The social determinants of cancer: a challenge for transdisciplinary science

Using system dynamics modeling approach to strengthen health systems to combat cancer: a systematic literature review

AIM

Dynamic cancer control is a current health system priority, yet methods for achieving it are lacking. This study aims to review the application of system dynamics modeling (SDM) on cancer control and evaluate the research quality.

METHODS

Articles were searched in PubMed, Web of Science, and Scopus from the inception of the study to 15 November 2023. Inclusion criteria were English original studies focusing on cancer control with SDM methodology, including prevention, early detection, diagnosis and treatment, and palliative care. Exclusion criteria were non-original research, and studies lacking SDM focus. Analysis involved categorization of studies and extraction of relevant data to answer the research question, ensuring a comprehensive synthesis of the field. Quality assessment was used to evaluate the SDM for cancer control.

RESULTS

Sixteen studies were included in this systematic review predominantly from the United States (7, 43.75%), with a focus on breast cancer research (5, 31.25%). Studies were categorized by WHO cancer control modules, and some studies may contribute to multiple modules. The results showed that included studies comprised two focused on prevention (1.25%), ten on early detection (62.50%), six on diagnosis and treatment (37.50%), with none addressing palliative care. Seven studies presented a complete SDM process, among which nine developed causal loop diagrams for conceptual models, ten utilized stock-flow charts to develop computational models, and thirteen conducted simulations.

LIMITATIONS

This review's macrofocus on SDM in cancer control missed detailed methodological analysis. The limited number of studies and lack of stage-specific intervention comparisons limit comprehensiveness. Detailed analysis of SDM construction was also not conducted, potentially overlooking nuances in cancer control strategies.

CONCLUSION

SDM in cancer control is underutilized, focusing mainly on early detection and treatment. Inconsistencies suggest a need for standardized SDM approaches. Future research should expand SDM's application and integrate it into cancer control strategies.

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.

SBDH-Reader: an LLM-powered method for extracting social and behavioral determinants of health from medical notes

Introduction

Social and behavioral determinants of health (SBDH) are increasingly recognized as essential for prognostication and informing targeted interventions. While medical notes contain rich SBDH details, these are unstructured and conventional extraction methods tend to be labor intensive, inaccurate, and/or unscalable. The emergence of large language models (LLMs) presents an opportunity to develop more effective approaches for extracting SBDH data.

Materials and Methods

We developed the SBDH-Reader, an LLM-powered method to extract structured SBDH data from full-length medical notes through prompt engineering. Six SBDH categories were queried including: employment, housing, marital relationship, and substance use including alcohol, tobacco, and drug use. The development dataset included 7,225 notes from 6,382 patients in the MIMIC-III database. The method was then independently tested on 971 notes from 437 patients at UT Southwestern Medical Center (UTSW). We evaluated SBDH-Reader's performance using precision, recall, F1, and confusion matrix.

Results

When tested on the UTSW validation set, the GPT-4o-based SBDH-Reader achieved a macro-average F1 ranging from 0.85 to 0.98 across six SBDH categories. For clinically relevant adverse attributes, F1 ranged from 0.94 (employment) to 0.99 (tobacco use). When extracting any adverse attributes across all SBDH categories, the SBDH-Reader achieved an F1 of 0.96, recall of 0.97, and precision of 0.96 in this independent validation set.

Conclusion

A general-purpose LLM can accurately extract structured SBDH data through effective prompt engineering. The SBDH-Reader has the potential to serve as a scalable and effective method for collecting real-time, patient-level SBDH data to support clinical research and care.

A framework and process for community-engaged, mixed-methods cancer needs assessments

PURPOSE

Community health needs assessments are required for most state and local public health agencies and non-profit hospitals. Typically based on community health improvement planning models, these assessments encompass overall community health and multiple diseases to inform program planning. National Cancer Institute (NCI)-designated Cancer Centers and community-based cancer-focused programs share the goal of reducing cancer burden in the catchment areas they serve. However, to date, no published models exist to guide cancer-specific needs assessments for a determined geographic area that can inform both public health and research initiatives. The purpose of this article is to outline a cancer needs assessment (CNA) framework and community-engaged, mixed-methods process, along with a case study of how we applied it in Kentucky.

METHODS

We convened a steering committee of key organizational partners to provide input throughout the process. We developed a conceptual framework of multi-level determinants affecting cancer-related outcomes. We incorporated both quantitative and qualitative data gathered through a variety of means, including a novel application of group concept mapping to guide definition of priorities.

RESULTS

The resulting CNA has helped guide strategic planning and priorities for Kentucky's Cancer Action Plan, Markey Cancer Center, state agencies, and community-based organizations.

CONCLUSION

This framework and process can be used collaboratively by cancer center Community Outreach and Engagement offices, public health agencies, oncology programs, and community partners to plan impactful cancer control programs and research in their catchment areas. Universities can also use them to inform the planning of community engagement and health equity research efforts.

Barriers to care for musculoskeletal sarcoma patients: a public health perspective

Introduction

This study seeks to investigate the barriers to care that exist for patients presenting with sarcomas of musculoskeletal origin. Understanding the roots of delays in care for patients with musculoskeletal sarcoma is particularly important given the necessity of prompt treatment for oncologic diagnoses. Investigators reviewed relevant studies of publications reporting barriers to care in patients undergoing diagnosis and treatment of musculoskeletal tumors.

Methods

A comprehensive literature search was conducted using Scopus, Embase, Web of Science, and PubMed-MEDLINE. Twenty publications were analyzed, including a total of 114,056 patients.

Results

Four barrier subtypes were identified: Socioeconomic Status, Geographic Location, Healthcare Quality, Sociocultural Factors. Socioeconomic status included access to health insurance and income level. Geographic location included distance traveled by patients, access to referral centers, type of hospital system and resource-challenged environments. Healthcare quality included substandard imaging, access to healthcare resources, and healthcare utilization prior to diagnosis. Sociocultural factors included psychological states, nutrition, education and social support.

Conclusion

After identifying the most significant barriers in this study, we can target specific public health issues within our community that may reduce delays in care. The assessment of barriers to care is an important first step for improving the delivery of oncologic patient care to this patient population.

Advancing health equity in cancer survivorship research: National Institutes of Health 2017-2022 portfolio review

BACKGROUND

Communities and researchers have called for a paradigm shift from describing health disparities to a health equity research agenda that addresses structural drivers. Therefore, we examined whether the cancer survivorship research portfolio has made this shift.

METHODS

We identified grants focused on populations experiencing health disparities from the National Institutes of Health (NIH) Cancer Survivorship Research Portfolio (N = 724), Fiscal Years 2017-2022. Grant characteristics were abstracted, drivers of health disparities were mapped onto the levels and domains of influence, and opportunities for future research were identified.

RESULTS

A total of 147 survivorship grants focused on health disparities were identified, of which 73.5% of grants focused on survivors from racial and ethnic minoritized groups, 25.9% living in rural areas, 24.5% socioeconomically disadvantaged, and 2.7% sexual and gender minority groups. Study designs were 51.0% observational; 82.3% of grants measured or intervened on at least 1 individual-level of influence compared to higher levels of influence (32.7% interpersonal, 41.5% institutional and community, and 12.2% societal). Behavioral and health care system domains of influence were commonly represented, especially at the individual level (47.6% and 36.1%, respectively). Less frequently represented was the physical and built environment (12.2%).

CONCLUSIONS

NIH-funded cancer survivorship research on health disparities is still focused on individual level of influence. However, the proportion of grants examining structural and social drivers as well as the mechanisms that drive disparities in health care and health outcomes among cancer survivors have increased over time. Gaps in funded research on specific populations, cancer types, and focus areas of survivorship science were identified and warrant priority.

Identifying social determinants of health from clinical narratives: A study of performance, documentation ratio, and potential bias

OBJECTIVE

To develop a natural language processing (NLP) package to extract social determinants of health (SDoH) from clinical narratives, examine the bias among race and gender groups, test the generalizability of extracting SDoH for different disease groups, and examine population-level extraction ratio.

