The effect of socioeconomic status on health-care delay and treatment of esophageal cancer

Disparities in Access to Multidisciplinary Cancer Consultations and Treatment for Patients With Early-Stage Non-Small Cell Lung Cancer: A SEER-Medicare Analysis

PURPOSE

Disparities in access to a multidisciplinary cancer consultation (MDCc) persist, and the role of physician relationships remains understudied. This study examined the extent to which multilevel factors, including patient characteristics and patient-sharing network measures reflecting the structure of physician relationships, are associated with an MDCc and receipt of stereotactic body radiation therapy versus surgery among patients with early-stage non-small cell lung cancer (NSCLC).

METHODS AND MATERIALS

In this cross-sectional study, we analyzed Surveillance, Epidemiology, and End Results (SEER)-Medicare data for patients diagnosed with stage I-IIA NSCLC from 2016 to 2017. We assembled patient-sharing networks and identified cancer specialists who were locally unique for their specialty, herein referred to as linchpins. The proportion of linchpin cancer specialists for each hospital referral region (HRR) was calculated as a network-based measure of specialist scarcity. We used multilevel multinomial logistic regression to estimate associations between study variables and receipt of an MDCc and multilevel logistic regression to examine the relationship between patient receipt of an MDCc and initial treatment.

RESULTS

Our study included 6120 patients with stage I-IIA NSCLC, of whom 751 (12.3%) received an MDCc, 1729 (28.3%) consulted only a radiation oncologist, 2010 (32.8%) consulted only a surgeon, and 1630 (26.6%) consulted neither specialist within 2 months of diagnosis. Compared with patients residing in an HRR with a low proportion of linchpin surgeons, those residing in an HRR with a high proportion of linchpin surgeons had a 2.99 (95% CI, 1.87-4.78) greater relative risk of consulting only a radiation oncologist versus receiving an MDCc and a 2.70 (95% CI, 1.68-4.35) greater relative risk of consulting neither specialist versus receiving an MDCc. Patients who received an MDCc were 5.32 times (95% CI, 4.27-6.63) more likely to receive stereotactic body radiation therapy versus surgery.

CONCLUSIONS

Physician networks are associated with receipt of an MDCc and treatment, underscoring the potential for leveraging patient-sharing network analysis to improve access to lung cancer care.

Nativity differences in socioeconomic barriers and healthcare delays among cancer survivors in the All of Us cohort

PURPOSE

We aimed to assess whether nativity differences in socioeconomic (SES) barriers and health literacy were associated with healthcare delays among US cancer survivors.

METHODS

"All of Us" survey data were analyzed among adult participants ever diagnosed with cancer. A binary measure of healthcare delay (1+ delays versus no delays) was created. Health literacy was assessed using the Brief Health Literacy Screen. A composite measure of SES barriers (education, employment, housing, income, and insurance statuses) was created as 0, 1, 2, or 3+. Multivariable logistic regression model tested the associations of (1) SES barriers and health literacy with healthcare delays, and (2) whether nativity modified this relationship.

RESULTS

Median participant age was 64 years (n = 10,020), with 8% foreign-born and 18% ethnic minorities. Compared to survivors with no SES barriers, those with 3+ had higher likelihood of experiencing healthcare delays (OR 2.18, 95% CI 1.84, 2.58). For every additional barrier, the odds of healthcare delays were greater among foreign-born (1.72, 1.43, 2.08) than US-born (1.27, 1.21, 1.34). For every 1-unit increase in health literacy among US-born, the odds of healthcare delay decreased by 9% (0.91, 0.89, 0.94).

CONCLUSION

We found that SES barriers to healthcare delays have a greater impact among foreign-born than US-born cancer survivors. Higher health literacy may mitigate healthcare delays among US cancer survivors. Healthcare providers, systems and policymakers should assess and address social determinants of health and promote health literacy as a way to minimize healthcare delays among both foreign- and US-born cancer survivors.

Distressed community index as a predictor of presentation and postoperative outcomes in ventral hernia repair

BACKGROUND

We evaluated the impact of socioeconomic status on presentation, management, and outcomes of ventral hernias.

