Enduring Cancer Disparities by Persistent Poverty, Rurality, and Race: 1990-1992 to 2014-2018

Prevalence of cannabis and medication use by indices of residential urbanicity and deprivation among Ohio cancer patients

PURPOSE

There is increasing interest in the use of cannabis products to alleviate symptom burden among cancer patients. Although data remain limited, some evidence suggests that state legalization of cannabis is associated with reduced opioid use. Indices of area-level social determinants of health may provide insights into the patterns of symptom-managing behaviors in the context of health equity.

METHODS

Residential ZIP codes from 854 Ohio residents diagnosed with invasive cancer at an academic cancer center were used to assign rural-urban commuting area (RUCA) codes and social deprivation index (SDI) values. RUCA was categorized as metropolitan and non-metropolitan, and SDI was dichotomized at the median. Participants completed a one-time cannabis-focused questionnaire which included items on medications used to alleviate symptoms.

RESULTS

The prevalence of self-reported cannabis (19% vs. 13%) and opioid use (30% vs. 21%) were higher among patients living in areas of higher social disadvantage vs. lower. No differences were observed for use of benzodiazepines or for any product by residential urbanicity.

CONCLUSION

Larger, multi-institutional studies with detailed measurement of cannabis and medications and an increased capacity to examine additional social determinants of health are needed to confirm and explain these descriptive findings.

Association of Rurality With Mortality After Congenital Heart Surgery

BACKGROUND

Disparities between metro and nonmetro areas exist in health outcomes. The effect of residing areas on mortality for patients with congenital heart disease remains unclear. We evaluated the relationship of residing areas with survival outcomes after congenital heart surgery (CHS).

METHODS

This is a retrospective cohort study of patients enrolled in the Pediatric Cardiac Care Consortium who had a history of CHS. Outcomes were tracked by the National Death Index through 2022. Logistic regression and Cox proportional hazards models were fitted to examine the associations between residence at CHS with in-hospital mortality and long-term survival after adjustment for covariates.

RESULTS

Among 28 504 eligible patients (47.0% female patients) with a history of CHS, 19 772 (69.4%) patients resided in metro areas. Patients with congenital heart disease living in nonmetro areas at CHS had a lower (86.5%) 30-year survival rate following discharge from initial CHS versus patients living in metro areas (88.4%). After adjustment for sex, birth era, congenital heart disease severity, and presence of chromosomal abnormality, residing in nonmetro areas was associated with an increased risk of long-term mortality (adjusted hazard ratio, 1.12 [95% CI, 1.03-1.21]). Further adjustment for the neighborhood socioeconomic status attenuated the observed reduction in risk of death between nonmetro and metro areas. Patients with mild congenital heart disease who resided in nonmetro and not adjacent to metro areas were independently associated with an increased risk of long-term death (adjusted hazard ratio, 1.34 [95% CI, 1.00-1.77]), after adjustment for covariates and neighborhood socioeconomic status.

CONCLUSIONS

Residence in nonmetro areas at CHS is associated with an increased risk of death both in the immediate postoperative period in-hospital and on the long-term up to 30 years after CHS discharge, but this association is explained by differential neighborhood socioeconomic status at the time of CHS. These findings provide opportunities for targeted interventions to reduce disparities and improve outcomes for all patients after CHS.

Current, persistent, and low-poverty area residence and social risks among Black cancer survivors

BACKGROUND

Persistent area-level poverty may be associated with long-term social and economic disinvestment, which can contribute to social risks and financial difficulties for individuals. This study examines the associations between census tract poverty and the prevalence of social risks and financial hardship among Black cancer survivors.

METHODS

Data were used from 4066 participants in the population-based Detroit Research on Cancer Survivors cohort. Census tract poverty was categorized as persistent (≥20% of residents in poverty for 30+ years), current (≥20% currently in poverty), and low (<20% in poverty). Participants self-reported social risks related to food, housing, utilities, access to care, and safety as well as material and behavioral financial hardship. Prevalence ratios and 95% confidence intervals (CIs) were estimated with modified Poisson models controlling for sociodemographic and cancer-related factors.

RESULTS

Overall, 36% of participants reported any social risks. The prevalence was higher in persistent (45%) relative to both current (40%) and low-poverty areas (25%). The prevalence of each social risk and of behavioral financial hardship was higher in current and persistent versus low-poverty areas in unadjusted models but most attenuated in adjusted models. The adjusted prevalence of any social risk was 21% higher in both persistent (95% CI, 7%-37%) and current (95% CI, 7%-36%) compared with low-poverty areas. Area poverty was not associated with financial hardship in adjusted models.

CONCLUSIONS

Living in current but not persistent or persistent high-poverty areas is associated with a higher prevalence of social risks. Residents of high-poverty areas may represent a priority population for screening and intervention.

Persistent Poverty and Pediatric Cancer Survival

BACKGROUND

Cancer is the leading cause of death by disease among US children. While previous studies have examined the impact of poverty on pediatric cancer outcomes, most relied on single time point measures, which may not capture the long-term, systemic effects of poverty. Persistent poverty, defined as having 20% or more of an area's population below the poverty level for 30 years, represents a more comprehensive measure of sustained socioeconomic disadvantage.

METHODS

In this population-based study, we used Surveillance, Epidemiology, and End Results (SEER)-22 Registries Incidence Data with Census Tract Attributes Database data. Primary cases of cancer diagnosed among children from 2006 to 2020 were included. Cox proportional hazards models were used to compute the association between persistent poverty and (1) early mortality (death from cancer within 3 months of diagnosis) and (2) overall cancer-specific mortality.

RESULTS

In total, 97 132 children were included in our study; 12.63% resided in a persistent-poverty neighborhood at diagnosis. In the adjusted models, living in a persistent-poverty neighborhood was associated with a higher risk of early mortality (adjusted hazard ratio [aHR], 1.26; 95% CI, 1.10-1.45) and a higher risk of overall cancer death (aHR, 1.15; 95% CI, 1.10-1.21). Persistent poverty was associated with survival for children with leukemias (aHR, 1.20; 95% CI, 1.09-1.31), central nervous system tumors (aHR, 1.14; 95% CI, 1.04-1.26), and hepatic tumors (aHR, 1.37; 95% CI, 1.01-1.85).

CONCLUSIONS

Our study observed increased risk of cancer death among children in persistent-poverty neighborhoods. Continued investment and research are critical to developing effective strategies that reduce disparities and improve outcomes for pediatric cancer patients affected by persistent poverty.

Methodological Approaches for Incorporating Marginalized Populations into HPV Vaccine Modeling: A Systematic Review

Background. Delineation of historically marginalized populations in decision models can identify strategies to improve equity but requires assumptions in both model structure and stratification of input data. Purpose. We sought to characterize alternative methodological approaches for incorporating marginalized populations into human papillomavirus (HPV) vaccine decision-support models. Data Sources. We conducted a systematic search of PubMed, CINAHL, Scopus, and Embase from January 2006 through June 2022. Study Selection. We identified simulation models of HPV vaccination that refine any model input to specifically reflect a marginalized population. Data Extraction. We extracted data on key methodological decisions across modeling approaches to incorporate marginalized populations, including stratification of inputs, model structure, attribution of prevaccine disparities, calibration, validation, and sensitivity analyses. Data Synthesis. We identified 30 models that stratified inputs by sexual behavior (i.e., men who have sex with men), HIV infection status, race, ethnicity, income, rurality, or combinations of these. We identified 5 common approaches used to incorporate marginalized groups. These included models based primarily on differences in sexual behavior (k = 6), HPV cancer incidence (k = 10), cancer screening and care access (k = 4), and HPV natural history (through either direct incorporation of data [k = 10] or calibration [k = 5]). Few models evaluated sensitivity around their conceptualization of the marginalized group, and only 5 models validated outcomes for the marginalized group. Limitations. Evaluated studies reflected a variety of settings and research questions, making it difficult to evaluate the implications of differences across modeling approaches. Conclusions. Modelers should be explicit about the assumptions and theory driving their model structure and input parameters specific to key marginalized populations, such as the causes of prevaccination differences in outcomes. More emphasis is needed on model validation and rigorous sensitivity analysis.HighlightsWe identified 30 unique HPV vaccination models that incorporated marginalized populations, including populations living with HIV, low-income or rural populations, and individuals of a marginalized race, ethnicity, or sexual behavior.Methods for incorporating these populations, as well as the assumptions inherent in the modeling structure and parameter selections, varied substantially, with models explicitly or implicitly attributing prevaccine differences to alternative combinations of biological, behavioral, and societal mechanisms.Modelers seeking to incorporate marginalized populations should be transparent about assumptions underlying model structure and data and examine these assumptions in sensitivity analysis when possible.