METHODS

We developed SDoH corpora using clinical notes identified at the University of Florida (UF) Health. We systematically compared 7 transformer-based large language models (LLMs) and developed an open-source package - SODA (i.e., SOcial DeterminAnts) to facilitate SDoH extraction from clinical narratives. We examined the performance and potential bias of SODA for different race and gender groups, tested the generalizability of SODA using two disease domains including cancer and opioid use, and explored strategies for improvement. We applied SODA to extract 19 categories of SDoH from the breast (n = 7,971), lung (n = 11,804), and colorectal cancer (n = 6,240) cohorts to assess patient-level extraction ratio and examine the differences among race and gender groups.

RESULTS

We developed an SDoH corpus using 629 clinical notes of cancer patients with annotations of 13,193 SDoH concepts/attributes from 19 categories of SDoH, and another cross-disease validation corpus using 200 notes from opioid use patients with 4,342 SDoH concepts/attributes. We compared 7 transformer models and the GatorTron model achieved the best mean average strict/lenient F1 scores of 0.9122 and 0.9367 for SDoH concept extraction and 0.9584 and 0.9593 for linking attributes to SDoH concepts. There is a small performance gap (∼4%) between Males and Females, but a large performance gap (>16 %) among race groups. The performance dropped when we applied the cancer SDoH model to the opioid cohort; fine-tuning using a smaller opioid SDoH corpus improved the performance. The extraction ratio varied in the three cancer cohorts, in which 10 SDoH could be extracted from over 70 % of cancer patients, but 9 SDoH could be extracted from less than 70 % of cancer patients. Individuals from the White and Black groups have a higher extraction ratio than other minority race groups.

CONCLUSIONS

Our SODA package achieved good performance in extracting 19 categories of SDoH from clinical narratives. The SODA package with pre-trained transformer models is available at https://github.com/uf-hobi-informatics-lab/SODA_Docker.

Together We Go Farther: Improving Access to Cancer Screening Through a Multidisciplinary, One-Stop-Shop Approach

RATIONALE AND OBJECTIVES

Despite significant scientific advances in cancer treatment in recent decades, Black Americans still face marked inequities in cancer screening, diagnosis, and treatment. Redressing these persistent inequities will require innovative strategies for community engagement. Radiologists, as experts in cancer screening and diagnosis for multiple malignancies, including breast, lung, and colon, are ideally suited to lead and implement community-based strategies to address local cancer disparities.

MATERIALS AND METHODS

Through an established academic-community partnership in West Philadelphia built over the course of multiple prior community healthcare events, the authors piloted a novel radiology-led multidisciplinary approach to improve access to cancer screening for the predominantly Black, medically-underserved residents. Using a "one-stop-shop" framework to provide a comprehensive suite of screening and ancillary services in the heart of the community, the authors sought to remove as many impediments to screening as possible.

RESULTS

Approximately 350 participants attended the health fair, and a total of 232 screening tests or assessments were completed. Data from this event suggest that this inclusive approach, as well as the use of a health fair "passport" to incentivize engagement, can successfully improve access to screening and follow-up in an underserved community.

CONCLUSION

This "one-stop-shop" community approach can be replicated by radiology-led teams in other settings as a high-value, scalable opportunity to reduce disparities in access to cancer screening.

Social vulnerability and lung malignancy mortality

INTRODUCTION

Lung cancer is a major cause of death in the United States. Social determinants of health (SDOH) are important factors that impact the treatment and prognosis of lung cancer. The social vulnerability index (SVI) is a validated measure of SDOH. This cross-sectional study aimed to investigate the impact of the SVI on lung cancer mortality using descriptive epidemiology.

METHODS

Mortality data for lung malignancies from 2014 to 2018 was obtained from the CDC database and was age-adjusted and standardized to the population in the year 2000. The SVI for the same years was obtained from the CDC Agency for Toxic Substances and Disease Registry database. Age-adjusted mortality rates (AAMR) were estimated for each SVI quartile (SVI-Q) and demographic subgroup.

RESULTS

We found that counties in SVI-Q4 (most vulnerable) had a higher cumulative AAMR compared to counties in SVI-Q1 (least vulnerable), accounting for a 4.48 excess death rate per 100,000 person-years. AAMR among males in SVI-Q4 was higher compared to SVI-Q1, accounting for a 9.96 excess death rate per 100,000 person-years, whereas no mortality differences were observed for female populations between SVI-Q4 and SVI-Q1. AAMR in SVI-Q4 was higher for both Hispanic and non-Hispanic populations, except for American Indian/Alaska Native populations. Similar trends were observed in both metropolitan and non-metropolitan counties.

CONCLUSION

Our study suggests that the SVI may play a significant role in lung cancer mortality and highlights the need for interventions targeting vulnerable populations to improve outcomes.

Cancer Research in 2030: A unique strategic planning process at a comprehensive cancer center

Following the successful renewal of its Cancer Center Support Grant (CCSG), leadership of the UCSF Helen Diller Comprehensive Cancer Center (HDFCCC) began a strategic planning process. The motivation was to think about where cancer research was going in the future; and with this vision to define a general scientific direction, mission, and priorities. HDFCCC Leadership began discussions about a new strategic plan in early 2018. From these meetings, the theme of "Cancer Research in 2030" arose: that is, what will cancer research look like in 2030? This forward-looking focus was intended to encourage creativity unconfined by a particular institutional structure or grant mechanism. Focusing on the science paved the way for an innovative, actionable, and motivating strategic planning process. Here, we describe the three-phase process, and the various groups involved across the HDFCCC and UCSF. We present the unique framework based on a cells-to-society model and an individual experience perspective, which led to the development of a logic model and ongoing implementation of tactics and tracking progress. We believe that sharing this process and its results will be of value to cancer centers and cancer researchers across the network of NCI comprehensive cancer centers, and cancer research centers in general.

What Are Healthy Societies? A Thematic Analysis of Relevant Conceptual Frameworks

BACKGROUND

While support for the idea of fostering healthy societies is longstanding, there is a gap in the literature on what they are, how to beget them, and how experience might inform future efforts. This paper explores developments since Alma Ata (1978) to understand how a range of related concepts and fields inform approaches to healthy societies and to develop a model to help conceptualize future research and policy initiatives.

METHODS

Drawing on 68 purposively selected documents, including political declarations, commission and agency reports, peer-reviewed papers and guidance notes, we undertook qualitative thematic analysis. Three independent researchers compiled and categorised themes describing the domains of a potential healthy societies approach.

RESULTS

The literature provides numerous frameworks. Some of these frameworks promote alternative endpoints to development, eschewing short-term economic growth in favour of health, equity, well-being and sustainability. They also identify values, such as gender equality, collaboration, human rights and empowerment that provide the pathways to, or underpin, such endpoints. We categorize the literature into four "components": people; places; products; and planet. People refers to social positions, interactions and networks creating well-being. Places are physical environments-built and natural-and the interests and policies shaping them. Products are commodities and commercial practices impacting population health. Planet places human health in the context of the 'Anthropocene.' These components interact in complex ways across global, regional, country and community levels as outlined in our heuristic.

CONCLUSION

The literature offers little critical reflection on why greater progress has not been made, or on the need to organise and resist the prevailing systems which perpetuate ill-health.

