patients treated in high-volume facilities have better survival, regionalizing the care of low SES patients toward high-volume facilities might reduce SES disparities in survival.

OBJECTIVE

We leverage a natural experiment in New York state to examine whether a policy precluding payment for breast cancer surgery for New York Medicaid beneficiaries undergoing surgery in low-volume facilities led to reduced SES disparities in mortality.

RESEARCH DESIGN

A multivariable difference-in-differences regression analysis compared mortality of low SES (dual enrollees, Medicare-Medicaid) breast cancer patients to that of wealthier patients exempt from the policy (Medicare only) for time periods before and after the policy implementation.

SUBJECTS

A total of 14,183 Medicare beneficiaries with breast cancer in 2006-2008 or 2014-2015.

MEASURES

All-cause mortality at 3 years after diagnosis and Medicaid status, determined by Medicare administrative data.

RESULTS

Both low SES and Medicare-only patients had better 3-year survival after the policy implementation. However, the decline in mortality was larger in magnitude among the low SES women than others, resulting in a 53% smaller SES survival disparity after the policy after adjustment for age, race, and comorbid illness.

CONCLUSION

Regionalization of early breast cancer care away from low-volume centers may improve outcomes and reduce SES disparities in survival.

Racial Differences in the Influence of Health Care System Factors on Informal Support for Cancer Care Among Black and White Breast and Lung Cancer Survivors

This retrospective, secondary qualitative analysis investigates whether health system factors influence social support among Black and white breast and lung cancer survivors and racial differences in support. These data come from race- and cancer-stratified focus groups (n = 6) and interviews (n = 2) to inform a randomized controlled trial utilizing antiracism and community-based participatory research approaches. Findings indicate social support was helpful for overcoming treatment-related challenges, including symptom management and patient-provider communication; racial differences in support needs and provision were noted. Resources within individual support networks reflect broader sociostructural factors. Reliance on family/friends to fill gaps in cancer care may exacerbate racial disparities.

Symptom Experience, Management, and Outcomes According to Race and Social Determinants Including Genomics, Epigenomics, and Metabolomics (SEMOARS + GEM): an Explanatory Model for Breast Cancer Treatment Disparity

Even after controlling for stage, comorbidity, age, and insurance status, black women with breast cancer (BC) in the USA have the lowest 5-year survival as compared with all other races for stage-matched disease. One potential cause of this survival difference is the disparity in cancer treatment, evident in many population clinical trials. Specifically, during BC chemotherapy, black women receive less relative dose intensity with more dose reductions and early chemotherapy cessation compared with white women. Symptom incidence, cancer-related distress, and ineffective communication, including the disparity in patient-centeredness of care surrounding patient symptom reporting and clinician assessment, are important factors contributing to racial disparity in dose reduction and early therapy termination. We present an evidence-based overview and an explanatory model for racial disparity in the symptom experience during BC chemotherapy that may lead to a reduction in dose intensity and a subsequent disparity in outcomes. This explanatory model, the Symptom Experience, Management, Outcomes and Adherence according to Race and Social determinants + Genomics Epigenomics and Metabolomics (SEMOARS + GEM), considers essential factors such as social determinants of health, clinician communication, symptoms and symptom management, genomics, epigenomics, and pharmacologic metabolism as contributory factors.

Healthcare system distrust and the breast cancer continuum of care

PURPOSE

To identify and synthesize the literature on healthcare system distrust across the breast cancer continuum of care.

METHODS

We searched CINAHL, Cochrane, EMBASE, PubMed, PsycINFO, and Web of Science from January 1, 1990 to December 31, 2018 for all peer-reviewed publications addressing the role of healthcare system trust, distrust or mistrust in the breast cancer continuum of care.

RESULTS

We identified a total of 20 studies, seven qualitative studies and thirteen quantitative studies. Two studies assessed genetic testing, eleven assessed screening and seven assessed treatment and follow-up. Twelve studies evaluated mistrust, five evaluated distrust, and three evaluated trust. Study populations included African American, American Indian, Latina, Hispanic, and Asian American participants.

CONCLUSION

Healthcare system distrust is prevalent across many different racial and ethnic groups and operates across the entire breast cancer continuum of care. It is an important yet understudied barrier to cancer. We hope that the knowledge garnered by this study will enable researchers to form effective and targeted interventions to reduce healthcare system distrust mediated disparities in breast cancer outcomes.