Structural Racism in Cervical Cancer Care and Survival Outcomes: A Systematic Review of Inequities and Barriers

Purpose of Review

Despite cervical cancer (CC) being a cancer that can be eliminated, CC disparities persist such that minoritized populations shoulder a disproportionate mortality burden. This may reflect upstream, fundamental drivers of health that impede equitable access to prevention, screening, early detection, and treatment among some groups. This systematic review summarizes evidence on the relationships between structural racism and CC care across the continuum.

Recent Findings

Following PRISMA guidelines, we conducted a comprehensive search for peer-reviewed, English-language studies relevant to our research question that were published from 2012-2022 using PubMed, CINAHL, Web of Science, and Embase. Of 8,924 articles identified, 4,383 duplicates were removed, and 4,541 underwent screening, with 206 articles meeting eligibility criteria for inclusion in our data synthesis. Among reviewed studies, 60.2% (n = 124) compared CC outcomes by race and ethnicity, often as proxies for upstream racism. Key findings included evidence of lower CC screening rates among Asian American and Pacific Islander women and higher rates among Black and Hispanic/Latinx women. Barriers to healthcare access and socioeconomic status (SES) factors contributed to delayed follow-up, later-stage CC diagnoses, and poorer outcomes, particularly for Black and Hispanic/Latinx women and those residing in low-SES neighborhoods.

Summary

This review underscores associations between race, ethnicity, SES, and outcomes across the CC continuum. Most studies examined racial and ethnic disparities in the outcomes of interest rather than directly evaluating measures of structural racism. Future research should refine measures of structural racism to deepen our understanding of its impact on CC across the care continuum.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40471-025-00360-y.

Barriers and Enablers to Cancer Prevention, Screening and Early Detection Among Travellers in Ireland: Healthcare Professionals Perspectives

OBJECTIVES

Travellers, a minority ethnic group in Ireland, experience higher-than-expected cancer-specific mortality. This codesigned research study explored the perceptions of community-based primary healthcare professionals (HCPs) regarding the barriers and enablers for Travellers in the context of cancer prevention and early detection behaviors (ie, screening participation, and timely reporting of cancer symptoms).

METHODS

Semistructured phone/Zoom interviews were conducted with 15 community-based HCPs. Thematic analysis was used to analyze the data.

RESULTS

A total of 4 key themes were generated. (1) Poverty and exclusion: the corrosive impact of the social determinants of health (SDoH); (2) Health system barriers include health services access challenges, cultural insensitivity and discrimination; (3) Certain individual and/or cultural barriers impact cancer prevention and early detection behaviors; (4) National and local level strategies are warranted for improved cancer prevention and early detection behaviors among Travellers. A whole-of-government approach is required to address these barriers while working in partnership with Traveller organizations.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must engage in cultural sensitivity training to enhance their understanding of the barriers and enablers to cancer prevention and early detection behaviors among minority ethnic groups. Nurses can advocate for and engage in actions to address these barriers at a national, local and individual level.

The Influence of Poverty and Rurality on Colorectal Cancer Survival by Race/Ethnicity: An Analysis of SEER Data with a Census Tract-Level Measure of Persistent Poverty

Purpose: Because of shared mechanisms such as decreased access to health care, rurality and poverty may act synergistically to decrease colorectal cancer (CRC) survival. Methods: We conducted a retrospective cohort analysis of SEER data (22 registries) with census tract-level measures of poverty/rurality for the period 2006-2015. Multivariable Cox proportional hazard regressions were applied to examine the independent and intersectional associations of persistent poverty and rurality on 5-year cause-specific CRC survival across five racial/ethnic groups. Results: Among 532,868 CRC patients, non-Hispanic Blacks (NHB) demonstrated lower 5-year survival probability (64.2% vs. 68.3% in non-Hispanic Whites [NHW], 66.5% in American Indian/Alaska Natives [AI/AN], 72.1% in Asian/Pacific Islanders, and 68.7% in Hispanic groups) (p-value < 0.001). In adjusted analysis, CRC patients living in rural areas with poverty were at a 1.2-1.6-fold increased risk of CRC death than those who did not live in these areas in five racial/ethnic groups. In particular, AI/AN patients living in rural areas with poverty were 66% more likely to die from CRC (95% CI, 1.32, 2.08). Conclusions: CRC patients who live in rural or poverty areas in SEER areas in the U.S. have a poorer survival compared with those who do not live in such areas regardless of race/ethnicity. Significantly greater risk of CRC death was observed in AI/ANs. Impact: Patient navigators, community education or screening, and other health care system interventions may be helpful to address these disparities by socioeconomic status, race, and geographic residence. Multi-level interventions aimed at institutional racism and medical mistrust may also be helpful.

Lung cancer disparities in rural, persistent poverty counties: a secondary data analysis

BACKGROUND

In the US, lung cancer burden is greater in counties that are either rural or in persistent poverty. This study examined lung cancer risk (e.g., smoking), incidence, and mortality across four county types defined by cross-classification of rurality and persistent poverty.

METHODS

We conducted a secondary analysis of county characteristics and lung cancer risk, incidence and mortality. We used data from USDA to classify counties according to rurality (using rural-urban continuum codes) and persistent poverty (i.e., 20% + of residents living below the poverty line for 30 + years). We used publicly-available data to calculate mean county-level prevalence of smoking among adults (in 2019), lung cancer incidence (2015-2019), and lung cancer mortality (2015-2019) across county types. Beta and binomial regression models assessed differences in smoking, lung cancer incidence, and lung cancer mortality by rurality and persistent poverty.

RESULTS

Among U.S. counties, 1,115 were urban, non-persistent poverty, 1,675 were rural, non-persistent poverty, 52 were urban, persistent poverty, and 301 were rural, persistent poverty. Smoking, lung cancer incidence, and lung cancer mortality were higher in rural counties and in persistent poverty counties than in their comparison counties. Counties that were both rural and persistent poverty had the highest rates of smoking, lung cancer incidence, and lung cancer mortality. Persistent poverty and rurality interacted in their relationship with smoking prevalence (p < 0.01), and lung cancer mortality (p < 0.10).

CONCLUSIONS

Smoking, lung cancer incidence, and lung cancer mortality are highest in counties that are both rural and persistent poverty, suggesting an urgent need to develop targeted lung cancer interventions in these communities.

Geographic and racial disparities in the quality of surgical care among patients with nonmetastatic uterine cancer

BACKGROUND

Although the rates of minimally invasive surgery and sentinel lymph node biopsy have increased considerably over time in the surgical management of early-stage uterine cancer, practice varies significantly in the United States, and there are disparities among low-volume centers and patients of Black race. A significant number of counties in the United States are without a gynecologic oncologist, and almost half of the counties with the highest gynecologic cancer rates lack a local gynecologic oncologist.

OBJECTIVE

This study aimed to evaluate the relationships of distance traveled and proximity to gynecologic oncologists with the receipt of and racial disparities in the quality of surgical care among patients who underwent a hysterectomy for nonmetastatic uterine cancer.

STUDY DESIGN

Patients who underwent a hysterectomy for nonmetastatic uterine cancer in Kentucky, Maryland, Florida, and North Carolina were identified in the 2012 to 2018 State Inpatient Database and the State Ambulatory Surgery Services Database files. County-to-county distances were used as the distances traveled to the nearest gynecologic oncologist. Factors associated with the receipt of minimally invasive surgery and lymph node dissection were analyzed using multivariable logistic regression models, as was the assessment of the interaction between travel for surgery and patient race.