Change in Neighborhood Socioeconomic Status and Adherence to the Cancer Prevention Lifestyle Guidelines in Hispanic/Latino Adults: Results from the HCHS/SOL Study

Neighborhood conditions are dynamic; the association of changing neighborhood socioeconomic factors with cancer preventive behaviors remains unclear. We examined associations of neighborhood socioeconomic deprivation, gentrification, and change in income inequality with adherence to the American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention in The Hispanic Community Health Study/Study of Latinos (HCHS/SOL). The HCHS/SOL enrolled 16,415 adults, ages 18–74 years, at baseline (2008–2011), from communities in the Bronx, NY, Chicago, IL, Miami, FL, and San Diego, CA. Geocoded baseline addresses were linked to the 2000 decennial Census and 5-year American Community Survey (2005–2009 and 2012–2016) tracts to operationalize neighborhood deprivation index (NDI), gentrification, and income inequality. Complex survey multinominal logistic regression models estimated the relative risk ratio (RRR) with overall guideline adherence level (low, moderate, high) and by components—diet, physical activity, body mass index (BMI), and alcohol intake. Overall, 14%, 60%, and 26% of the population had low, moderate, and high ACS guideline adherence, respectively. NDI was negatively associated with risk of high (vs. low) guideline adherence [RRR = 0.87, 95% confidence interval (CI) = 0.78–0.98], although attenuated after controlling for individual socioeconomic status (SES; RRR = 0.89, 95% CI = 0.80–1.00), and associated with lower adherence to BMI recommendations (low vs. moderate RRR = 0.90, 95% CI = 0.84–0.97; high RRR = 0.86, 95% CI = 0.77–0.97). Gentrification was associated with higher likelihood of meeting the dietary recommendations (low vs. moderate RRR = 1.04, 95% CI = 1.01–1.07), but not with overall adherence or individual components. Change in income inequality was not associated with outcomes. Neighborhood deprivation may be negatively associated with ACS guideline adherence among Hispanic/Latino adults.

SIGNIFICANCE

This study provides new evidence on the link between neighborhood gentrification, changing income inequality and adoption and maintenance of cancer preventive behaviors in an understudied population in cancer research. We observed that while neighborhood deprivation may deter from healthy lifestyle behaviors, positive changes in neighborhood SES via the process of gentrification, may not influence lifestyle guideline adherence among Hispanic/Latino adults.

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.

Partially Recursively Induced Structured Moderation (PRISM) for modeling racial differences in endometrial cancer survival

PURPOSE

Health disparities are driven by a complex interplay of determinants operating across multiple levels of influence. However, while recognized conceptually, much disparities research fails to capture this inherent complexity in study focus and/or design; little of such work accounts for the interplay across the multiple levels of influence from structural (contextual) to biological or clinical. We developed a novel modeling framework that addresses these challenges and provides new insights.

METHODS

We used data from the Florida Cancer Data System on endometrial cancer patients and geocoded-derived social determinants of health to demonstrate the applicability of a new modeling paradigm we term PRISM regression. PRISM is a new highly interpretable tree-based modeling framework that allows for automatic discovery of potentially non-linear hierarchical interactions between health determinants at multiple levels and differences in survival outcomes between groups of interest, including through a new specific area-level disparity estimate (SPADE) incorporating these multilevel influences.

RESULTS

PRISM demonstrates that hierarchical influences on racial disparity in endometrial cancer survival appear to be statistically relevant and that these better predict survival differences than only using individual level determinants. The interpretability of the models allows more careful inspection of the nature of these hierarchical effects on disparity. Additionally, SPADE estimates show distinct geographical patterns across census tracts in Florida.

CONCLUSION

PRISM can provide a powerful new modeling framework with which to better understand racial disparities in cancer survival.

Inequalities in reported use of cervical screening in Estonia: results from cross-sectional studies in 2004-2020

BACKGROUND

Despite the national cervical cancer (CC) screening program established in 2006, the CC incidence in Estonia in 2020 was still one of the highest in Europe. To better understand the possible barriers among women, the aim of this study was to describe the inequalities in the Pap smear uptake trend in 2004-2020 and to analyse the associations between different factors in Estonia.

METHODS

Weighted data of 25-64-year-old women (N = 6685) from population-based cross-sectional studies of Health Behaviour among Estonian Adult Population in 2004-2020 was used. Linear trends in uptake of Pap smear over time were tested using the Cochrane-Armitage test. Binary logistic regression with interactions was performed to analyse associations between the uptake of Pap smear and sociodemographic, socioeconomic, health-related and lifestyle factors. Crude and adjusted odds ratios with 95% confidence intervals were calculated.

RESULTS

Prevalence of lifetime uptake of Pap smear increased in 2004-2020 from 50.6 to 86.7% (P < 0.001). From 2004 to 2020, uptake of Pap smear increased significantly among women aged 25-34, 35-44, 45-54 and 55-64, in both ethnicity groups and among women with basic, secondary and higher education (P < 0.001). The gap in Pap smear uptake increased between Estonians and non-Estonians but decreased between education levels over time. Lower lifetime uptake of Pap smear was associated from sociodemographic factors with younger age, being non-Estonian and single, from socioeconomic factors with lower educational level and unemployment, from health indicators with higher body mass index indicating overweight and obesity, presence of chronic disease and depressiveness, and from lifestyle factors with non-smoking.

CONCLUSIONS

Although Pap smear uptake among 25-64 year old women increased significantly in Estonia in 2004-2020, inequalities were found indicating an opportunity for development of targeted CC prevention strategies.

Construction and case study of a novel lung cancer risk index

PURPOSE

This study constructs a lung cancer risk index (LCRI) that incorporates many modifiable risk factors using an easily reproducible and adaptable method that relies on publicly available data.

METHODS

We used meta-analysis followed by Analytic Hierarchy Process (AHP) to generate a lung cancer risk index (LCRI) that incorporates seven modifiable risk factors (active smoking, indoor air pollution, occupational exposure, alcohol consumption, secondhand smoke exposure, outdoor air pollution, and radon exposure) for lung cancer. Using county-level population data, we then performed a case study in which we tailored the LCRI for use in the state of Illinois (LCRI_IL).

RESULTS

For both the LCRI and the LCRI_IL, active smoking had the highest weights (46.1% and 70%, respectively), whereas radon had the lowest weights (3.0% and 5.7%, respectively). The weights for alcohol consumption were 7.8% and 14.7% for the LCRI and the LCRI_IL, respectively, and were 3.8% and 0.95% for outdoor air pollution. Three variables were only included in the LCRI: indoor air pollution (18.5%), occupational exposure (13.2%), and secondhand smoke exposure (7.6%). The Consistency Ratio (CR) was well below the 0.1 cut point. The LCRI_IL was moderate though significantly correlated with age-adjusted lung cancer incidence (r = 0.449, P < 0.05) and mortality rates (r = 0.495, P < 0.05).

CONCLUSION

This study presents an index that incorporates multiple modifiable risk factors for lung cancer into one composite score. Since the LCRI allows data comprising the composite score to vary based on the location of interest, this measurement tool can be used for any geographic location where population-based data for individual risk factors exist. Researchers, policymakers, and public health professionals may utilize this framework to determine areas that are most in need of lung cancer-related interventions and resources.

The impact of greenspace or nature-based interventions on cardiovascular health or cancer-related outcomes: A systematic review of experimental studies

SIGNIFICANCE

Globally, cardiovascular disease (CVD) and cancer are leading causes of morbidity and mortality. While having different etiologies, CVD and cancer are linked by multiple shared risk factors, the presence of which exacerbate adverse outcomes for individuals with either disease. For both pathologies, factors such as poverty, lack of physical activity (PA), poor dietary intake, and climate change increase risk of adverse outcomes. Prior research has shown that greenspaces and other nature-based interventions (NBIs) contribute to improved health outcomes and climate change resilience.

OBJECTIVE

To summarize evidence on the impact of greenspaces or NBIs on cardiovascular health and/or cancer-related outcomes and identify knowledge gaps to inform future research.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and Peer Review of Electronic Search Strategies (PRESS) guidelines, we searched five databases: Web of Science, Scopus, Medline, PsycINFO and GreenFile. Two blinded reviewers used Rayyan AI and a predefined criteria for article inclusion and exclusion. The risk of bias was assessed using a modified version of the Newcastle-Ottawa Scale (NOS). This review is registered with PROSPERO, ID # CRD42021231619.

RESULTS & DISCUSSION

Of 2565 articles retrieved, 31 articles met the inclusion criteria, and overall had a low risk of bias. 26 articles studied cardiovascular related outcomes and 5 studied cancer-related outcomes. Interventions were coded into 4 categories: forest bathing, green exercise, gardening, and nature viewing. Outcomes included blood pressure (BP), cancer-related quality of life (QoL) and (more infrequently) biomarkers of CVD risk. Descriptions of findings are presented as well as visual presentations of trends across the findings using RAW graphs. Overall studies included have a low risk of bias; and alluvial chart trends indicated that NBIs may have beneficial effects on CVD and cancer-related outcomes.