Integrating access to care and tumor patterns by race and age in the Carolina Breast Cancer Study, 2008-2013

PURPOSE

Understanding breast cancer mortality disparities by race and age is complex due to disease heterogeneity, comorbid disease, and the range of factors influencing access to care. It is important to understand how these factors group together within patients.

METHODS

We compared socioeconomic status (SES) and comorbidity factors in the Carolina Breast Cancer Study Phase 3 (CBCS3, 2008-2013) to those for North Carolina using the 2010 Behavioral Risk Factor Surveillance Study. In addition, we used latent class analysis of CBCS3 data to identify covariate patterns by SES/comorbidities, barriers to care, and tumor characteristics and examined their associations with race and age using multinomial logistic regression.

RESULTS

Major SES and comorbidity patterns in CBCS3 participants were generally similar to patterns in the state. Latent classes were identified for SES/comorbidities, barriers to care, and tumor characteristics that varied by race and age. Compared to white women, black women had lower SES (odds ratio (OR)  6.3, 95% confidence interval (CI) 5.2, 7.8), more barriers to care (OR 5.6, 95% CI 3.9, 8.1) and several aggregated tumor aggressiveness features. Compared to older women, younger women had higher SES (OR 0.5, 95% CI 0.4, 0.6), more barriers to care (OR 2.1, 95% CI 1.6, 2.9) and aggregated tumor aggressiveness features.

CONCLUSIONS

CBCS3 is representative of North Carolina on comparable factors. Patterns of access to care and tumor characteristics are intertwined with race and age, suggesting that interventions to address disparities will need to target both access and biology.

Socioeconomic determinants of cancer screening utilisation in Latin America: A systematic review

INTRODUCTION

Cancer incidence and mortality in Latin America are rising. While effective cancer screening services, accessible to the whole population and enabling early cancer detection are needed, existing research shows the existence of disparities in screening uptake in the region.

OBJECTIVE

We conducted a systematic review to investigate the socioeconomic determinants for the disparities in the use of breast, cervical and colorectal cancer screening services in Latin America.

METHODS

We searched for studies reporting on socioeconomic determinants impacting on access to breast, cervical and colorectal cancer screening, published from 2009 through 2018. The studies that qualified for inclusion contained original analyses on utilisation of breast, cervical and colorectal cancer screening across socioeconomic levels in Latin America. For each study, paired reviewers performed a quality analysis followed by detailed review and data extraction.

RESULTS

Twenty-four articles that met the eligibility criteria and were of sufficient quality were included in this review. Thirteen of the included articles were written in English, eight in Portuguese and three in Spanish, and they reported on the use of breast or cervical cancer screening. No studies were found on the socioeconomic determinants regarding the utilisation of colorectal cancer screening in Latin America. Low income, low education level, lack of health insurance and single marital status were all found to be determinants of underuse of breast and cervical cancer screening services.

CONCLUSIONS

Cancer screening programs in the region must prioritize reaching those populations that underuse cancer screening services to ensure equitable access to preventive services. It is important to develop national screening programmes that are accessible to all (including uninsured people) through, for example, the use of mobile units for mammography and self-screening methods.

A Comparison of Different Intensities of Patient Navigation After Abnormal Mammography

Background. Patient navigation is a practice strategy to address barriers to timely diagnosis and treatment of cancer. The aim of this study was to examine the effectiveness of varying intensities of patient navigation and timely diagnostic resolution after abnormal mammography. Method. This is a secondary analysis of a subset of women with an abnormal screening or diagnostic mammogram who participated in the "patient navigation in medically underserved areas" 5-year randomized trial. We compared timely diagnostic resolution in women assigned to different intensities of patient navigation including, full navigation intervention, no contact with navigators, or limited contact with navigators. Results. The sample included 1,725 women with abnormal mammogram results. Women who interacted with patient navigators had significantly fewer days to diagnostic resolution after abnormal mammography compared with women who did not interact with patient navigators. Discussion. Results from our study suggest that even limited contact with navigators encourages women to seek more timely diagnostic resolution after an abnormal mammogram, which may offer a low-cost practice strategy to improve timely diagnosis for disadvantaged and underserved women.