RESULTS

Among 21,837 cases, 45.5% lived in a county without a gynecologic oncologist; overall, 55.5% traveled to another county for surgery, including 88% of those who lacked a local gynecologic oncologist. Patients who lacked access to a local gynecologic oncologist in their county who did not travel for surgery were more likely to receive open surgery and no lymph node dissection, and those in counties without access in any surrounding county were affected even more. Among patients in counties without a gynecologic oncologist, those who traveled for surgery had a similar likelihood of undergoing minimally invasive surgery (71%) but had a greater likelihood of undergoing lymph node dissection (64.7% vs 57.2%) than nontravelers. Among those in counties without a gynecologic oncologist, a longer distance traveled was associated with receipt of a lymph node assessment. When compared with non-Black patients, Black patients were less likely to undergo minimally invasive surgery (57.0% vs 74.1%). In adjusted regression models that controlled for a diagnosis of fibroids, Black race was an independent risk factor for the receipt of open surgery. There was a significant interaction between Black race and travel for surgery, and Black patients who lived in counties without a gynecologic oncologist who did not travel faced an incrementally lower likelihood of receiving minimally invasive surgery (odds ratio, 0.57 when compared with non-Black patients who traveled for surgery; odds ratio, 0.60 as interaction term; P<.001 for both). Similar disparities in surgical quality by race were noted for Black patients who lived in counties with a gynecologic oncologist who traveled out of county for surgery.

CONCLUSION

Patients, particularly those of Black race, who lacked local access to gynecologic oncologist specialty care benefitted from traveling to specialty centers to ensure access to high-quality surgery for nonmetastatic uterine cancer. Further work is needed to ensure equitable and universal access to high-quality care through patient travel or specialist outreach.

Longer travel times to acute hospitals are associated with lower likelihood of cancer screening receipt among rural-dwelling adults in the U.S. South

PURPOSE

Given rural hospitals' role in providing outpatient services, we examined the association between travel burdens and receipt of cancer screening among rural-dwelling adults in the U.S. South region.

METHODS

First, we estimated network travel times and distances to access the nearest and second nearest acute care hospital from each rural census tract in the U.S. South. After appending the Centers for Disease Control's PLACES dataset, we fitted generalized linear mixed models.

RESULTS

Longer distances to the second nearest hospital are negatively associated with breast, colorectal, and cervical cancer screening receipt among eligible rural-dwelling adults. Rural-dwelling women in counties with 1 closure had reduced likelihood of breast cancer screening. Residence in a partial- or whole-county Health Professional Shortage Area (HPSA) was negatively associated with cancer screening receipt. Specialist (OB/GYN and gastroenterologist) supply was positively associated with receipt of cancer screening. Uninsurance was positively associated with cervical and breast cancer screening receipt. Medicaid expansion was associated with increased breast and cervical cancer screening.

CONCLUSIONS

Rural residents in partial-county primary care HPSAs had the lowest rates of breast, cervical, and colorectal cancer screening, compared with whole-county HPSAs and non-shortage areas. These residents also faced the greatest distances to their nearest and second nearest hospital. This is notable because rural residents in the South face greater travel burdens for cancer care compared with residents in other regions. Finally, the positive association between uninsurance and breast and cervical cancer screening may reflect the CDC's National Breast and Cervical Cancer Early Detection Program's effectiveness.

"Just give it to us straight!": a qualitative analysis of midwestern rural lung cancer survivors and caregivers about survivorship care experiences

PURPOSE

We assessed the experiences of rural lung cancer survivors and caregivers to understand and identify barriers to posttreatment survivorship care management.

METHODS

From May 2021 to June 2022, we conducted semi-structured interviews with a purposively sampled cohort. Participants were either posttreatment lung cancer survivors (within 5 years of their last active treatment) or caregivers of a lung cancer survivor. Interviews probed participants regarding survivorship care knowledge, implementation, and navigation. Two analysts inductively coded verbatim transcripts and conducted a thematic analysis.

RESULTS

We interviewed N = 21 participants: lung cancer survivors (76%) and caregivers (24%). Participants self-identified as Non-Hispanic White (100%), were at least 65 years old (77%), identified as male (62%), and previously smoked ≥ 5 packs over the lifetime (71%). The perspectives of survivors and caregivers were similar; thus, we analyzed them together. Themes related to survivorship care included (1) frustrations and uncertainty regarding unexpected barriers, (2) strategies to improve the delivery of posttreatment information, (3) strategies to remain positive and respond to emotional concerns of survivorship care, and (4) the impact of engaging and patient-centered care teams.

CONCLUSION

Given the limited access to lung cancer care resources in rural communities, our findings reveal that following a survivorship care program or plan requires a high level of individual resilience and community/interpersonal networking.

IMPLICATIONS FOR SURVIVORS

This study's findings can be applied to improve practice-based care for rural posttreatment lung cancer survivors and provide an impetus for developing tools to assist patient navigation toward community-based supportive care and care management resources.

Cancer statistics, 2025

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population-based cancer occurrence and outcomes using incidence data collected by central cancer registries (through 2021) and mortality data collected by the National Center for Health Statistics (through 2022). In 2025, 2,041,910 new cancer cases and 618,120 cancer deaths are projected to occur in the United States. The cancer mortality rate continued to decline through 2022, averting nearly 4.5 million deaths since 1991 because of smoking reductions, earlier detection for some cancers, and improved treatment. Yet alarming disparities persist; Native American people bear the highest cancer mortality, including rates that are two to three times those in White people for kidney, liver, stomach, and cervical cancers. Similarly, Black people have two-fold higher mortality than White people for prostate, stomach, and uterine corpus cancers. Overall cancer incidence has generally declined in men but has risen in women, narrowing the male-to-female rate ratio (RR) from a peak of 1.6 (95% confidence interval, 1.57-1.61) in 1992 to 1.1 (95% confidence interval, 1.12-1.12) in 2021. However, rates in women aged 50-64 years have already surpassed those in men (832.5 vs. 830.6 per 100,000), and younger women (younger than 50 years) have an 82% higher incidence rate than their male counterparts (141.1 vs. 77.4 per 100,000), up from 51% in 2002. Notably, lung cancer incidence in women surpassed that in men among people younger than 65 years in 2021 (15.7 vs. 15.4 per 100,000; RR, 0.98, p = 0.03). In summary, cancer mortality continues to decline, but future gains are threatened by rampant racial inequalities and a growing burden of disease in middle-aged and young adults, especially women. Continued progress will require investment in cancer prevention and access to equitable treatment, especially for Native American and Black individuals.

Impact of Structural Racism and Social Determinants of Health on Disparities in Breast Cancer Mortality

The striking ethnic and racial disparities in breast cancer mortality are not explained fully by pathologic or clinical features. Structural racism contributes to adverse conditions that promote cancer inequities, but the pathways by which this occurs are not fully understood. Social determinants of health, such as economic status and access to care, account for a portion of this variability, yet interventions designed to mitigate these barriers have not consistently led to improved outcomes. Based on the current evidence from multiple disciplines, we describe a conceptual model in which structural racism and racial discrimination contribute to increased mortality risk in diverse groups of patients by promoting adverse social determinants of health that elevate exposure to environmental hazards and stress; these exposures in turn contribute to epigenetic and immune dysregulation, thereby altering breast cancer outcomes. Based on this model, opportunities and challenges arise for interventions to reduce racial and ethnic disparities in breast cancer mortality.

Poverty Traps and Mortality From Liver Diseases in the United States

INTRODUCTION

Poverty traps, locations with multigenerational poverty, result from structural and economic factors that can affect health of residents within these locations. The aim of this study was to define poverty traps within the contiguous United States and their impact on outcomes from liver diseases or cancers.

METHODS

A systematic census-tract level analysis was used to spatially define regions that encompassed poverty traps. Clusters of prevalent poverty and mortality from chronic liver diseases or liver cancers were identified. Temporal trends and the relationship between race and ethnicity, type of space and escape from poverty traps on disease mortality within hot spots were determined.