CONCLUSIONS & IMPLICATIONS

(1) Clinical implication: Healthcare providers should consider the promotion of nature-based programs to improve health outcomes. (2) Policy implication: There is a need for investment in equitable greenspaces to improve health outcomes and build climate resilient neighborhoods. (3) Research or academic implication: Research partnerships with community-based organizations for a comprehensive study of benefits associated with NBIs should be encouraged to reduce health disparities and ensure intergenerational health equity. There is a need for investigation of the mechanisms by which NBIs impact CVD and exploration of the role of CVD biological markers of inflammation among cancer survivors.

Multi-, Inter-, and Transdisciplinarity within the Public Health Workforce: A Scoping Review to Assess Definitions and Applications of Concepts

In light of the current public health challenges, calls for more inter- and transdisciplinarity in the public health workforce are increasing, particularly to respond to complex and intersecting health challenges, such as those presented by the climate crisis, emerging infectious diseases, or military conflict. Although widely used, it is unclear how the concepts of multi-, inter-, and transdisciplinarity are applied with respect to the public health workforce. We conducted a scoping review and qualitative content analysis to provide an overview of how the concepts of multi-, inter-, and transdisciplinarity are defined and applied in the academic literature about the public health workforce. Of the 1957 records identified, 324 articles were included in the review. Of those, 193, 176, and 53 mentioned the concepts of multi-, inter-, and transdisciplinarity, respectively. Overall, 44 articles provided a definition. Whilst definitions of multidisciplinarity were scarce, definitions of inter- and transdisciplinarity were more common and richer, highlighting the aim of the collaboration and the blurring and dissolution of disciplinary boundaries. A better understanding of the application of multi-, inter-, and transdisciplinarity is an important step to implementing these concepts in practice, including in institutional structures, academic curricula, and approaches in tackling public health challenges.

Social Determinants of Cancer Risk Among American Indian and Alaska Native Populations: An Evidence Review and Map

Objectives:

To explore current literature on social determinants of health (SDOH) and cancer among American Indian and Alaska Native (AI/AN) populations.

Methods:

We searched Ovid MEDLINE^®, CINAHL, and PsycINFO databases for articles published during 2000 to 2020, which included terms for SDOH and cancer occurrence in AI/AN populations. We derived the data extraction elements from the PROGRESS-Plus framework. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-Equity extension guided the evidence map.

Results:

From 2180 screened articles, 297 were included. Most were observational (93.9%), employed a cross-sectional design (83.2%), were categorized as cancer occurrence and surveillance research (62%), and included no cancer-related risk factors (70.7%). Race, gender, and place were the most frequently included PROGRESS-Plus categories. Religion, relationship features, and characteristics of discrimination were least common. Only 12% of articles mentioned historical/current trauma or historical context.

Conclusions:

Gaps exist in our understanding of SDOH as drivers of cancer disparities in AI/AN populations. Future studies in health equity science may incorporate historical and cultural factors into SDOH frameworks tailored for AI/AN populations.

Neighborhood disadvantage, health status, and health care utilization after blood or marrow transplant: BMTSS report

Living in a disadvantaged neighborhood is associated with poor health outcomes. Blood or Marrow Transplant (BMT) survivors remain at risk of chronic health conditions requiring anticipatory management. We hypothesized that among BMT survivors, neighborhood disadvantage was associated with poor self-reported routine health care utilization and health. We leveraged data from BMTSS - a retrospective cohort study examining long-term outcomes among individuals surviving ≥2 y following BMT at three institutions between 1974 and 2014. Participants in this analysis completed the BMTSS survey (sociodemographics; chronic health conditions; time since routine check-up; self-reported health). The Area Deprivation Index (ADI) represented neighborhood disadvantage; this composite indicator of 17 census measures is a percentile rank (0 = least deprived to 100 = most deprived). Multivariable ordered logit regression adjusted for clinical factors and individual-level sociodemographics, modeling associations between ADI, time since routine check-up, and self-reported health. Among 2,857 survivors, median ADI was 24 (interquartile range: 10-46). Adjusting for self-reported individual-level socioeconomic indicators and chronic health conditions, patients in more disadvantaged neighborhoods had higher odds of reporting longer intervals since routine check-up (ORADI_continuous = 1.007, P < .001) and poorer health status (controlling for time since check-up; ORADI_continuous = 1.005, P = .003). Compared with patients living in the least disadvantaged neighborhood (ADI = 1), patients in the most disadvantaged neighborhood (ADI = 100), had twice the odds (ORADI = 1.007^99 = 2.06) of reporting no routine visits and 1.65-times the odds of reporting poor health (ORADI = 1.005^99 = 1.65). In BMT survivors, access to health care and health status are associated with area disadvantage. These findings may inform strategies to address long-term care coordination and retention for vulnerable survivors.

A Scoping Review of Food Insecurity and Related Factors among Cancer Survivors

Despite growing awareness of the financial burden that a cancer diagnosis places on a household, there is limited understanding of the risk for food insecurity among this population. The current study reviewed literature focusing on the relationship between food insecurity, cancer, and related factors among cancer survivors and their caregivers. In total, 49 articles (across 45 studies) were reviewed and spanned topic areas: patient navigation/social worker role, caregiver role, psychosocial impacts, and food insecurity/financial toxicity. Patient navigation yielded positive impacts including perceptions of better quality of care and improved health related quality of life. Caregivers served multiple roles: managing medications, emotional support, and medical advocacy. Subsequently, caregivers experience financial burden with loss of employment and work productivity. Negative psychosocial impacts experienced by cancer survivors included: cognitive impairment, financial constraints, and lack of coping skills. Financial strain experienced by cancer survivors was reported to influence ratings of physical/mental health and symptom burden. These results highlight that fields of food insecurity, obesity, and cancer control have typically grappled with these issues in isolation and have not robustly studied these factors in conjunction. There is an urgent need for well-designed studies with appropriate methods to establish key determinants of food insecurity among cancer survivors with multidisciplinary collaborators.

A Socio-Ecological Framework for Cancer Prevention in Low and Middle-Income Countries

Cancer incidence and mortality rates continue to rise globally, a trend mostly driven by preventable cancers occurring in low-and middle-income countries (LMICs). There is growing concern that many LMICs are ill-equipped to cope with markedly increased burden of cancer due to lack of comprehensive cancer control programs that incorporate primary, secondary, and tertiary prevention strategies. Notably, few countries have allocated budgets to implement such programs. In this review, we utilize a socio-ecological framework to summarize primary (risk reduction), secondary (early detection), and tertiary (treatment and survivorship) strategies to reduce the cancer burden in these countries across the individual, organizational, community, and policy levels. We highlight strategies that center on promoting health behaviors and reducing cancer risk, including diet, tobacco, alcohol, and vaccine uptake, approaches to promote routine cancer screenings, and policies to support comprehensive cancer treatment. Consistent with goals promulgated by the United Nations General Assembly on Noncommunicable Disease Prevention and Control, our review supports the development and implementation of sustainable national comprehensive cancer control plans in partnership with local communities to enhance cultural relevance and adoption, incorporating strategies across the socio-ecological framework. Such a concerted commitment will be necessary to curtail the rising cancer and chronic disease burden in LMICs.

Assessing the Documentation of Social Determinants of Health for Lung Cancer Patients in Clinical Narratives

Social determinants of health (SDoH) are important factors associated with cancer risk and treatment outcomes. There is an increasing interest in exploring SDoH captured in electronic health records (EHRs) to assess cancer risk and outcomes; however, most SDoH are only captured in free-text clinical narratives such as physicians' notes that are not readily accessible. In this study, we applied a natural language processing (NLP) system to identify 15 categories of SDoH from a total of 10,855 lung cancer patients at the University of Florida Health. We aggregated the SDoH concepts into patient-level and assessed how each of the 15 categories of SDoH were documented in cancer patient's notes. To the best of our knowledge, this is one of the first studies to examine the documentation of SDoH in clinical narratives from a real-world lung cancer patient cohort. This study could guide future studies to better utilize SDoH information documented in clinical narratives.