Community Empowerment Partners (CEPs): A Breast Health Education Program for African-American Women

Peer educators have been shown to provide effective interventions in breast cancer screening. Few studies have compared the effects of peer education on breast cancer knowledge among peer educators and the community members who are subsequently reached through the peer education. Further, little is known as to whether those who received the education then go on to educate others in the community. The purpose of this study is to address those gaps. Using a pre- and post-test study design, we trained peer educators, provided the educators with resources to train community members, and assessed changes in knowledge. We sought to train ten educators and recommended each train ten community members in breast cancer knowledge and screening strategies. A total of 14 peer educators were trained, who subsequently trained a total of 121 community members, of whom 94 were African American women. Peer educators and community members, showed comparable increases in knowledge. Community members who were educated also increased intention to discuss breast cancer and breast cancer screening with their family, friends, and acquaintances. Our study suggests that it is feasible to train peer educators to increase knowledge among community members to the same level that they themselves experience when trained. Further, community members are interested in sharing information learned related to how much they learn from peer educators.

Housing discrimination and racial cancer disparities among the 100 largest US metropolitan areas

BACKGROUND

Cancer contributes substantially to the life expectancy gap between US blacks and whites, and racial cancer disparities remain stubborn to eradicate. Disparities vary geographically, suggesting that they are not inevitable.

METHODS

The authors examined the relationship between housing discrimination and the size of cancer disparities across large US metropolitan statistical areas (MSAs). MSA-level cancer disparities were measured using data from the US Centers for Disease Control and Prevention. Mortgage discrimination for each MSA was estimated using the Home Mortgage Disclosure Act database, and MSA racial segregation was determined using US Census data. Patterns of housing discrimination and cancer disparities were mapped, and the associations between these place-based factors and cancer disparities across MSAs were measured.

RESULTS

Black-to-white cancer mortality disparities (rate ratios) varied geographically, ranging from 1.50 to 0.86; 88% of mortality ratios were >1, indicating higher mortality for blacks. In areas with greater mortgage discrimination, the gap between black and white cancer mortality rates was larger (correlation coefficient [r] = 0.32; P = .001). This relationship persisted in sex-specific analyses (males, r = 0.37; P < .001; females, r = 0.23; P = .02) and in models controlling for confounders. In contrast, segregation was inconsistently associated with disparities. Adjusting for incidence disparities attenuated, but did not eliminate, the correlation between mortgage discrimination and mortality disparities (r = 0.22-0.24), suggesting that cancer incidence and survival each account for part of the mortality disparity.

CONCLUSIONS

Mortgage discrimination is associated with larger black-to-white cancer mortality disparities. Some areas are exceptions to this trend. Examination of these exceptions and of policies related to housing discrimination may offer novel strategies for explaining and eliminating cancer disparities.

Health and Racial Disparity in Breast Cancer

Breast cancer is the most common noncutaneous malignancy and the second most lethal form of cancer among women in the United States. It currently affects more than one in ten women worldwide. The chance for a female to be diagnosed with breast cancer during her lifetime has significantly increased from 1 in 11 women in 1975 to 1 in 8 women (Altekruse, SEER Cancer Statistics Review, 1975-2007. National Cancer Institute, Bethesda, 2010). This chance for a female of being diagnosed with cancer generally increases with age (Howlader et al, SEER Cancer Statistics Review, 1975-2010. National Cancer Institute, Bethesda, 2013). Fortunately, the mortality rate from breast cancer has decreased in recent years due to increased emphasis on early detection and more effective treatments in the White population. Although the mortality rates have declined in some ethnic populations, the overall cancer incidence among African American and Hispanic population has continued to grow. The goal of the work presented in this book chapter is to highlight similarities and differences in breast cancer morbidity and mortality rates among non-Hispanic white and non-Hispanic black populations. This book chapter also provides an overview of breast cancer, racial/ethnic disparities in breast cancer, breast cancer incidence and mortality rate linked to hereditary, major risk factors of breast cancer among minority population, breast cancer treatment, and health disparity. A considerable amount of breast cancer treatment research have been conducted, but with limited success for African Americans compared to other ethnic groups. Therefore, new strategies and approaches are needed to promote breast cancer prevention, improve survival rates, reduce breast cancer mortality, and ultimately improve the health outcomes of racial/ethnic minorities. In addition, it is vital that leaders and medical professionals from minority population groups be represented in decision-making in research so that racial disparity in breast cancer can be well-studied, fully addressed, and ultimately eliminated in breast cancer.