RESULTS

The proportion of census tracts enduring multigenerational poverty within counties was strongly associated with mortality from liver disease or cancer. There was a highly significant clustering of persistent poverty and increased mortality. Hot spots of high-mortality areas correlated with factors related to income, ethnicity, and access to health care. Location or noneconomic individual factors such as race and ethnicity were important determinants of disparities within hot spots. Distinct groups of poverty traps were defined. The highly characteristic demographics and disease outcomes within each of these groups underscored the need for location-specific interventions.

DISCUSSION

Poverty traps are a major and important spatially determined risk factor for mortality from liver diseases and cancers. Targeted location-specific interventions and economic development aimed at addressing the underlying causes of poverty and enhancing prosperity will be required to reduce mortality from liver diseases within poverty traps.

The Context of Poverty and Cancer: Denying Human Potential

Poverty is a carcinogen and a leading cause of cancer disparities and overall mortality in the United States. Poverty is often viewed as an individual failure for "being poor," but in fact, poverty is structurally driven, intergenerational, and place-based that socially deprives and denies human potential. Disparities in timely cancer prevention, diagnosis, treatment, survivorship, and survival disproportionally impact people living in poverty and especially in persistent poverty areas, an extreme form of place-based poverty that affects communities over multiple generations. There has been some progress made to address place-based conditions that exacerbate poverty, such as the NCI's initiative on persistent poverty. However, gross inequality and cancer disparities continue to exist and persist. The time is now to accelerate the development of research-informed strategies and solutions with communities along with multisectoral collaborations with education, housing, occupation/workforce, foster care, criminal justice, transportation, and data collection systems. This commentary discusses the structural, place-based, and generational context of poverty, illustrates how entrenched inequities shape poor cancer outcomes, and describes opportunities for future research.

Advances in clinical research on pharmacological management of chemotherapy-induced constipation in gastrointestinal tumor: A perspective

Gastrointestinal tumors, including those of the stomach, colon, rectum, and esophagus, present significant global health challenges. Chemotherapy, essential for treating these cancers, often causes constipation, adversely affecting patients' quality of life. This study examines the mechanisms behind chemotherapy-induced constipation, such as the direct impact of chemotherapeutic drugs on intestinal function, reduced fluid intake, decreased physical activity, opioid use, and psychological stress. While traditional treatments like stimulant and osmotic laxatives are commonly used, emerging therapies such as 5-HT4 receptor agonists and probiotics show promise. Traditional Chinese medicine offers additional strategies with herbal remedies and dietary adjustments. Future research should prioritize precision medicine, combining pharmacological and non-pharmacological approaches, and developing innovative therapeutics utilizing biologics and nanotechnology. Ongoing research is crucial for improving chemotherapy-induced constipation management, aiming to enhance treatment outcomes and the quality of life for chemotherapy patients with gastrointestinal tumors.

Factors Associated with Abnormal Mammogram Results Among Low-Income Uninsured Populations in Medically Underserved And Rural Texas Regions

Background

This study investigated the potential associations between neighborhood characteristics, rurality, ethnicity/race, and breast cancer screening outcomes in designated Health Professional Shortage Areas in Central Texas. Limited access to preventive medical care can impact screening rates and outcomes. Previous research on the effects of factors such as rurality, neighborhood socioeconomic status, and education level on cancer prevention behaviors has yielded inconsistent results.

Materials and Methods

We analyzed data from a state-funded breast and cervical cancer screening programs for disadvantaged and medically underserved individuals. A mixed-effects logistic regression model was used to assess the impact of residency characteristics (rurality, educational attainment, unemployment, and poverty) on abnormal breast cancer screening outcomes, with individual level (age, ethnicity, race, and education) as control variables.

Results

During the studied time, there were 1,139 women screened and 134 abnormal mammograms found. Residency characteristics were not significantly associated with abnormal mammography outcomes at 0.05. However, individual factors are strongly associated with abnormal screening results. Non-Hispanic or Latino white women had increased odds of abnormal clinical outcomes compared with Hispanic or Latino women (OR = 2.03, CI 1.25-3.28; p = 0.004). Additionally, women residing in counties with more than 30% of the population completing college had increased odds of abnormal mammogram outcomes compared with counties with less than 15% college attainment (OR = 2.89, CI 0.99-8.38; p = 0.051).

Conclusions

This study found a significant correlation between area-level educational characteristics and abnormal mammography outcomes. Future research should explore the contextual risk factors influencing breast cancer occurrence and develop targeted interventions for this population.

The intersection of travel burdens and financial hardship in cancer care: a scoping review

BACKGROUND

In addition to greater delays in cancer screening and greater financial hardship, rural-dwelling cancer patients experience greater costs associated with accessing cancer care, including higher cumulative travel costs. This study aimed to identify and synthesize peer-reviewed research on the cumulative and overlapping costs associated with care access and utilization.

METHODS

A scoping review was conducted to identify relevant studies published after 1995 by searching 5 electronic databases: PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsycInfo, and Healthcare Administration. Eligibility was determined using the PEO (Population, Exposure, and Outcomes) method, with clearly defined populations (cancer patients), exposures (financial hardship, toxicity, or distress; travel-related burdens), and outcomes (treatment access, treatment outcomes, health-related quality of life, and survival/mortality). Study characteristics, methods, and findings were extracted and summarized.

RESULTS

Database searches yielded 6439 results, of which 3366 were unique citations. Of those, 141 were eligible for full-text review, and 98 studies at the intersection of cancer-related travel burdens and financial hardship were included. Five themes emerged as we extracted from the full texts of the included articles: 1) Cancer treatment choices, 2) Receipt of guideline-concordant care, 3) Cancer treatment outcomes, 4) Health-related quality of life, and 5) Propensity to participate in clinical trials.

CONCLUSIONS

This scoping review identifies and summarizes available research at the intersection of cancer care-related travel burdens and financial hardship. This review will inform the development of future interventions aimed at reducing the negative effects of cancer-care related costs on patient outcomes and quality of life.

The COVID-19 pandemic and associated declines in cancer incidence by race/ethnicity and census-tract level SES, rurality, and persistent poverty status

BACKGROUND

The COVID-19 pandemic had a significant impact on cancer screening and treatment, particularly in 2020. However, no single study has comprehensively analyzed its effects on cancer incidence and disparities among groups such as race/ethnicity, socioeconomic status (SES), persistent poverty (PP), and rurality.

METHODS

Utilizing the recent data from the United States National Cancer Institute's Surveillance, Epidemiology, and End Results Program, we calculated delay- and age-adjusted incidence rates for 13 cancer sites in 2020 and 2015-2019. Percent changes (PCs) of rates in 2020 compared to 2015-2019 were measured and compared across race/ethnic, census tract-level SES, PP, and rurality groups.

RESULTS

Overall, incidence rates decreased from 2015-2019 to 2020, with varying PCs by cancer sites and population groups. Notably, NH Blacks showed significantly larger PCs than NH Whites in female lung, prostate, and colon cancers (e.g., prostate cancer: NH Blacks -7.3, 95% CI: [-9.0, -5.5]; NH Whites: -3.1, 95% CI: [-3.9, -2.2]). Significantly larger PCs were observed for the lowest versus highest SES groups (prostate cancer), PP versus non-PP groups (prostate and female breast cancer), and all urban versus rural areas (prostate, female breast, female and male lung, colon, cervix, melanoma, liver, bladder, and kidney cancer).

CONCLUSIONS

The COVID-19 pandemic coincided with reduction in incidence rates in the U.S. in 2020 and was associated with worsening disparities among groups, including race/ethnicity, SES, rurality, and PP groups, across most cancer sites. Further investigation is needed to understand the specific effects of COVID-19 on different population groups of interest.

A meta-synthesis of the cycle of financial strain, coping behaviors and health outcomes across the life course

Background

The lived experience and impact of financial strain on broad physical and mental health outcomes is important and yet underexplored. Improving our depth of understanding of the relationship between financial strain and health may offer important insights to address this complex phenomenon.

Objective

The primary objective of this study was to conduct a meta-synthesis of existing qualitative literature that investigated or described the relationship between financial strain and health outcomes.

Methods

A search using Web of Science, PsycINFO, and PubMed identified 18,624 peer-reviewed manuscripts from 2009 to 2021 that examined the impact of financial strain on health outcomes. Selection for inclusion was limited to qualitative studies that included a research question or thematic finding related to financial strain. Literature reviews and non-U.S. based manuscripts were excluded. Selected studies (n = 25) underwent evaluation and thematic analysis using meta-synthesis methods.