METHODS

The Abdominal Core Health Quality Collaborative was queried for adult patients undergoing ventral hernia repair. Socioeconomic quintiles were assigned using the Distressed Community Index (DCI): prosperous (0-20), comfortable (21-40), mid-tier (41-60), at-risk (61-80), and distressed (81-100). Outcomes included presenting symptoms, urgency, operative details, 30-day outcomes, and one-year hernia recurrence rates. Multivariable regression evaluated 30-day wound complications.

RESULTS

39,494 subjects were identified; 32,471 had zip codes (82.2%).Urgent presentation (3.6% vs. 2.3%) and contaminated cases (0.83% vs. 2.06%) were more common in the distressed group compared to the prosperous group (p < 0.001). Higher DCI correlated with readmission (distressed: 4.7% vs prosperous: 2.9%,p < 0.001) and reoperation (distressed 1.8% vs prosperous: 0.92%,p < 0.001). Wound complications were independently associated with increasing DCI (p < 0.05). Clinical recurrence rates were similar at one-year (distressed: 10.4% vs prosperous: 8.6%, p = 0.54).

CONCLUSIONS

Inequity exists in presentation and perioperative outcomes for ventral hernia repair and efforts should be focused on increasing access to elective surgery and improving postoperative wound care.

Intake of Proton-Pump Inhibitors and Gastric Cancer within the Stomach Cancer Pooling (StoP) Project

BACKGROUND

A potential association between proton-pump inhibitors (PPI) and gastric cancer remains undefined. Thus, we aimed to evaluate such association within the Stomach cancer Pooling (StoP) Project.

METHODS

Data from five case-control studies of the StoP Project were included (1,889 cases and 6,517 controls). We assessed the impact of different exposure definitions, specifically any reported use of PPIs and exposure definitions based on the duration of PPI intake. Additionally, we modeled the dose-response relationship between the cumulative duration of PPI intake and gastric cancer.

RESULTS

Significant associations between PPI intake and gastric cancer, both overall and in the stratified analyses, were limited to exposure definitions based on short durations of intake. The overall odds ratio (OR) for any reported PPI intake was 1.78 [95% confidence interval (CI): 0.76-4.14]. In the dose-response analysis, the ORs of gastric cancer were found to be higher for short durations of PPI intake (6 months: OR 3.26; 95% CI: 2.40-4.42; one year: OR 2.14; 95% CI: 1.69-2.70; 2 years: OR 1.50; 95% CI: 1.22-1.85; 3 years: OR 1.27; 95% CI: 1.03-1.56), with the association becoming not significant for durations longer than 3 years.

CONCLUSIONS

Our findings suggest that the observed association between PPIs and gastric cancer might be mainly due to reverse causality.

IMPACT

The results of this study suggest that PPIs are a safe therapeutic choice regarding their effect on the occurrence of gastric cancer. See related commentary by Richman and Leiman, p. 1127.

Food Deserts Increase Readmission After Esophagectomy for Cancer: A Multi-institutional Study

BACKGROUND

Food deserts are low-income census tracts with poor access to supermarkets and are associated with worse outcomes in breast, colon, and a small number of esophageal cancer patients. This study investigated residency in food deserts on readmission rates in a multi-institutional cohort of esophageal cancer patients undergoing trimodality therapy.

METHODS

A retrospective review of patients who underwent trimodality therapy at 6 high-volume institutions from January 2015 to July 2019 was performed. Food desert status was defined by the United States Department of Agriculture by patient ZIP Code. The primary outcome was 30-day readmission after esophagectomy. Multilevel, multivariable logistic regression was used to model readmission on food desert status adjusted for diabetes, insurance type, length of stay, and any complication, treating the institution as a random factor.