Hispanic Breast Cancer Patients Travel Further for Equitable Surgical Care at a Comprehensive Cancer Center

Purpose: Disparities in surgical breast cancer care have been documented for racial and ethnic minorities. On average, these minorities are less likely to utilize National Cancer Institute (NCI)-designated cancer centers and travel shorter distances to receive care. With the growing population of Hispanic patients in California, we analyzed the travel distance and surgical care of Hispanic and non-Hispanic patients at our large referral cancer center.

Methods: Patients included were those who initiated treatment for a new diagnosis of ductal carcinoma in situ or invasive breast cancer at our NCI-designated cancer center during the period 2010–2014. Ethnicity was dichotomized as Hispanic and non-Hispanic. Google Maps were used to determine the distance from patient zip code to our institution, classified as 0–10, 10–30, 30–60, and >60 miles.

Results: A total of 1765 non-Hispanic and 173 Hispanic patients were identified. Clinical stage by tumor size and nodal status were comparable between the two groups. Hispanic patients were younger (p<0.001) and more had Medicaid insurance (p<0.001). Hispanic patients traveled further when compared with non-Hispanics (p<0.001). In non-Hispanics and Hispanics, rates of breast conservation were 57.4% and 52.3% (p=0.30), unilateral mastectomy 34.2% and 36.2% (p=0.44), bilateral mastectomy 8.4% and 11.5% (p=0.24), and immediate postmastectomy reconstruction 42.6% and 50.6% (p=0.34), respectively. Hispanic ethnicity was not associated with different odds of receiving breast conservation (odds ratio [OR] 1.01, confidence interval [CI] 0.73–1.40), unilateral mastectomy (OR 1.05, CI 0.75–1.44), bilateral mastectomy (OR 1.37, CI 0.81–2.31), or immediate postmastectomy breast reconstruction (OR 1.27, CI 0.86–1.88), when compared with non-Hispanic ethnicity, after controlling for patient age, insurance status, and distance traveled.

Conclusions: Surgical care was similar for Hispanic and non-Hispanic patients treated at our NCI-designated cancer center. However, this Hispanic population traveled further than non-Hispanic patients. Our findings suggest that accessibility to transportation and institutional practices are instrumental in delivering equitable breast cancer surgical care for Hispanic patients.

Cancer screening inequities in a time of primary care reform: a population-based longitudinal study in Ontario, Canada

BACKGROUND

Primary care has been reformed in recent years in Ontario, Canada, with a move away from traditional fee-for-service to enhanced fee-for-service and capitation-based models. It is unclear how new models have affected disparities in cancer screening. We evaluated whether Ontario's enhanced fee-for-service model was associated with a change in the gaps in cancer screening for people living with low income and people who are foreign-born.

METHODS

We conducted a population-based longitudinal analysis from 2002 to 2013 of Ontario family physicians who transitioned from traditional fee-for-service to enhanced fee-for-service. The binary outcomes of interest were adherence to cervical, breast and colorectal cancer screening recommendations. Outcomes were analyzed using mixed-effects logistic regression. Analyses produced annual odds ratios comparing the odds of being up-to-date for screening among patients in enhanced fee-for-service versus patients in traditional fee-for-service for each social stratum separately. We calculated the ratios of stratum-specific odds ratios to assess whether the transition from traditional to enhanced fee-for-service was associated with a change in screening gaps between immigrants and long-term residents, and between people in the lowest and highest neighbourhood income quintiles.

RESULTS

Throughout the study period, cancer screening was consistently lower among immigrants and among people in the lowest income quintile. Transition to enhanced fee-for-service was generally associated with increased screening uptake for all, however for most years, ratios of ratios were significantly less than 1 for all three cancer screening types, indicating that there was a widening of the screening gap between immigrants and long-term residents and between people living in the lowest vs. highest income quintile associated with transitions.

CONCLUSION

The transition to enhanced fee-for-service in Ontario was generally associated with a widening of screening inequities for foreign-born and low-income patients.

Primary Health Care and Cervical Cancer Mortality Rates in Brazil: A Longitudinal Ecological Study

Supplemental Digital Content is Available in the Text.