Mammography adherence in relation to function-related indicators in older women

Prior studies of screening mammography patterns by functional status in older women show inconsistent results. We used Breast Cancer Surveillance Consortium-Medicare linked data (1999-2014) to investigate the association of functional limitations with adherence to screening mammography in 145,478 women aged 66-74 years. Functional limitation was represented by a claims-based function-related indicator (FRI) score which incorporated 16 items reflecting functional status. Baseline adherence was defined as mammography utilization 9-30 months after the index screening mammography. Longitudinal adherence was examined among women adherent at baseline and defined as time from the index mammography to end of the first 30-month gap in mammography. Multivariable logistic regression and Cox proportional hazards models were used to investigate baseline and longitudinal adherence, respectively. Subgroup analyses were conducted by age (66-70 vs. 71-74 years). Overall, 69.6% of participants had no substantial functional limitation (FRI score 0), 23.5% had some substantial limitations (FRI score 1), and 6.8% had serious limitations (FRI score ≥ 2). Mean age at baseline was 68.5 years (SD = 2.6), 85.3% of participants were white, and 77.1% were adherent to screening mammography at baseline. Women with a higher FRI score were more likely to be non-adherent at baseline (FRI ≥ 2 vs. 0: aOR = 1.13, 95% CI = 1.06, 1.20, p-trend < 0.01). Similarly, a higher FRI score was associated with longitudinal non-adherence (FRI ≥ 2 vs. 0: aHR = 1.16, 95% CI = 1.11, 1.22, p-trend < 0.01). Effect measures of FRI did not differ substantially by age categories. Older women with a higher burden of functional limitations are less likely to be adherent to screening mammography recommendations.

The Impact of Socioeconomic Deprivation on Clinical Outcomes for Pancreatic Adenocarcinoma at a High-volume Cancer Center: A Retrospective Cohort Analysis

OBJECTIVE

To assess the impact of a granular measure of SED on pancreatic surgical and cancer-related outcomes at a high-volume cancer center that employs a standardized clinic pathway.

SUMMARY OF BACKGROUND DATA

Prior research has shown that low socioeconomic status leads to less treatment and worse outcomes for PDAC. However, these studies employed inconsistent definitions and categorizations of socioeconomic status, aggregated individual socioeconomic data using large geographic areas, and lacked detailed clinicopathologic variables.

METHODS

We conducted a retrospective cohort study of 1552 PDAC patients between 2008 and 2015. Patients were stratified using the area deprivation index, a validated dataset that ranks census block groups based on SED. Multivariable models were used in the curative surgery cohort to predict the impact of SED on (1) grade 3/4 Clavien-Dindo complications, (2) initiation of adjuvant therapy, (3) completion of adjuvant therapy, and (4) overall survival.

RESULTS

Patients from high SED neighborhoods constituted 29.9% of the cohort. Median overall survival was 28 months. The rate of Clavien-Dindo grade 3/4 complications was 14.2% and completion of adjuvant therapy was 65.6%. There was no evidence that SED impacted surgical evaluation, receipt of curative-intent surgery, postoperative complications, receipt of adjuvant therapy or overall survival.

CONCLUSIONS

Although nearly one-quarter of curative-intent surgery patients were from high SED neighborhoods, this factor was not associated with measures of treatment quality or survival. These observations suggest that treatment at a high-volume cancer center employing a standardized clinical pathway may in part address socioeconomic disparities in pancreatic cancer.

Campania and cancer mortality: An inseparable pair? The role of environmental quality and socio-economic deprivation

The region of Campania in Southern Italy features high levels of socio-economic deprivation and low levels of environmental quality. A vast strand of the scientific literature has tried to verify whether poor environmental quality and widespread socio-economic deprivation might explain the high cancer mortality rates (CMRs) observed, especially in the municipalities - infamously labelled as the 'Land of Fires' - that were hit most severely by the crisis. While some studies managed to identify links between these two confounding factors and cancer mortality, the evidence is overall mixed. Interesting information may be drawn from the observation of municipal data: in spite of previous claims, some municipalities featuring high environmental quality and low socio-economic deprivation also display high CMRs, while other Campanian municipalities facing disastrous environmental and socio-economic conditions are characterised by low CMRs. These figures, in contrast to common sentiment and previous studies, need to be investigated thoroughly in order to assess the exact role of the confounding factors. In this work, we aim to identify the municipalities where confounding factors act as driving forces in the determination of high CMRs through an original multi-step analysis based on frequentist and Bayesian analysis. Pinpointing these municipalities could allow policymakers to design targeted and effective policy measures aimed at reducing cancer mortality.

Resilience and Equity in a Time of Crises: Investing in Public Urban Greenspace Is Now More Essential Than Ever in the US and Beyond

The intersecting negative effects of structural racism, COVID-19, climate change, and chronic diseases disproportionately affect racial and ethnic minorities in the US and around the world. Urban populations of color are concentrated in historically redlined, segregated, disinvested, and marginalized neighborhoods with inadequate quality housing and limited access to resources, including quality greenspaces designed to support natural ecosystems and healthy outdoor activities while mitigating urban environmental challenges such as air pollution, heat island effects, combined sewer overflows and poor water quality. Disinvested urban environments thus contribute to health inequity via physical and social environmental exposures, resulting in disparities across numerous health outcomes, including COVID-19 and chronic diseases such as cancer and cardiovascular diseases (CVD). In this paper, we build off an existing conceptual framework and propose another conceptual framework for the role of greenspace in contributing to resilience and health equity in the US and beyond. We argue that strategic investments in public greenspaces in urban neighborhoods impacted by long term economic disinvestment are critically needed to adapt and build resilience in communities of color, with urgency due to immediate health threats of climate change, COVID-19, and endemic disparities in chronic diseases. We suggest that equity-focused investments in public urban greenspaces are needed to reduce social inequalities, expand economic opportunities with diversity in workforce initiatives, build resilient urban ecosystems, and improve health equity. We recommend key strategies and considerations to guide this investment, drawing upon a robust compilation of scientific literature along with decades of community-based work, using strategic partnerships from multiple efforts in Milwaukee Wisconsin as examples of success.

The impact of sociodemographic factors on the utilization of radiation therapy in breast cancer patients in Estonia: a register-based study

Background

Radiation therapy is an important part of multimodal breast cancer treatment. The aim was to examine the impact of sociodemographic factors on radiation therapy use in breast cancer (BC) patients in Estonia, linking cancer registry data to administrative databases.

Methods

Estonian Cancer Registry provided data on women diagnosed with BC in Estonia in 2007–2018, including TNM stage at diagnosis. Use of radiation therapy within 12 months of diagnosis was determined from Estonian Health Insurance Funds claims, and sociodemographic characteristics from population registry. Receipt of radiation therapy was evaluated over time and by clinical and sociodemographic factors. Poisson regression with robust variance was used to calculate univariate and multivariate prevalence rate ratios (PRR) with 95 % confidence intervals (CI) for receipt of radiation therapy among stage I–III BC patients age < 70 years who underwent primary surgery.

Results

Overall, of 8637 women included in the study, 4310 (50 %) received radiation therapy within 12 months of diagnosis. This proportion increased from 39 to 58 % from 2007 to 2009 to 2016–2018 (p < 0.001). Multivariate regression analysis showed that compared to women with stage I BC, those with more advanced stage were less likely to receive radiation therapy. Receipt of radiation therapy increased significantly over time and was nearly 40 % higher in 2016–2018 than in 2007–2009. Use of radiation therapy was significantly lower for women with the lowest level of education compared to those with a university degree (PRR 0.88, 95 % CI 0.80–0.97), and for divorced/widowed women (PRR 0.95, 95 % CI 0.91–0.99) and single women (PRR 0.92, 95 % CI 0.86–0.99), compared to married women. Age at diagnosis, nationality and place of residence were not associated with receipt of radiation therapy.

Conclusions

The study showed considerable increase in the use of radiation therapy in Estonia over the study period, which is in line with increases in available equipment. The lack of geographic variations suggests equal access to therapy for patients living in remote regions. However, educational level and marital status were significantly associated with receipt of radiation therapy, highlighting the importance of psychosocial support in ensuring equal access to care.