RESULTS

Of the 453 records evaluated, 425 were included in the analysis. Seventy-three patients (17.4%) resided in a food desert. Univariate analysis demonstrated food desert patients had significantly increased 30-day readmission. No differences were seen in length of stay, complications, or 30-day mortality. In the adjusted logistic regression model, residing in a food desert remained a significant risk factor for readmission (odds ratio, 2.11; 95% CI, 1.07-4.15). There were no differences in 30-day, 90-day, or 1-year mortality based on food desert status, although readmission was associated with worse 90-day and 1-year mortality.

CONCLUSIONS

Food desert residence was associated with 30-day readmission after esophagectomy in patients undergoing trimodality treatment for esophageal cancer in this multi-institutional population. Identification of patients residing in a food desert may allow surgeons to focus preventative interventions during treatment and postoperatively to improve outcomes.

Sex differences in treatment allocation and survival of potentially curable gastroesophageal cancer: A population-based study

BACKGROUND

Although curative treatment options are identical for male and female gastroesophageal cancer patients, access to care and survival may vary. This study aimed to compare treatment allocation and survival between male and female patients with potentially curable gastroesophageal cancer.

METHODS

Nationwide cohort study including all patients with potentially curable gastroesophageal squamous cell or adenocarcinoma diagnosed between 2006 and 2018 registered in the Netherlands Cancer Registry. The main outcome, treatment allocation, was compared between male and female patients with oesophageal adenocarcinoma (EAC), oesophageal squamous cell carcinoma (ESCC), and gastric adenocarcinoma (GAC). Additionally, 5-year relative survival with relative excess risk (RER), that is, adjusted for the normal life expectancy, was compared.

RESULTS

Among 27,496 patients (68.8% men), most were allocated to curative treatment (62.8%), although rates dropped to 45.6%>70 years. Curative treatment rates were comparable among younger male and female patients (≤70 years) with gastroesophageal adenocarcinoma, while older females with EAC were less frequently allocated to curative treatment than males (OR = 0.85, 95% confidence interval [CI] 0.73-0.99). For those allocated to curative treatment, relative survival was superior for female patients with EAC (RER = 0.88, 95% CI 0.80-0.96) and ESCC (RER = 0.82, 95% CI 0.75-0.91), and comparable for males and females with GAC (RER = 1.02, 95% CI 0.94-1.11).

CONCLUSIONS

While curative treatment rates were comparable between younger male and female patients with gastroesophageal adenocarcinoma, treatment disparities were present between older patients. When treated, the survival of females with EAC and ESCC was superior to males. The treatment and survival gaps between male and female patients with gastroesophageal cancer warrant further exploration and could potentially improve treatment strategies and survival.

Factors associated with health care utilization and catastrophic health expenditure among cancer patients in China: Evidence from the China health and retirement longitudinal study

Background

Cancer, the leading cause of mortality in China, is a significant burden on patients, their families, the medical system, and society at large. However, there is minimal data on health service utilization and catastrophic health expenditure (CHE) among cancer patients in China. The objective of this study was to identify factors associated with health care utilization and CHE in Chinese cancer patients.

Methods

The 2018 wave of a nationally representative dataset, the China Health and Retirement Longitudinal Study, was used in our study. Of 18,968 respondents recruited for the analysis, 388 were clinically diagnosed with cancer. CHE was defined as household health expenditure that exceeded 40% of non-food household expenses. A binary logistic regression model was used to identify the risks of cancer exposure among all participants, along with the likelihood of CHE in households with cancer patients at the 40% threshold. A negative binomial regression model was used to identify determinants of health service utilization among cancer patients.

Results

Contracting a family physician (incidence rate ratio IRR: 2.38, 1.18-4.77), Urban Employee Basic Medical Insurance (IRR: 4.02, 1.91-8.46, compared to the uninsured), Urban and Rural Resident Basic Medical Insurance (IRR: 3.08, 1.46-6.49, compared to the uninsured), and higher per-capita household consumption were positively associated with inpatient service utilization. Patients with a college education and above reported a greater number of outpatient visits (IRR: 5.78, 2.56-13.02) but fewer inpatient hospital days (IRR: 0.37, 0.20-0.67). Being diagnosed with a non-cancer chronic non-communicable disease was associated with an increased number of outpatient visits (IRR: 1.20, 1.10-1.31). Of the 388 participants, 50.1% of households had CHE, which was negatively correlated with a larger household size (odds ratio OR: 0.52, 0.32-0.86) and lower socioeconomic status [for quintile 5 (lowest group) OR: 0.32, 0.14-0.72].