Cervical cancer is a common neoplasm that is responsible for nearly 230 000 deaths annually in Brazil. Despite this burden, cervical cancer is considered preventable with appropriate care. We conducted a longitudinal ecological study from 2002 to 2012 to examine the relationship between the delivery of preventive primary care and cervical cancer mortality rates in Brazil. Brazilian states and the federal district were the unit of analysis (N = 27). Results suggest that primary health care has contributed to reducing cervical cancer mortality rates in Brazil; however, the full potential of preventive care has yet to be realized.

Absence of socioeconomic inequalities in access to good-quality breast cancer treatment within a population-wide screening programme in Turin (Italy)

Several studies suggest that population-based breast cancer screening programmes might help reduce social inequalities in breast cancer survival both by increasing early diagnosis and by improving access to effective treatments. To start disentangling the two effects, we evaluated social inequalities in quality of treatment of screen-detected breast cancer in the city of Turin (Italy). Combining data from the Audit System on Quality of Breast Cancer Treatment and the Turin Longitudinal Study, we analysed 2700 cases in the screening target age class 50-69 diagnosed in the period 1995-2008. We selected 10 indicators of the pathway of care, relative to timeliness and appropriateness of diagnosis and treatment, and three indicators of socioeconomic position: education, occupational status and housing characteristics. For each indicator of care, relative risks of failure were estimated by robust Poisson regression models, controlling for calendar period of diagnosis, size of tumour and activity volume of the surgery units. The principal predictor of failure of the good care indicators was the calendar period of diagnosis, with a general improvement with time in the quality of diagnosis and treatment, followed by size of the tumour and volume of activity. Socioeconomic indicators show only a marginal independent effect on timeliness indicators. The observed associations of quality indicators with socioeconomic characteristics are lower than expected, suggesting a possible role of the screening programme in reducing disparities in the access to good-quality treatments thanks to its capability to enter screen-detected women into a protected pathway of care.

Social determinants of breast cancer in the Caribbean: a systematic review

BACKGROUND

Breast cancer is the leading cause of cancer deaths among women in the Caribbean and accounts for >1 million disability adjusted life years. Little is known about the social inequalities of this disease in the Caribbean. In support of the Rio Political Declaration on addressing health inequities, this article presents a systematic review of evidence on the distribution, by social determinants, of breast cancer risk factors, frequency, and adverse outcomes in Caribbean women.

METHODS

MEDLINE, EMBASE, SciELO, CINAHL, CUMED, LILACS, and IBECS were searched for observational studies reporting associations between social determinants and breast cancer risk factors, frequency, or outcomes. Based on the PROGRESS-plus checklist, we considered 8 social determinant groups for 14 breast cancer endpoints, which totalled to 189 possible ways ('relationship groups') to explore the role of social determinants on breast cancer. Studies with >50 participants conducted in Caribbean territories between 2004 and 2014 were eligible for inclusion. The review was conducted according to STROBE and PRISMA guidelines and results were planned as a narrative synthesis, with meta-analysis if possible.

RESULTS

Thirty-four articles were included from 5,190 screened citations. From these included studies, 75 inequality relationships were reported examining 30 distinct relationship groups, leaving 84% of relationship groups unexplored. Most inequality relationships were reported for risk factors, particularly alcohol and overweight/obesity which generally showed a positive relationship with indicators of lower socioeconomic position. Evidence for breast cancer frequency and outcomes was scarce. Unmarried women tended to have a higher likelihood of being diagnosed with breast cancer when compared to married women. While no association was observed between breast cancer frequency and ethnicity, mortality from breast cancer was shown to be slightly higher among Asian-Indian compared to African-descent populations in Trinidad (OR 1.2, 95% CI 1.1-1.4) and Guyana (OR 1.3, 95% CI 1.0-1.6).

CONCLUSION

Study quantity, quality, and variability in outcomes and reporting limited the synthesis of evidence on the role of social determinants on breast cancer in the Caribbean. This report represents important current evidence on the region, and can guide future research priorities for better describing and understanding of Caribbean breast cancer inequalities.