Hybrid models as transdisciplinary research enablers

Modelling and simulation (M&S) techniques are frequently used in Operations Research (OR) to aid decision-making. With growing complexity of systems to be modelled, an increasing number of studies now apply multiple M&S techniques or hybrid simulation (HS) to represent the underlying system of interest. A parallel but related theme of research is extending the HS approach to include the development of hybrid models (HM). HM extends the M&S discipline by combining theories, methods and tools from across disciplines and applying multidisciplinary, interdisciplinary and transdisciplinary solutions to practice. In the broader OR literature, there are numerous examples of cross-disciplinary approaches in model development. However, within M&S, there is limited evidence of the application of conjoined methods for building HM. Where a stream of such research does exist, the integration of approaches is mostly at a technical level. In this paper, we argue that HM requires cross-disciplinary research engagement and a conceptual framework. The framework will enable the synthesis of discipline-specific methods and techniques, further cross-disciplinary research within the M&S community, and will serve as a transcending framework for the transdisciplinary alignment of M&S research with domain knowledge, hypotheses and theories from diverse disciplines. The framework will support the development of new composable HM methods, tools and applications. Although our framework is built around M&S literature, it is generally applicable to other disciplines, especially those with a computational element. The objective is to motivate a transdisciplinarity-enabling framework that supports the collaboration of research efforts from multiple disciplines, allowing them to grow into transdisciplinary research.

Black American and Latinx Parent/Caregiver Participation in Digital Health Obesity Interventions for Children: A Systematic Review

Parents/caregivers are consistently described as integral targets given their influential role in supporting and managing behaviors such as diet and physical activity. Identifying effective obesity prevention interventions to enhance and sustain parent participation is needed. Digital obesity prevention interventions are a promising strategy to improve parent/caregiver participation. Digital health interventions demonstrate acceptable participation and retention among parents/caregivers. However, our understanding of digital obesity prevention interventions targeting Black American and Latinx parents/caregivers is limited. This systematic review aims to identify Black American and Latinx parents'/caregivers' level of participation in digital obesity prevention and treatment interventions and determine the relationship between parent/caregiver participation and behavioral and weight status outcomes. This review adheres to PRISMA guidelines and is registered in PROSPERO. Eligibility criteria include: intervention delivered by digital technology, targeted Black American and Latinx parents/caregivers of young children (2-12 years), reported parent/caregiver participation outcomes, targeted diet or physical activity behaviors, and randomized controlled trial study design. Searches were conducted in September 2020 in ERIC, PsychInfo, PubMed, and Web of Science. Initial searches returned 499 results. Four reviewers screened records against eligibility criteria and 12 studies met inclusion criteria. Across all studies, parent/caregiver participation ranged from low to high. Only half of the included studies reported significant improvements in behavioral or weight status outcomes for parents/caregivers and/or children. Of these studies, three reported high parental/caregiver participation rates, and three reported high satisfaction rates. These findings suggest that participation and satisfaction may impact behavior change and weight status. The small number of studies indicates that additional research is needed to determine whether engagement or other factors predict responsiveness to the digital health intervention. Our results lay the groundwork for developing and testing future digital health interventions with the explicit goal of parental/caregiver participation and considers the need to expand our digital health intervention research methodologies to address obesity inequities among diverse families better.

Quantifying the contribution of modifiable risk factors to socio-economic inequities in cancer morbidity and mortality: a nationally representative population-based cohort study

BACKGROUND

Compared with those with a higher socio-economic position (SEP), individuals with a lower SEP have higher cancer morbidity and mortality. However, the contribution of modifiable risk factors to these inequities is not known. This study aimed to quantify the mediating effects of modifiable risk factors to associations between SEP and cancer morbidity and mortality.

METHODS

This study used a prospective observational cohort design. We combined eight cycles of the Canadian Community Health Survey (2000/2001-2011) as baseline data to identify a cohort of adults (≥35 years) without cancer at the time of survey administration (n = 309 800). The cohort was linked to the Discharge Abstract Database and the Canadian Mortality Database for cancer morbidity and mortality ascertainment. Individuals were followed from the date they completed the Canadian Community Health Survey until 31 March 2013. Dates of individual first hospitalizations for cancer and deaths due to cancer were captured during this time period. SEP was operationalized using a latent variable combining measures of education and household income. Self-reported modifiable risk factors, including smoking, excess alcohol consumption, low fruit-and-vegetable intake, physical inactivity and obesity, were considered as potential mediators. Generalized structural equation modelling was used to estimate the mediating effects of modifiable risk factors in associations between low SEP and cancer morbidity and mortality in the total population and stratified by sex.

RESULTS

Modifiable risk factors together explained 45.6% of associations between low SEP and overall cancer morbidity and mortality. Smoking was the most important mediator in the total population and for males, accounting for 15.5% and 40.2% of the total effect, respectively. For females, obesity was the most important mediator.

CONCLUSIONS

Modifiable risk factors are important mediators of socio-economic inequities in cancer morbidity and mortality. Nevertheless, more than half of the variance in these associations remained unexplained. Midstream interventions that target modifiable risk factors may help to alleviate inequities in cancer risk in the short term. However, ultimately, upstream interventions that target structural determinants of health are needed to reduce overall socio-economic inequities in cancer morbidity and mortality.

Determinants of stage at diagnosis of HPV-related cancer including area deprivation and clinical factors

Background

Collecting social determinants of health in electronic health records is time-consuming. Meanwhile, an Area Deprivation Index (ADI) aggregates sociodemographic information from census data. The objective of this study was to ascertain whether ADI is associated with stage of human papillomavirus (HPV)-related cancer at diagnosis.

Methods

We tested for the association between the stage of HPV-related cancer presentation and ADI as well as the association between stage and the value of each census-based measure using ordered logistic regression, adjusting for age, race and sex.

Results

Among 3247 cases of HPV-related cancers presenting to an urban academic medical center, the average age at diagnosis was 57. The average stage at diagnosis was Surveillance, Epidemiology and End Results Stage 3. In the study population, 43% of patients were female and 87% were white. In this study population, there was no association between stage of HPV-related cancer presentation and either aggregate or individual census variables.

Conclusions

These results may reflect insufficient sample size, a lack of socio-demographic diversity in our population, or suggest that simplifying social determinants of health into a single geocoded index is not a reliable surrogate for assessing a patient’s risk for HPV-related cancer.

Education, income and risk of cancer: results from a Norwegian registry-based study

INTRODUCTION

Several studies have shown an association between socioeconomic status and incidence of cancer. In this study, we have examined the association between socioeconomic factors, using income and education as proxies, and cancer incidence in Norway, a country known to be egalitarian, with universal access to health care and scoring high on the human development index.

METHODS

We linked individual data for the total Norwegian population with information on all cancer patients registered in the Cancer Registry of Norway (CRN) with any cancer diagnosed between 2012 and 2016. Data on education, and individual income, were provided from Statistics Norway. We used Poisson regression to obtain incidence rate ratios (IRR) across education and income levels for 23 cancer sites.

RESULTS

A total of 9 cancers among men and 13 cancers among women were observed to have significantly higher incidence rates in cases with the lowest level of education. Melanoma for both sexes, testis and prostate cancer in men, and breast cancer in women were found to have a higher incidence rate among those with the highest level of education. The largest differences in IRR were found for lung cancer, where men and women with college or university education as their highest completed education had a two- to threefold decreased risk, compared to those with primary school (IRR men; 0.40 [0.37-0.43], women 0.34 [0.31-0.37]). The results for income mirrored the results for education among men, while for women we did not observe many differences in cancer risk across income groups.

CONCLUSION

Our findings were consistent with findings from other studies showing that the incidence rate of cancer differs across levels of socioeconomic status. We may need behavioral change campaigns focused on lifestyle changes that lower the risk of cancer and target perhaps to those with lower socioeconomic status.

Management of neuroblastoma in limited-resource settings

BACKGROUND

Neuroblastoma (NB) is a heterogeneous disease with variable outcomes among countries. Little is known about NB in low- and middle-income countries (LMICs).