Conclusions

The socioeconomic characteristics of cancer patients had a considerable impact on their healthcare utilization. Individualized and targeted strategies for cancer management should be implemented to identify high-risk populations and trace the utilization of care among Chinese cancer patients. Strategic purchasing models in cancer care and social health insurance with expanded benefits packages for cancer patients are crucial to tackling the cancer burden in China.

The influence of socioeconomic status on access to cancer care and survival in resectable pancreatic cancer: a systematic review and meta-analysis

BACKGROUND

Socioeconomic status (SES) is an important factor affecting access to cancer care and survival. Its role in pancreatic cancer warrants scrutiny.

METHODS

A systematic review of major reference databases was undertaken. Categorization of the study population into low SES (LSES) and high SES (HSES) was based on the criteria employed in the individual studies. The outcome measures studied were stage of cancer presentation, access to care and overall survival. Meta-analysis was performed using random-effects models and trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results.

RESULTS

Thirteen studies meeting inclusion criteria were included in the meta-analysis, which demonstrated that LSES was associated with significantly lower rates of presentation at a non-metastatic stage and poorer access to cancer care, viz. surgery, chemotherapy and radiation therapy. Despite heterogeneity, TSA supported the findings, displaying minimal type I error.

CONCLUSION

As LSES is associated with delayed presentation, poorer access to care and poorer survival, SES should be considered a modifiable risk factor for poor outcomes in pancreatic cancer.

Gender Disparity and the Association Between Socioeconomic Status, Mental Health, and the Need for Long-Term Services and Support Among the Older Koreans

Background

Population aging-the inevitable increase in the percentage of older adults-is occurring all around the world as the fertility rate declines and life expectancy rises. This study examined the relationship between socioeconomic status (SES), mental health, and the need for long-term services and support (LTSS) among Korean older adults. It also aimed to provide evidence-based information for South Korea's long-term support services and programs.

Methods

This study used the data on older adults aged over 60 years from the 2018 Korean Longitudinal Study of Aging (KLoSA). Ultimately, 5,527 older adults were included in the database (42.6% men, 57.4% women). To clarify the association between SES, mental health, and the need for LTSS among older Korean men and women, chi-squared test, t-test, and structural equation modeling (SEM) were performed.

Results

The SEM analysis showed that a significant, negative association was observed between SES and the need for LTSS among these older adults-the higher SES groups would generally have less need for LTSS. Mental health had a strong, negative impact on the need for LTSS-better mental health status of the older individuals would indicate a lower need for LTSS, and the effect was stronger among older men. Meanwhile, the positive relationship between SES and mental health was verified-the higher the SES of these older adults the better their mental health.

Conclusions

Gender- and social class-sensitive impacts of mental health on the need for LTSS were observed in this study. These findings could provide an evidence-based reference for interventions targeting different genders and social classes in Korea's long-term care system, such as the enhancement of social welfare and mental health status of the older adults.

Residing in a food desert is associated with an increased risk of readmission following esophagectomy for cancer

Background

Nutritional status is related to treatment outcomes for esophageal cancer. Residing in a food desert (FD) has been associated with worse outcomes in breast and colon cancer. We assessed the association of residing in a FD on 30-day outcomes of esophageal cancer patients who received tri-modality therapy.

Methods

A retrospective review of patients who underwent esophagectomy (1/2015 to 7/2020, in New Hampshire, USA) was performed. Patients were excluded if they did not undergo neo-adjuvant treatment, required treatment outside of standard Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) protocol, or lacked both pre and post neo-adjuvant treatment computed tomography (CT) scans for review. Demographics, nutrition parameters, treatment characteristics, 30-day complications and 90-day mortality were reviewed. FD status was defined by the United States Department of Agriculture (USDA) Food Access Research Atlas and cross-referenced with patients' home zip code. Readmission was defined as readmission to any hospital for any reason within 30-day of discharge. Univariable analysis was conducted using Student's t-test or Wilcoxon rank-sum for continuous variables, and Fisher's exact test for categorical variables. Multivariable logistic regression was then used to model readmission status on FD status adjusted for measures statistically associated with readmission status at the P<0.10 in univariable analyses.