Relationship of Social Determinants of Health with the Three-year Survival Rate of Breast Cancer

Background: Social determinants of health are among the key factors affecting the pathogenesis of diseases. Considering the increasingly high prevalence of breast cancer and the association of social determinants of health with its occurrence, related morbidity and mortality and survival rate, this study sought to assess the relationship of three-year survival rate of breast cancer with social determinants of health. Materials and Methods: This cohort study was conducted on males and females presenting to the Cancer Research Center of Shohada-E-Tajrish Hospital from 2006 to 2010 with definite diagnosis of breast cancer. Data were collected via phone interviews. Kaplan-Meier and Cox regression was fitted using SPSS (version 18) and PH assumption was tested by STATA (version 11) software. Results: The study was performed on 797 breast cancer patients, aged 25-93 years with mean age of 54.66 (SD=11.86) years. After 3 years from diagnosing cancer 700 (87.8%) patients were alive and 97 (12.2%) patients were dead. Using log rank test, there was relationship between 3-year survivals with age, education, childhood residence, sibling, treatment type, and district were significant (p<0.05). Using Cox PH regression, 3-year survival was related to age, level of education, municipal district of residence and childhood condition (p<0.05). Conclusion: Social determinants of health such as childhood condition, city region residency, level of education and age affect the three-year survival rate of breast cancer. Future studies must focus on the effect of childhood social class on the survival rates of cancers, which have been paid less attention to.

Clinical Considerations of Risk, Incidence, and Outcomes of Breast Cancer in Sexual Minorities

BACKGROUND

Breast cancer is a leading cause of cancer-related mortality in women. Limited research exists on the impact of sexual orientation on overall risk of and mortality from breast cancer. We sought to summarize the medical literature on breast cancer in sexual minority women and identify possible disparities in this population.

METHODS

A comprehensive literature search was conducted for English-language studies in peer-reviewed medical journals that referenced breast cancer and sexual minority, lesbian, bisexual, or transgender individuals. Articles published between January 2000 and November 2015 were included. They were reviewed for relevance to breast cancer risk stratification, breast cancer mortality, breast reconstruction, and transgender issues.

RESULTS

Behavioral risks, reproductive risks, and risks associated with decreased access to health care may all affect outcomes for sexual minorities with breast cancer. Limited studies have mixed results regarding mortality associated with breast cancer in sexual minorities due to an inconsistent reporting of sexual orientation.

CONCLUSIONS

Overall, the research examining breast cancer in sexual minority women remains limited. This finding is likely due to limitations in the reporting of sexual orientation within large databases, thus making broader-scale research difficult.

The global burden of women's cancers: a grand challenge in global health

Every year, more than 2 million women worldwide are diagnosed with breast or cervical cancer, yet where a woman lives, her socioeconomic status, and agency largely determines whether she will develop one of these cancers and will ultimately survive. In regions with scarce resources, fragile or fragmented health systems, cancer contributes to the cycle of poverty. Proven and cost-effective interventions are available for both these common cancers, yet for so many women access to these is beyond reach. These inequities highlight the urgent need in low-income and middle-income countries for sustainable investments in the entire continuum of cancer control, from prevention to palliative care, and in the development of high-quality population-based cancer registries. In this first paper of the Series on health, equity, and women's cancers, we describe the burden of breast and cervical cancer, with an emphasis on global and regional trends in incidence, mortality, and survival, and the consequences, especially in socioeconomically disadvantaged women in different settings.

Health-related Factors Associated with Adherence to Breast Cancer Screening

Introduction:

In Belgium, an effective preventive program for breast cancer exists but as in many countries to few women participates in the screening. This study aims to describe the factors that affect the participation in the national breast cancer screening program.

Methods:

The participants were aged between 50 and 69 years and were recruited during an exhibition at the Brussels Exhibition Centre. Medical history and health-related parameters of the participants were recorded.

Results:

In total, 350 women aged between 50 and 69 years participated. After adjustment for age and region, 81.5% of the participants had a mammography during the past 2 years. The multivariate analysis confirms the association between not having had a mammography and (a) having an older age (odds ratio [OR]: 0.25–0.87), (b) having diabetes (OR: 0.08–0.80), (c) having a family history of coronary heart disease (OR: 0.16–0.80), (d) not following a cholesterol diet or treatment (OR: 0.10–0.91) and (e) having a higher body mass index (OR: 0.39–0.97). Having had a mammogram was associated with adherence to cervical smear screening (OR: 2.74–11.21).

Conclusions:

Most of these associations are most likely related to socioeconomic status. However, the relationship with diabetes offers opportunities to increase the participation in breast cancer screening programs because these patients have regular contacts with their family physicians.