Results

Twenty-five qualitative studies with a combined total of 1385 participants examined financial strain in relation to health. We identified three themes: 1) Financial strain: An intersection of threats to meeting basic needs; 2) Financial strain across the life course and intergenerational stress; and 3) The cycle of financial strain, coping behaviors and health outcomes. Our conceptual framework proposes that financial strain cyclically influences health outcomes, with threats to meeting basic needs resulting in decision making and coping that lead to disparities in health outcomes. We propose this model for further hypothesis generation and qualitative inquiry.

Conclusion

This meta-synthesis emphasizes the importance of considering the intersectionality of insecurities that affect safety and health and the need for adopting a life course perspective when researching the lived experience of financial strain. The complexity of the relationship between financial strain, coping behaviors, and health outcomes merits innovative approaches and further study.

Looking Back, Moving Forward: Challenges and Opportunities for Global Cervical Cancer Prevention and Control

Despite the introduction of Pap testing for screening to prevent cervical cancer in the mid-20th century, cervical cancer remains a common cause of cancer-related mortality and morbidity globally. This is primarily due to differences in access to screening and care between low-income and high-income resource settings, resulting in cervical cancer being one of the cancers with the greatest health disparity. The discovery of human papillomavirus (HPV) as the near-obligate viral cause of cervical cancer can revolutionize how it can be prevented: HPV vaccination against infection for prophylaxis and HPV testing-based screening for the detection and treatment of cervical pre-cancers for interception. As a result of this progress, the World Health Organization has championed the elimination of cervical cancer as a global health problem. However, unless research, investments, and actions are taken to ensure equitable global access to these highly effective preventive interventions, there is a real threat to exacerbating the current health inequities in cervical cancer. In this review, the progress to date and the challenges and opportunities for fulfilling the potential of HPV-targeted prevention for global cervical cancer control are discussed.

Persistent Neighborhood Poverty and Breast Cancer Outcomes

IMPORTANCE

Patients with breast cancer residing in socioeconomically disadvantaged communities often face poorer outcomes (eg, mortality) compared with individuals living in neighborhoods without persistent poverty.

OBJECTIVE

To examine persistent neighborhood poverty and breast tumor characteristics, surgical treatment, and mortality.

DESIGN, Setting, and Participants

A retrospective cohort analysis of women aged 18 years or older diagnosed with stage I to III breast cancer between January 1, 2010, and December 31, 2018, and followed up until December 31, 2020, was conducted. Data were obtained from the Surveillance, Epidemiology, and End Results Program, and data analysis was performed from August 2023 to March 2024.

EXPOSURE

Residence in areas affected by persistent poverty is defined as a condition where 20% or more of the population has lived below the poverty level for approximately 30 years.

MAIN OUTCOME AND MEASURES

All-cause and breast cancer-specific mortality.

RESULTS

Among 312 145 patients (mean [SD] age, 61.9 [13.3] years), 20 007 (6.4%) lived in a CT with persistent poverty. Compared with individuals living in areas without persistent poverty, patients residing in persistently impoverished CTs were more likely to identify as Black (8735 of 20 007 [43.7%] vs 29 588 of 292 138 [10.1%]; P < .001) or Hispanic (2605 of 20 007 [13.0%] vs 23 792 of 292 138 [8.1%]; P < .001), and present with more-aggressive tumor characteristics, including higher grade disease, triple-negative breast cancer, and advanced stage. A higher proportion of patients residing in areas with persistent poverty underwent mastectomy and axillary lymph node dissection. Living in a persistently impoverished CT was associated with a higher risk of breast cancer-specific (adjusted hazard ratio [AHR], 1.10; 95% CI, 1.03-1.17) and all-cause (AHR, 1.13; 95% CI, 1.08-1.18) mortality. As early as 3 years following diagnosis, mortality risks diverged for both breast cancer-specific (rate ratio [RR], 1.80; 95% CI, 1.68-1.92) and all-cause (RR, 1.62; 95% CI, 1.56-1.70) mortality.

CONCLUSIONS AND RELEVANCE

In this cohort study of women aged 18 years or older diagnosed with stage I to III breast cancer between 2010 and 2018, living in neighborhoods characterized by persistent poverty had implications on tumor characteristics, surgical management, and mortality.

Description of census-tract-level social determinants of health in cancer surveillance data

BACKGROUND

Disparities in cancer incidence, stage at diagnosis, and mortality persist by race, ethnicity, and many other social determinants, such as census-tract-level socioeconomic status (SES), poverty, and rurality. Census-tract-level measures of these determinants are useful for analyzing trends in cancer disparities.

METHODS

The purpose of this paper was to demonstrate the availability of the Surveillance, Epidemiology, and End Results Program's specialized census-tract-level dataset and provide basic descriptive cancer incidence, stage at diagnosis, and survival for 8 cancer sites, which can be screened regularly or associated with infectious agents. We present these analyses according to several census-tract-level measures, including the newly available persistent poverty as well as SES quintile, rurality, and race and ethnicity.

RESULTS

Census tracts with persistent poverty and low SES had higher cancer incidence rates (except for breast and prostate cancer), higher percentages of cases diagnosed with regional or distant-stage disease, and lower survival than non-persistent-poverty and higher-SES tracts. Outcomes varied by cancer site when analyzing based on rurality as well as race and ethnicity. Analyses stratified by multiple determinants showed unique patterns of outcomes, which bear further investigation.

CONCLUSIONS

This article introduces the Surveillance, Epidemiology, and End Results specialized dataset, which contains census-tract-level social determinants measures, including persistent poverty, rurality, SES quintile, and race and ethnicity. We demonstrate the capacity of these variables for use in producing trends and analyses focusing on cancer health disparities. Analyses may inform interventions and policy changes that improve cancer outcomes among populations living in disadvantaged areas, such as persistent-poverty tracts.

Rural-Urban Cancer Incidence and Trends in the United States, 2000 to 2019

BACKGROUND

Despite consistent improvements in cancer prevention and care, rural and urban disparities in cancer incidence persist in the United States. Our objective was to further examine rural-urban differences in cancer incidence and trends.

METHODS

We used the North American Association of Central Cancer Registries dataset to investigate rural-urban differences in 5-year age-adjusted cancer incidence (2015-2019) and trends (2000-2019), also examining differences by region, sex, race/ethnicity, and tumor site. Age-adjusted rates were calculated using SEER∗Stat 8.4.1, and trend analysis was done using Joinpoint, reporting annual percent changes (APC).

RESULTS

We observed higher all cancer combined 5-year incidence rates in rural areas (457.6 per 100,000) compared with urban areas (447.9), with the largest rural-urban difference in the South (464.4 vs. 449.3). Rural populations also exhibited higher rates of tobacco-associated, human papillomavirus-associated, and colorectal cancers, including early-onset cancers. Tobacco-associated cancer incidence trends widened between rural and urban from 2000 to 2019, with significant, but varying, decreases in urban areas throughout the study period, whereas significant rural decreases only occurred between 2016 and 2019 (APC = -0.96). Human papillomavirus-associated cancer rates increased in both populations until recently with urban rates plateauing whereas rural rates continued to increase (e.g., APC = 1.56, 2002-2019).

CONCLUSIONS

Rural populations had higher overall cancer incidence rates and higher rates of cancers with preventive opportunities compared with urban populations. Improvements in these rates were typically slower in rural populations.

IMPACT

Our findings underscore the complex nature of rural-urban disparities, emphasizing the need for targeted interventions and policies to reduce disparities and achieve equitable health outcomes.

Persistent poverty disparities in incidence and outcomes among oral and pharynx cancer patients

PURPOSE

Disparities in oral cavity and pharyngeal cancer based on race/ethnicity and socioeconomic status have been reported, but the impact of living within areas that are persistently poor at the time of diagnosis and outcome is unknown. This study aimed to investigate whether the incidence, 5-year relative survival, stage at diagnosis, and mortality among patients with oral cavity and pharyngeal cancers varied by persistent poverty.