Results

Seventy-eight patients were included in the analysis. Overall pre-treatment prevalence of sarcopenia was 11.5% (9/78) and did not vary by FD status. Univariable analysis, demonstrated few significant differences between those who were readmitted and those who were not. On unadjusted analysis, patients who lived in a FD were 5 times more likely to be readmitted [5.16; 95% confidence interval (CI): 1.70-15.67] compared to those who did not. Residing in a FD remained a significant risk factor for readmission after adjustment for operative time, discharge to a rehabilitation facility and development of a grade III/IV complication [adjusted odds ratio (OR): 6.38; 95% CI: 1.45-28.08].

Conclusions

Our data suggest that residing in a FD is a prognostic factor for readmission after tri-modality therapy for esophageal cancer. Clinicians need to be aware that previously established nutritional markers may not completely capture nutritional status and living in a FD may significantly increase the risk of readmission in these patients.

Systematic review of neighborhood socioeconomic indices studied across the cancer control continuum

BACKGROUND

There is extensive interest in understanding how neighborhood socioeconomic status (nSES) may affect cancer incidence or survival. However, variability regarding items included and approaches used to form a composite nSES index presents challenges in summarizing overall associations with cancer. Given recent calls for standardized measures of neighborhood sociodemographic effects in cancer disparity research, the objective of this systematic review was to identify and compare existing nSES indices studied across the cancer continuum (incidence, screening, diagnosis, treatment, survival/mortality) and summarize associations by race/ethnicity and cancer site to inform future cancer disparity studies.

METHODS

Using PRISMA guidelines, peer-reviewed articles published between 2010 and 2019 containing keywords related to nSES and cancer were identified in PubMed.

RESULTS

Twenty-four nSES indices were identified from 75 studies. In general, findings indicated a significant association between nSES and cancer outcomes (n = 64/75 studies; 85.33%), with 42/64 (65.63%) adjusting for highly-correlated individual SES factors (e.g., education). However, the direction of association differed by cancer site, race/ethnicity, and nSES index.

CONCLUSIONS

This review highlights several methodologic and conceptual issues surrounding nSES measurement and potential associations with cancer disparities. Recommendations pertaining to the selection of nSES measures are provided, which may help inform disparity-related disease processes and improve the identification of vulnerable populations in need of intervention.

Association of Esophageal Cancer Mortality with Municipal Socioeconomic Deprivation Level in Japan, 2013–2017: An Ecological Study Using Nationwide Data

This study aimed to show geographical differences in esophageal cancer mortality in Japan and reveal an association of esophageal cancer mortality with municipal socioeconomic deprivation level. Esophageal cancer mortality data in the Vital Statistics from 2013 to 2017 for each municipality and corresponding population data were analyzed. The deprivation level was derived from the municipal socioeconomic variables by principal component analysis. Municipalities were classified into five quintiles based on the deprivation level, and an association between the level and esophageal cancer mortality was evaluated using a Bayesian spatial model. As a result of regression analysis, the relative risk of esophageal cancer mortality tended to become larger as the deprivation level increased irrespective of sex, and the relative risk of esophageal cancer mortality was significantly higher in quintile 5 (most deprived) than quintile 1 (least deprived) among men and women. These results suggest that the deprivation level increases the risk of esophageal cancer mortality in Japan.