AIM

The aim of this review was to evaluate regional management protocols and challenges in treating NB in paediatric oncology units in LMICs compared to high-income countries (HICs).

METHODS

PubMed, Global Health, Embase, SciELO, African Index Medicus and Google Scholar were searched for publications with keywords pertaining to NB, LMICs and outcomes. Only English language manuscripts and abstracts were included. A descriptive review was done, and tables illustrating the findings were constructed.

RESULTS

Limited information beyond single-institution experiences regarding NB outcomes in LMICs was available. The disease characteristics varied among countries for the following variables: sex, age at presentation, MYCN amplification, stage and outcome. LMICs were found to be burdened with a higher percentage of stage 4 and high-risk NB compared to HICs. Implementation of evidence-based treatment protocols was still a barrier to care. Many socioeconomic variables also influenced the diagnosis, management and follow-up of patients with NB.

CONCLUSION

Patients presented at a later age with more advanced disease in LMICs. Management was limited by the lack of resources and genetic studies for improved NB classification. Further research is needed to develop modified diagnostic and treatment protocols for LMICs in the face of limited resources.

A critical realist synthesis of cross-disciplinary health policy and systems research: defining characteristic features, developing an evaluation framework and identifying challenges

BACKGROUND

Health policy and systems research (HPSR) is an inherently cross-disciplinary field of investigation. However, conflicting conceptualisations about inter-, multi- and transdisciplinary research have contributed to confusion about the characteristics of cross-disciplinary approaches in HPSR. This review was conducted to (1) define the characteristic features of context-mechanism-outcome (CMO) configurations in cross-disciplinary HPSR, (2) develop criteria for evaluating cross-disciplinarity and (3) synthesise emerging challenges of the approach.

METHOD

The paper is a critical realist synthesis conducted in three phases, as follows: (1) scoping the literature, (2) searching for and screening the evidence, and (3) extracting and synthesising the evidence. Five databases, namely the International Bibliography of the Social Sciences and Web of Science, PubMed central, Embase and CINHAL, and reference lists of studies that qualified for inclusion in the review were searched. The search covered peer-reviewed original research, reviews, commentary papers, and institutional or government reports published in English between January 1998 and January 2020.

RESULTS

A total of 7792 titles were identified in the online search and 137 publications, comprising pilot studies as well as anecdotal and empirical literature were selected for the final review. The review draws attention to the fact that cross-disciplinary HPSR is not defined by individual characteristics but by the combination of a particular type of research question and setting (context), a specific way of researchers working together (mechanism), and research output (outcome) that is superior to what could be achieved under a monodisciplinary approach. This CMO framework also informs the criteria for assessing whether a given HPSR is truly cross-disciplinary. The challenges of cross-disciplinary HPSR and their accompanying coping mechanisms were also found to be context driven, originating mainly from conceptual disagreements, institutional restrictions, communication and information management challenges, coordination problems, and resource limitations.

CONCLUSION

These findings have important implications. First, the CMO framework of cross-disciplinary HPSR can provide guidance for researchers engaging in new projects and for policy-makers using their findings. Second, the proposed criteria for evaluating theory and practice of cross-disciplinary HPSR may inform the systematic development of new research projects and the structured assessment of existing ones. Third, a better understanding of the challenges of cross-disciplinary HPSR and potential response mechanisms may help researchers to avoid these problems in the future.

Fostering international collaboration in implementation science and research: a concept mapping exploratory study

OBJECTIVE

International collaboration in science has received increasing attention given emphases on relevance, generalizability, and impact of research. Implementation science (IS) is a growing discipline that aims to translate clinical research findings into health services. Research is needed to identify efficient and effective ways to foster international collaboration in IS. Concept-mapping (CM) was utilized with a targeted sample for preliminary exploration of fostering international collaboration. Concept-mapping is a mixed-method approach (qualitative/quantitative) particularly suited for identifying essential themes and action items to facilitate planning among diverse stakeholders. We sought to identify key factors likely to facilitate productive and rewarding international collaborations in implementation research.

RESULTS

We identified eleven dimensions: Strategic Planning; Practicality; Define Common Principles; Technological Tools for Collaboration; Funding; Disseminate Importance of Fostering International Collaboration in IS; Knowledge Sharing; Innovative & Adaptive Research; Training IS Researchers; Networking & Shared Identity; Facilitate Meetings. Strategic Planning and Funding were highest rated for importance and Strategic Planning and Networking and Shared Identity were rated most feasible to institute. Fostering international collaboration in IS can accelerate the efficiency, relevance, and generalizability of implementation research. Strategies should be developed and tested to improve international collaborations and engage junior and experienced investigators in collaborations advancing implementation science and practice.

Social Inequalities Along the Childhood Cancer Continuum: An Overview of Evidence and a Conceptual Framework to Identify Underlying Mechanisms and Pathways

Inequalities in health according to social conditions are regarded as unnecessary and unjust. There is a large body of evidence on inequalities in adult cancer, observable throughout the societies on a national level as well as on a global scale. Socioeconomic influences on health matter at all ages including childhood, for which childhood cancer is the leading cause of disease related death in high-income countries (HICs). Substantial differences in the reported incidence of childhood cancers have been observed globally by socioeconomic development of a population. This is reflected in the higher incidence rates reported for HICs, particularly for acute lymphoblastic leukemia, and for cancer in infants (below 1 year), compared to low- and middle-income countries (LMICs). Considerable inequalities between populations and degree of socioeconomic development are also noted for survival from childhood cancer, with substantially lower survival rates seen in most LMICs compared to HICs. With respect to inequalities by socioeconomic position (SEP) within countries, findings of an association between SEP and childhood cancer risk are diverse and limited to studies from HICs. On the contrary, observations on social inequalities in survival within countries are accumulating and indicate that survival inequalities do not only concern resource-poor countries but also high-income populations including European countries. In turn, a childhood cancer diagnosis in itself may have implications on the parents' socioeconomic situation as well as on the later socioeconomic life after having survived the disease. The underlying mechanisms and causal pathways of these empirically demonstrated social inequalities are poorly understood, although it is of significant public health relevance for any actions or strategies to reduce childhood cancer-related inequity. We propose a conceptual framework on potential underlying mechanism and pathways specifically addressing social inequalities in childhood cancer and after childhood cancer to (i) illustrate potential pathways by which social determinants may create health inequities at different points of the childhood cancer continuum; (ii) illustrate potential pathways by which a childhood cancer diagnosis may impact the socioeconomic situation of the concerned family or the later life of a childhood survivor; and (iii) point out how major determinants may relate to each other.

Using Population Health Measures to Evaluate the Environmental Burden of Cancer at the County Level

Introduction

Burden of disease is often defined by using epidemiologic measures. However, there may be latent aspects of disease burden that are not factored into these types of estimates. This study quantified environmental burden of disease by using population health indicators and exploratory factor analysis at the county level across the United States.

Methods

Ninety-nine variables drawn from public use data sets from 2010 to 2016 were used to create a multifactor index — the burden index. We applied principal components analysis with promax rotation to allow the factors to correlate. Correlation coefficients for each factor and the outcome of interest, age-adjusted cancer death rate, were calculated. We used both unadjusted and adjusted linear regression techniques.

Results

The final additive county-level index included 9 factors that explained 68.3% of the variance in the counties and county equivalents. The burden index had a moderate association with the age-adjusted cancer death rates (r =.48, P <.001), and adjusted linear regression with all 9 factors explained 34% of the variance in the age-adjusted cancer death rate. Results were mapped, and the geographic distribution of both the burden index and age-adjusted cancer mortality were assessed. There are distinct geospatial patterns for both.

Conclusions

Results from this study show potential areas of need, as well as the importance of including environmental variables in the study of cancer etiology. Future studies can aim to validate these findings by quantifying burden as it relates to overall cancer mortality by using epidemiologic measures, along with other confirmatory statistical methods.