METHODS

Data were drawn from the SEER database (2006-2017) and included individuals diagnosed with oral cavity and pharyngeal cancers. Persistent poverty (at census tract) is defined as areas where ≥ 20% of the population has lived below the poverty level for ~ 30 years. Age-adjusted incidence and 5-year survival rates were calculated. Multivariable logistic regression was used to estimate the association between persistent poverty and advanced stage cancer. Cumulative incidence and multivariable subdistribution hazard models were used to evaluate mortality risk. In addition, results were stratified by cancer primary site, sex, race/ethnicity, and rurality.

RESULTS

Of the 90,631 patients included in the analysis (61.7% < 65 years old, 71.6% males), 8.8% lived in persistent poverty. Compared to non-persistent poverty, patients in persistent poverty had higher incidence and lower 5-year survival rates. Throughout 10 years, the cumulative incidence of cancer death was greater in patients from persistent poverty and were more likely to present with advanced-stage cancer and higher mortality risk. In the stratified analysis by primary site, patients in persistent poverty with oropharyngeal, oral cavity, and nasopharyngeal cancers had an increased risk of mortality compared to the patients in non-persistent poverty.

CONCLUSION

This study found an association between oral cavity and pharyngeal cancer outcomes among patients in persistent poverty indicating a multidimensional strategy to improve survival.

Place-Based Measures of Inequity and Vision Difficulty and Blindness

Importance

Known social risk factors associated with poor visual and systemic health in the US include segregation, income inequality, and persistent poverty.

Objective

To investigate the association of vision difficulty, including blindness, in neighborhoods with measures of inequity (Theil H index, Gini index, and persistent poverty).

Design, Setting, and Participants

This cross-sectional study used data from the 2012-2016 American Community Survey and 2010 US census tracts as well as Theil H index, Gini index, and persistent poverty measures from PolicyMap. Data analysis was completed in July 2023.

Main Outcomes and Measures

The main outcome was the number of census tract residents reporting vision difficulty and blindness (VDB) and the association with the Theil H index, Gini index, or persistent poverty, assessed using logistic regression.

Results

In total, 73 198 census tracts were analyzed. For every 0.1-unit increase in Theil H index and Gini index, there was an increased odds of VDB after controlling for census tract-level median age, the percentage of the population that identified as female sex, the percentage of the population that identified as a member of a racial or ethnic minority group, state, and population size (Theil H index: odds ratio [OR], 1.14 [95% CI, 1.14-1.14; P < .001]; Gini index: OR, 1.15 [95% CI, 1.15-1.15; P < .001]). Persistent poverty was associated with an increased odds of VDB after controlling for census tract-level median age, the percentage of the population that identified as female sex, the percentage of the population that identified as a member of a racial or ethnic minority group, state, and population size compared with nonpersistent poverty (OR, 1.36; 95% CI, 1.35-1.36; P < .001).

Conclusions and Relevance

In this cross-sectional study, residential measures of inequity through segregation, income inequality, or persistent poverty were associated with a greater number of residents living with VDB. It is essential to understand and address how neighborhood characteristics can impact rates of VDB.

Inclusion of marginalized populations in HPV vaccine modeling: A systematic review

OBJECTIVE

Models simulating the potential impacts of Human Papillomavirus (HPV) vaccine have been used globally to guide vaccination policies and programs. We sought to understand how and why marginalized populations have been incorporated into HPV vaccine simulation models.

METHODS

We conducted a systematic search of PubMed, CINAHL, Scopus, and Embase to identify studies using simulation models of HPV vaccination incorporating one or more marginalized population through stratification or subgroup analysis. We extracted data on study characteristics and described these overall and by included marginalized groups.

RESULTS

We identified 36 studies that met inclusion criteria, which modeled vaccination in 21 countries. Models included men who have sex with men (MSM; k = 16), stratification by HIV status (k = 9), race/ethnicity (k = 6), poverty (k = 5), rurality (k = 4), and female sex workers (k = 1). When evaluating for a marginalized group (k = 10), HPV vaccination was generally found to be cost-effective, including for MSM, individuals living with HIV, and rural populations. In studies evaluating equity in cancer prevention (k = 9), HPV vaccination generally advanced equity, but this was sensitive to differences in HPV vaccine uptake and use of absolute or relative measures of inequities. Only one study assessed the impact of an intervention promoting HPV vaccine uptake.

DISCUSSION

Incorporating marginalized populations into decision models can provide valuable insights to guide decision making and improve equity in cancer prevention. More research is needed to understand the equity impact of HPV vaccination on cancer outcomes among marginalized groups. Research should emphasize implementation - including identifying and evaluating specific interventions to increase HPV vaccine uptake.

Association between a network-based physician linchpin score and cancer patient mortality: a SEER-Medicare analysis

BACKGROUND

Patients with cancer frequently require multidisciplinary teams for optimal cancer outcomes. Network analysis can capture relationships among cancer specialists, and we developed a novel physician linchpin score to characterize "linchpin" physicians whose peers have fewer ties to other physicians of the same oncologic specialty. Our study examined whether being treated by a linchpin physician was associated with worse survival.

METHODS

In this cross-sectional study, we analyzed Surveillance, Epidemiology, and End Results-Medicare data for patients diagnosed with stage I to III non-small cell lung cancer or colorectal cancer (CRC) in 2016-2017. We assembled patient-sharing networks and calculated linchpin scores for medical oncologists, radiation oncologists, and surgeons. Physicians were considered linchpins if their linchpin score was within the top 15% for their specialty. We used Cox proportional hazards models to examine associations between being treated by a linchpin physician and survival, with a 2-year follow-up period.

RESULTS

The study cohort included 10 081 patients with non-small cell lung cancer and 9036 patients with CRC. Patients with lung cancer treated by a linchpin radiation oncologist had a 17% (95% confidence interval = 1.04 to 1.32) greater hazard of mortality, and similar trends were observed for linchpin medical oncologists. Patients with CRC treated by a linchpin surgeon had a 22% (95% confidence interval = 1.03 to 1.43) greater hazard of mortality.

CONCLUSIONS

In an analysis of Medicare beneficiaries with nonmetastatic lung cancer or CRC, those treated by linchpin physicians often experienced worse survival. Efforts to improve outcomes can use network analysis to identify areas with reduced access to multidisciplinary specialists.

Cancer statistics, 2024

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population-based cancer occurrence and outcomes using incidence data collected by central cancer registries (through 2020) and mortality data collected by the National Center for Health Statistics (through 2021). In 2024, 2,001,140 new cancer cases and 611,720 cancer deaths are projected to occur in the United States. Cancer mortality continued to decline through 2021, averting over 4 million deaths since 1991 because of reductions in smoking, earlier detection for some cancers, and improved treatment options in both the adjuvant and metastatic settings. However, these gains are threatened by increasing incidence for 6 of the top 10 cancers. Incidence rates increased during 2015-2019 by 0.6%-1% annually for breast, pancreas, and uterine corpus cancers and by 2%-3% annually for prostate, liver (female), kidney, and human papillomavirus-associated oral cancers and for melanoma. Incidence rates also increased by 1%-2% annually for cervical (ages 30-44 years) and colorectal cancers (ages <55 years) in young adults. Colorectal cancer was the fourth-leading cause of cancer death in both men and women younger than 50 years in the late-1990s but is now first in men and second in women. Progress is also hampered by wide persistent cancer disparities; compared to White people, mortality rates are two-fold higher for prostate, stomach and uterine corpus cancers in Black people and for liver, stomach, and kidney cancers in Native American people. Continued national progress will require increased investment in cancer prevention and access to equitable treatment, especially among American Indian and Alaska Native and Black individuals.

Racial and Ethnic Disparities in Cancer Occurrence and Outcomes in Rural United States: A Scoping Review

BACKGROUND

Cancer is the second-leading cause of death in the United States. Most studies have reported rural versus urban and Black versus White cancer disparities. However, few studies have investigated racial disparities in rural areas.

OBJECTIVE

We conducted a literature review to explore the current state of knowledge on racial and ethnic disparities in cancer attitudes, knowledge, occurrence, and outcomes in rural United States.