The Influence of Socioeconomic Status on Esophageal Cancer in Taiwan: A Population-Based Study

Background: Esophageal cancer has extreme worldwide demographic and histologic variations in occurrence; thus, understanding the pathogenesis of esophageal cancer must be region- or country-based. We examined the incidence and tumor stage at diagnosis of esophageal cancer in relation to patients’ socioeconomic status (SES) in Taiwan. Method: This retrospective cohort study used data from Taiwan’s National Health Insurance Research Database and Taiwan Cancer Registry collected between January 2008 and December 2014. The records of 40- to 79-year-old patients diagnosed with esophageal cancer were retrieved. The distribution of the crude incidence rates of esophageal cancer by occupation and income variables was studied retrospectively. Cox proportional hazard model was used to adjust for potential confounders and compare the esophageal cancer incidence among four independent variables: age, gender, occupation, and income. Logistic regression analysis was applied to find the power of the independent variables on the odds ratio of late-stage presentation. Results: The analysis included 7763 subjects. Esophageal squamous cell carcinoma (ESCC) was the predominant histological type (96.6%) and 94.4% of patients were male. The peak affected age for ESCC was 50 to 59 years, whereas the risk of esophageal adenocarcinoma increased progressively with age. The risk of ESCC was significantly unfavorable for the most disadvantaged group, either in occupation or income, while in EAC, risk was unrelated to either factor. The stage of cancer at diagnosis was lower in the highest income groups than in the other two groups. Conclusion: Significant SES disparities in esophageal cancer incidence, based on occupation and income, are present in Taiwan. Low SES populations have a higher percentage of late-stage diagnosis. Resolution of the increasing socioeconomic disparities and narrowing the gaps in health inequities in Taiwan are needed.

Chemotherapy predictors and a time-dependent chemotherapy effect in metastatic esophageal cancer

BACKGROUND

Chemotherapy has long been shown to confer a survival benefit in patients with metastatic esophageal cancer. However, not all patients with metastatic disease receive chemotherapy.

AIM

To evaluate a large cancer database of metastatic esophageal cancer cases to identify predictors of receipt to chemotherapy and survival.

METHODS

We interrogated the National Cancer Database (NCDB) between 2004-2015 and included patients with M1 disease who had received or did not receive chemotherapy. A logistic regression model was used to examine the associations between chemotherapy and potential confounders and a Cox proportional hazards model was employed to examine the effect of chemotherapy on overall survival (OS). Propensity score analyses were further performed to balance measurable confounders between patients treated with and without chemotherapy.

RESULTS

A total of 29182 patients met criteria for inclusion in this analysis, with 21911 (75%) receiving chemotherapy and 7271 (25%) not receiving chemotherapy. The median follow-up was 69.45 mo. The median OS for patients receiving chemotherapy was 9.53 mo (9.33-9.72) vs 2.43 mo (2.27-2.60) with no chemotherapy. Year of diagnosis 2010-2014 [odds ratio (OR): 1.29, 95% confidence interval (CI): 1.17-1.43, P value < 0.001], median income > $46000 (OR: 1.49, 95%CI: 1.27-1.75, P value < 0.001), and node-positivity (OR: 1.35, 95%CI: 1.20-1.52, P < 0.001) were independent predictors of receiving chemotherapy, while female gender (OR: 0.86, 95%CI: 0.76-0.98, P = 0.019), black race (OR: 0.76, 95%CI: 0.67-0.93, P = 0.005), uninsured status (OR: 0.41, 95%CI: 0.33-0.52, P < 0.001), and high Charlson Comorbidity Index (CCI) (OR for CCI ≥ 2: 0.61, 95%CI: 0.50-0.74, P < 0.001) predicted for lower odds of receiving chemotherapy. Modeling the effect of chemotherapy on OS using a time-dependent coefficient showed that chemotherapy was associated with improved OS up to 10 mo, after which there is no significant effect on OS. Moreover, uninsured status [hazard ratio (HR): 1.20, 95%CI: 1.09-1.31, P < 0.001], being from the geographic Midwest (HR: 1.07, 95%CI: 1.01-1.14, P = 0.032), high CCI (HR for CCI ≥ 2: 1.16, 95%CI: 1.07-1.26, P < 0.001), and higher tumor grade (HR for grade 3 vs grade 1: 1.28, 95%CI: 1.14-1.44, P < 0.001) and higher T stage (HR for T1 vs T4: 0.89, 95%CI: 0.84-0.95, P < 0.001) were independent predictors of worse OS on multivariable analyses.