Socio-Environmental Patterns Associated with Cancer Mortality: A Study Based on a Quality of Life Approach

Background: With 18.6% of total deaths due to malignant tumors in 2016, cancer is the second leading death cause in Argentina. While there is a broad consensus on common risk factors at the individual cancer level, those operating at a contextual level have been poorly studied in developing countries. The objective of our study was to identify socio-environmental patterns in Argentina (2010), emphasizing quality of life, and to explore their associations with the spatial distribution of cancer mortality in the country. Methods: The study was conducted in 525 geographical divisions nested into 24 provinces. Sex-specific crude and age-standardized mortality rates (ASMR) for cancer (2009-2011 period) were calculated. Empirically derived socio-environmental patterns were identified through principal-component factor analysis on a selected set of variables: an urban scale and 29 indicators of a quality of life index in Argentina for 2010. Two-level Poisson regression models were used to estimate associations between the ASMR and the continuous factor scores for socio-environmental patterns as covariates. A random intercept was included to account for spatial variability in the ASMR distribution using Stata software. Results: Four socio-environmental patterns were identified, termed “Contexts with urban-related resources or cultural capital”, “Socioeconomically prosperous contexts”, “Environments with anthropic exposures” and “Plains region” (cumulative explained variance=57%). High mortality rates were found in counties characterized by socioeconomically prosperous contexts (RR=1.025 in women; 1.088 in men) and plain landscapes (RR=1.057 and 1.117, respectively). Counties featuring urban or cultural resources demonstrated increased mortality in women (RR=1.015, 95%CI=1.005-1.025), whereas rising rates associated with environments having anthropic exposures (RR=1.008, 95%CI=1.001-1.016) were observed only for men. Conclusion: This study identified four characteristic socio-environmental patterns in Argentina which incorporate features of quality of life, accounting to some extent for the differential burden of cancer mortality in this country.

Evaluating Neighborhood Correlates and Geospatial Distribution of Breast, Cervical, and Colorectal Cancer Incidence

Introduction: Though cancer research has traditionally centered on individual-level exposures, there is growing interest in the geography of both cancer and its risk factors. This geographic and epidemiological research has consistently shown that cancer outcomes and their known causal exposures exhibit geographic variation that coincide with area-level socioeconomic status and the composition of neighborhoods. A retrospective study was conducted to evaluate geospatial variation for female breast, cervical, and colorectal cancer incidence in Baltimore City.

Materials and Methods: Using a Maryland Cancer Registry dataset of incident breast, cervical, and colorectal cancers (N = 4,966) among Baltimore City female residents diagnosed from 2000 to 2010, spatial and epidemiological analyses were conducted through choropleth maps, spatial cluster identification, and local Moran's I. Ordinary least squares regression models identified characteristics associated with the geospatial clusters.

Results: Each cancer type exhibited geographic variation across Baltimore City with the neighborhoods showing high incidence differing by cancer type. Specifically, breast cancer had significant low incidence in downtown Baltimore while cervical cancer had high incidence. The neighborhood covariates associated with the geographic variation also differed by cancer type while local Moran's I identified discordant clusters.

Discussion: Cancer incidence varied geographically by cancer type within a single city (county). Small area estimates are needed to detect local patterns of disease when developing health and preventative programs. Given the observed variability of community-level characteristics associated with each cancer type incidence, local information is essential for developing place-, social-, and outcome-specific interventions.

A conceptual model of social networks and mechanisms of cancer mortality, and potential strategies to improve survival: an invited commentary

In this article, the importance of social factors for cancer survivorship has been theoretically considered and empirically studied. This commentary and Kroenke's narrative review highlight how social network theory and methods may innovatively expand this substantive body of work. First, we add to a new understanding of cancer survivorship through: (a) discussing the delineation and differences between multiple social factors of interest across existing conceptual models; (b) characterizing their relationships to each other and to cancer survivorship through a social network lens; and (c) overall, sharing terminology and strengthening connections within this diverse body of literature. Second, we note opportunities for future research in terms of (a) simultaneous measurement of multiple social factors at different levels and (b) adaptation of designs to leverage and measure the theorized mechanisms. This commentary describes how incorporation of social network research can optimize research, practice, and policy contributions regarding cancer survival and survivorship.

Origins of Cancer Disparities in Young Adults: Logic Models to Guide Research

Cancer disparities research is motivated by persistent inequities in cancer outcomes by race, ethnicity, social status, neighborhood location, and other subpopulation characteristics. These inequities have proven to be persistent and difficult to alter. Part of the reason for the frustration with slow progress is a lack of appreciation of the long-term nature of the undertaking. It is highly likely that the disparities observed in adulthood find their origins in young adulthood, if not earlier. A long-term perspective is needed, recognizing that successes may take many years to realize. This commentary presents the experience of the Center for Health And Risk in Minority youth and young adults project, which is a comprehensive center of excellence funded by the National Institute of Minority Health and Health Disparities for addressing disparities and chronic disease prevention in minority youth and young adults. The use of logic models is advanced for this kind of research because they can provide a theory of change and illustrate the course of knowledge translation over time. Logic models for cancer disparities research can place individual project activities in a realistic context that at one time indicates what is possible and reasonable to expect during the duration of a typical research project as well as the future steps that need to be taken on the way to an expected ultimate impact on cancer inequities.

Evolution of educational inequalities in site-specific cancer mortality among Belgian men between the 1990s and 2000s using a "fundamental cause" perspective

BACKGROUND

According to the "fundamental cause" theory, emerging knowledge on health-enhancing behaviours and technologies results in health disparities. This study aims to assess (trends in) educational inequalities in site-specific cancer mortality in Belgian men in the 1990s and the 2000s using this framework.

METHODS

Data were derived from record linkage between the Belgian censuses of 1991 and 2001 and register data on mortality. The study population comprised all Belgian men aged 50-79 years during follow-up. Both absolute and relative inequality measures have been calculated.

RESULTS

Despite an overall downward trend in cancer mortality, educational differences are observed for the majority of cancer sites in the 2000s. Generally, inequalities are largest for mortality from preventable cancers. Trends over time in inequalities are rather stable compared with the 1990s.

CONCLUSIONS

Educational differences in site-specific cancer mortality persist in the 2000s in Belgium, mainly for cancers related to behavioural change and medical interventions. Policy efforts focussing on behavioural change and healthcare utilization remain crucial in order to tackle these increasing inequalities.

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.

Social determinants of cancer incidence and mortality around the world: an ecological study

Cancer continues to be a leading cause of mortality and morbidity the world over. While the incidence of cancer is projected to increase by 70% over the next two decades, some research findings suggest a disproportionate distribution of new cancer cases and attendant fatalities across certain regions of the world, with poor and lower income countries worse affected at a time when advances in cancer research, medical technology, and drug development are giving rise to better cancer survival in developed countries. In this study, the role of selected social determinants of health in gauging cancer outcomes relative to incidence across various countries in different regions of the world was explored. The results indicated that the education index, income index, Gini coefficient, availability of cancer control policies and programs, as well as health system performance have an association with and are good predictors of the mortality to incidence ratio (MIR) of lung, breast, cervical, and colorectal cancers. In other words, populations with better education, higher incomes and lower inequalities, active cancer control policies and programs and high performing health systems have better cancer outcomes as reflected in lower MIRs relative to other populations.

Recommendations for Cancer Epidemiologic Research in Understudied Populations and Implications for Future Needs

Medically underserved populations in the United States continue to experience higher cancer burdens of incidence, mortality, and other cancer-related outcomes. It is imperative to understand how health inequities experienced by diverse population groups may contribute to our increasing unequal cancer burdens and disparate outcomes. The National Cancer Institute convened a diverse group of scientists to discuss research challenges and opportunities for cancer epidemiology in medically underserved and understudied populations. This report summarizes salient issues and discusses five recommendations from the group, including the next steps required to better examine and address cancer burden in the United States among our rapidly increasing diverse and understudied populations. Cancer Epidemiol Biomarkers Prev; 25(4); 573-80. ©2016 AACR SEE ALL ARTICLES IN THIS CEBP FOCUS SECTION, "MULTILEVEL APPROACHES TO ADDRESSING CANCER HEALTH DISPARITIES".