METHODS

A systematic search of PubMed and Embase was performed. Peer-reviewed articles published in English from 2004-2023 were included. Three authors independently reviewed the articles and reached a consensus.

RESULTS

After reviewing 993 articles, a total of 30 articles met the inclusion criteria and were included in the present review. Studies revealed that underrepresented racial and ethnic groups in rural areas were more likely to have low cancer-related knowledge, low screening, high incidence, less access to treatment, and high mortality compared to their White counterparts.

CONCLUSION

Underrepresented racial and ethnic groups in rural areas experienced a high burden of cancer. Improving social determinants of health may help reduce cancer disparities and promote health.

Barriers, facilitators, and priority needs related to cancer prevention, control, and research in rural, persistent poverty areas

PURPOSE

The purpose of this study was to identify the barriers, facilitators, and priority needs related to cancer prevention, control, and research in persistent poverty areas.

METHODS

We conducted three focus groups with 17 providers and staff of primary care clinics serving persistent poverty areas throughout the state of Arkansas.

RESULTS

We identified multiple barriers, facilitators, and priority needs related to cancer prevention and control at primary care clinics serving persistent poverty areas. Barriers included transportation, medical costs, limited providers and service availability, and patient fear/discomfort with cancer topics. Facilitators identified were cancer navigators and community health events/services, and priority needs included patient education, comprehensive workflows, improved communication, and integration of cancer navigators into healthcare teams. Barriers to cancer-related research were lack of provider/staff time, patient uncertainty/skepticism, patient health literacy, and provider skepticism/concerns regarding patient burden. Research facilitators included better informing providers/staff about research studies and leveraging navigators as a bridge between clinic and patients.

CONCLUSION

Our results inform opportunities to adapt and implement evidence-based interventions to improve cancer prevention, control, and research in persistent poverty areas. To improve cancer prevention and control, we recommend locally-informed strategies to mitigate patient barriers, improved patient education efforts, standardized patient navigation workflows, improved integration of cancer navigators into care teams, and leveraging community health events. Dedicated staff time for research, coordination of research and clinical activities, and educating providers/staff about research studies could improve cancer-related research activities in persistent poverty areas.

Association of rurality, socioeconomic status, and race with pancreatic cancer surgical treatment and survival

BACKGROUND

Pancreatectomy is a necessary component of curative intent therapy for pancreatic cancer, and patients living in nonmetropolitan areas may face barriers to accessing timely surgical care. We evaluated the intersecting associations of rurality, socioeconomic status (SES), and race on treatment and outcomes of Medicare beneficiaries with pancreatic cancer.

METHODS

We conducted a retrospective cohort study, using fee-for-service Medicare claims of beneficiaries with incident pancreatic cancer (2016-2018). We categorized beneficiary place of residence as metropolitan, micropolitan, or rural. Measures of SES were Medicare-Medicaid dual eligibility and the Area Deprivation Index. Primary study outcomes were receipt of pancreatectomy and 1-year mortality. Exposure-outcome associations were assessed with competing risks and logistic regression.

RESULTS

We identified 45 915 beneficiaries with pancreatic cancer, including 78.4%, 10.9%, and 10.7% residing in metropolitan, micropolitan, and rural areas, respectively. In analyses adjusted for age, sex, comorbidity, and metastasis, residents of micropolitan and rural areas were less likely to undergo pancreatectomy (adjusted subdistribution hazard ratio = 0.88 for rural, 95% confidence interval [CI] = 0.81 to 0.95) and had higher 1-year mortality (adjusted odds ratio = 1.25 for rural, 95% CI = 1.17 to 1.33) compared with metropolitan residents. Adjustment for measures of SES attenuated the association of nonmetropolitan residence with mortality, and there was no statistically significant association of rurality with pancreatectomy after adjustment. Black beneficiaries had lower likelihood of pancreatectomy than White, non-Hispanic beneficiaries (subdistribution hazard ratio = 0.80, 95% CI = 0.72 to 0.89, adjusted for SES). One-year mortality in metropolitan areas was higher for Black beneficiaries (adjusted odds ratio = 1.15, 95% CI = 1.05 to 1.26).

CONCLUSIONS

Rurality, socioeconomic deprivation, and race have complex interrelationships and are associated with disparities in pancreatic cancer treatment and outcomes.

Examining the association of clinician characteristics with perceived changes in cervical cancer screening and colposcopy practice during the COVID-19 pandemic: a mixed methods assessment

Background

The COVID-19 pandemic led to reductions in cervical cancer screening and colposcopy. Therefore, in this mixed method study we explored perceived pandemic-related practice changes to cervical cancer screenings and colposcopies.

Methods

In 2021, a national sample of 1251 clinicians completed surveys, including 675 clinicians who performed colposcopy; a subset (n=55) of clinicians completed qualitative interviews.

Results

Nearly half of all clinicians reported they were currently performing fewer cervical cancer screenings (47%) and colposcopies (44% of those who perform the procedure) than before the pandemic. About one-fifth (18.6%) of colposcopists reported performing fewer LEEPs than prior to the pandemic. Binomial regression analyses indicated that older, as well as internal medicine and family medicine clinicians (compared to OB-GYNs), and those practicing in community health centers (compared to private practice) had higher odds of reporting reduced screening. Among colposcopists, internal medicine physicians and those practicing in community health centers had higher odds of reporting reduced colposcopies. Qualitative interviews highlighted pandemic-related care disruptions and lack of tracking systems to identify overdue screenings.

Conclusions

Reductions in cervical cancer screening and colposcopy among nearly half of clinicians more than 1 year into the pandemic raise concerns that inadequate screening and follow-up will lead to future increases in preventable cancers.

Funding

This study was funded by the American Cancer Society, who had no role in the study's design, conduct, or reporting.

The contribution of prognostic factors to socio-demographic inequalities in breast cancer survival in Victoria, Australia

BACKGROUND

Breast cancer survival in Australia varies according to socio-economic status (SES) and between rural and urban places of residence. Part of this disparity may be due to differences in prognostic factors at the time of diagnosis.

METHODS

Women with invasive breast cancer diagnosed from 2008 until 2012 (n = 14,165) were identified from the Victorian Cancer Registry and followed up for 5 years, with death from breast cancer or other causes recorded. A prognostic score, based on stage at diagnosis, cancer grade, whether the cancer was detected via screening, reported comorbidities and age at diagnosis, was constructed for use in a mediation analysis.

RESULTS

Five-year breast cancer mortality for women with breast cancer who were in the lowest quintile of SES (10.3%) was almost double that of those in the highest quintile (5.7%). There was a small survival advantage (1.7% on average, within each socio-economic quintile) of living in inner-regional areas compared with major cities. About half of the socio-economic disparity was mediated by prognostic factors, particularly stage at diagnosis and the presence of comorbidities. The inner-regional survival advantage was not due to differences in prognostic factors.

CONCLUSIONS

Part of the socio-economic disparity in breast cancer survival could be addressed by earlier detection in, and improved general health for, more disadvantaged women. Further research is required to identify additional causes of socio-economic disparities as well as the observed inner-regional survival advantage.

Assessing the Needs of Those Who Serve the Underserved: A Qualitative Study among US Oncology Clinicians

BACKGROUND

The American Society of Clinical Oncology established the 'Supporting Providers Serving the Underserved' (SUS) Task Force with a goal to develop recommendations to support cancer clinicians who deliver care for populations at risk for cancer disparities. As a first step, the Task Force explored barriers and facilitators to equitable cancer care delivery.

METHODS

Clinicians across the United States who deliver care predominantly for low-income and racially and ethnically minoritized populations were identified based on lists generated by the Task Force and the Health Equity Committee. Through purposive sampling based on geographical location, clinicians were invited to participate in 30-60 min semi-structured interviews to explore experiences, barriers, and facilitators in their delivery of cancer care. Interviews were recorded, transcribed, imported into qualitative data management software, and analyzed using thematic analysis.

RESULTS

Thematic analysis revealed three major themes regarding barriers (lack of executive leadership recognition of resources; patient-related socio-economic needs; clinician burnout) and two major themes regarding facilitators (provider commitment, experiential training).

CONCLUSIONS

Findings reveal modifiable barriers and potential solutions to facilitate equitable cancer care delivery for populations at risk for cancer disparities.

Neighborhood deprivation, racial segregation and associations with cancer risk and outcomes across the cancer-control continuum

The racial/ethnic disparities in cancer incidence and outcome are partially due to the inequities in neighborhood advantage. Mounting evidences supported a link between neighborhood deprivation and cancer outcomes including higher mortality. In this review, we discuss some of the findings related to work on area-level neighborhood variables and cancer outcomes, and the potential biological and built/natural environmental mechanisms that might explain this link. Studies have also shown that residents of deprived neighborhoods or of racially or economically segregated neighborhoods have worse health outcomes than residents of more affluent neighborhoods and/or less racially or economically segregated neighborhoods, even after adjusting for the individual-level socioeconomic status. To date, little research has been conducted investigating the biological mediators that may play roles in the associations of neighborhood deprivation and segregation with cancer outcomes. The psychophysiological stress induced by neighborhood disadvantage among people living in these neighborhoods could be a potential underlying biological mechanism. We examined a number of chronic stress-related pathways that may potentially mediate the relationship between area-level neighborhood factors and cancer outcomes, including higher allostatic load, stress hormones, altered epigenome and telomere maintenance and biological aging. In conclusion, the extant evidence supports the notion that neighborhood deprivation and racial segregation have unfavorable impacts on cancer. Understanding how neighborhood factors influence the biological stress response has the potential to inform where and what types of resources are needed within the community to improve cancer outcomes and reduce disparities. More studies are warranted to directly assess the role of biological and social mechanisms in mediating the relationship between neighborhood factors and cancer outcomes.

Association of distance traveled on receipt of surgery in patients with locally advanced rectal cancer

PURPOSE

Studies have shown patients residing in rural settings have worse cancer-related outcomes than those in urban settings. Specifically, rural patients with colorectal cancer have lower rates of screening and longer time to treatment. However, physical distance traveled has not been as well studied. This study sought to determine disparities in receipt of surgery in patients by distance traveled for care.

METHODS

A retrospective cohort study of patients with AJCC stage II/III rectal adenocarcinoma was identified within the National Cancer Database (2004-2017). Primary outcome was correlation of distance traveled to receipt of surgery. Multi-variable logistic regression was used to adjust for confounding factors.

RESULTS

65,234 patients were included in the analysis. 94.6% resided in urban-metro areas while 2.2% resided in rural areas. Patients were predominantly non-Hispanic White (NHW) (75.2%) with an overall median age at diagnosis of 61 (IQR 52-71). Overall, 82.6% of patients received surgery. NHW patients were more likely to receive surgery than non-Hispanic Black patients (OR 0.67; 95% CI 0.61-0.73, p < 0.001), as were patients who were privately insured (OR 1.90, 95% CI 1.67-2.15, p < 0.001) or had Medicare (OR 1.68, 95% CI 1.47-1.92, p < 0.001) compared to uninsured patients. Patients traveling distances in the 4th quartile (median 47.9 miles) were more likely to receive surgery than those traveling the shortest distances (1st quartile: median 2.5 miles) (OR 1.37, 95% CI 1.24-1.50, p < 0.001).

CONCLUSION

Patients traveling farther distances were more likely to receive surgery than those traveling shorter distances. Shorter distance traveled does not appear to be associated with higher rates of surgical resection in patients with stage II/III rectal cancer.

Use of a Novel Network-Based Linchpin Score to Characterize Accessibility to the Oncology Physician Workforce in the United States

Importance

Physician headcounts provide useful information about the cancer care delivery workforce; however, efforts to track the oncology workforce would benefit from new measures that capture how essential a physician is for meeting the multidisciplinary cancer care needs of the region. Physicians are considered linchpins when fewer of their peers are connected to other physicians of the same specialty as the focal physician. Because they are locally unique for their specialty, these physicians' networks may be particularly vulnerable to their removal from the network (eg, through relocation or retirement).

Objective

To examine a novel network-based physician linchpin score within nationwide cancer patient-sharing networks and explore variation in network vulnerability across hospital referral regions (HRRs).

Design, Setting, and Participants

This cross-sectional study analyzed fee-for-service Medicare claims and included Medicare beneficiaries with an incident diagnosis of breast, colorectal, or lung cancer from 2016 to 2018 and their treating physicians. Data were analyzed from March 2022 to October 2022.

Exposures

Physician characteristics assessed were specialty, rurality, and Census region. HRR variables assessed include sociodemographic and socioeconomic characteristics and use of cancer services.

Main Outcomes and Measures

Oncologist linchpin score, which examined the extent to which a physician's peers were connected to other physicians of the same specialty as the focal physician. Network vulnerability, which distinguished HRRs with more linchpin oncologists than expected based on oncologist density. χ2 and Fisher exact tests were used to examine relationships between oncologist characteristics and linchpin score. Spearman rank correlation coefficient (ρ) was used to measure the strength and direction of relationships between HRR network vulnerability, oncologist density, population sociodemographic and socioeconomic characteristics, and cancer service use.

Results

The study cohort comprised 308 714 patients with breast, colorectal, or lung cancer. The study cohort of 308 714 patients included 161 206 (52.2%) patients with breast cancer, 76 604 (24.8%) patients with colorectal cancer, and 70 904 (23.0%) patients with lung cancer. In our sample, 272 425 patients (88%) were White, and 238 603 patients (77%) lived in metropolitan areas. The cancer patient-sharing network included 7221 medical oncologists and 3573 radiation oncologists. HRRs with more vulnerable networks for medical oncology had a higher percentage of beneficiaries eligible for Medicaid (ρ, 0.19; 95% CI, 0.08 to 0.29). HRRs with more vulnerable networks for radiation oncology had a higher percentage of beneficiaries living in poverty (ρ, 0.17; 95% CI, 0.06 to 0.27), and a higher percentage of beneficiaries eligible for Medicaid (ρ, 0.21; 95% CI, 0.09 to 0.31), and lower rates of cohort patients receiving radiation therapy (ρ, -0.18; 95% CI, -0.28 to -0.06; P = .003). The was no association between network vulnerability for medical oncology and percent of cohort patients receiving chemotherapy (ρ, -0.03; 95% CI, -0.15 to 0.08).

Conclusions and Relevance

This study found that patient-sharing network vulnerability was associated with poverty and lower rates of radiation therapy. Health policy strategies for addressing network vulnerability may improve access to interdisciplinary care and reduce treatment disparities.

Neighborhood disadvantage and lung cancer risk in a national cohort of never smoking Black women

BACKGROUND

Compared to women of other races who have never smoked, Black women have a higher risk of lung cancer. Whether neighborhood disadvantage, which Black women experience at higher rates than other women, is linked to never-smoking lung cancer risk remains unclear. This study investigates the association of neighborhood disadvantage and lung cancer risk in Black never-smoking women.

METHODS AND MATERIALS

This research utilized data from the Black Women's Health Study, a prospective cohort of 59,000 Black women recruited from across the US in 1995 and followed by biennial questionnaires. Associations of lung cancer incidence with neighborhood-level factors (including two composite variables derived from Census Bureau data: neighborhood socioeconomic status and neighborhood concentrated disadvantage), secondhand smoke exposure, and PM_2.5 were estimated using Fine-Gray subdistribution hazard models.

RESULTS

Among 37,650 never-smokers, 77 were diagnosed with lung cancer during follow-up from 1995 to 2018. The adjusted subdistribution hazard ratio (sHR) of lung cancer incidence with ten unit increase in neighborhood concentrated disadvantage index was 1.30 (95 % CI: 1.04, 1.63, p = 0.023). Exposure to secondhand smoke at work was associated with increased risk (sHR = 1.93, 95 % CI: 1.21, 3.10, p = 0.006), but exposure to secondhand smoke at home and PM_2.5 was not.

CONCLUSION

Worse neighborhood concentrated disadvantage was associated with increased lung cancer risk in Black women who never smoked. These findings suggest that non-tobacco-related factors in disadvantaged neighborhoods may be linked to lung cancer risk in Black women and that these factors must be understood and targeted to achieve health equity.