CONCLUSION

In this large, retrospective NCDB analysis, we identified several socioeconomic and clinicopathologic predictors for receiving chemotherapy and OS in patients with metastatic esophageal cancer. The benefit of chemotherapy on OS is time-dependent and favors early initiation. Focused outreach in lower income and underinsured patients is critical as receipt of chemotherapy is associated with improved OS.

Living experiences of patients with advanced cancer with low socioeconomic status: protocol for a systematic review of qualitative evidence

INTRODUCTION

The number of patients with advanced cancer is rapidly increasing, and the disease burden among those with low socioeconomic status (SES) has accordingly become a global concern. Low SES can adversely impact patients with advanced cancer. The purpose of this systematic review is to shed light on the life experiences of patients with advanced cancer with low SES to help provide targeted and effective strategies to improve their quality of life.

METHODS AND ANALYSIS

We will include the following English databases: Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, PubMed, MEDLINE, Embase, Web of Science, Joanna Briggs Institute (JBI) Database of Systematic Reviews, PsycINFO and OpenGrey, and the following Chinese databases: China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals and Wanfang Data Knowledge Service Platform. A comprehensive search of qualitative studies on the experiences of patients with advanced cancer with low SES will be conducted from the above databases, with no age limit. Quality assessments of the studies will be independently performed by two reviewers using the JBI Critical Assessment Checklist, and any disagreements will be resolved through a discussion with a third reviewer. Relevant data will be extracted using the JBI standardised data extraction tools. The JBI meta-aggregation tool will be used to compare, analyse and summarise the original results. The reliability and credibility of the overall quality of the studies included will be evaluated using the JBI ConQual approach.

ETHICS AND DISSEMINATION

This study is based on existing public literature and therefore does not require a formal ethics review. The results of the study may be presented in peer-reviewed international journals and presented at scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42021250423.

Socioeconomic status and clinical stage of patients presenting for treatment of chronic venous disease

OBJECTIVES

The association between socioeconomic status (SES) and chronic venous insufficiency has not been rigorously studied. This study aimed to determine the influence of SES on the clinical stage of patients presenting for chronic venous disease therapy.

METHODS

We performed a retrospective study of a prospectively collected data from the Vascular Quality Initiative Varicose Vein Registry at our tertiary referral center. Medical records of patients who underwent therapy for chronic venous disease between January 2015 and June 2019 were queried. SES was quantified using the neighborhood deprivation index (NDI), which summarizes 8 domains of socioeconomic deprivation and is based on census tract data derived from the patients' addresses at the time of the treatment. High NDI scores correspond with lower SES. The association between SES and severity of vein disease at presentation was assessed with bivariate analysis of variance and linear regression analysis.

RESULTS

A total of 449 patients with complete SES and clinical-etiology-anatomy-pathophysiology (CEAP) class data were included in the study. The mean age was 58 years, 67% were female, and 60% were White. CEAP classes were distributed as follows C2, 22%; C3, 50%; C4, 15%; C5, 5%; and C6, 8%. Patients with lower SES (higher NDI score) tended to have a higher CEAP class at presentation (P < 0.05). SES was not associated with history of deep venous thrombosis, use of compression therapy, or venous clinical severity score.

CONCLUSIONS

At our institution, patients with more advanced venous disease tended to belong to a lower SES group. This may reflect that patients with a lower SES have a longer time to presentation due to delay in seeking medical help for venous disease.

Social determinants of health and treatment decisions in head and neck cancer

BACKGROUND

This study compares select social determinants of health (SDOH) with treatment modality selection and treatment completion in head and neck cancer (HNC) patients, to better understand disparities in health outcomes.

METHODS

A retrospective cohort study of HNC (n = 1428) patients was conducted. Demographic and disease-specific variables were recorded, including treatment modality selection and completion. Data were analyzed using two-sample t tests, chi-square, and Fisher's exact tests.

RESULTS

Primary language was significantly associated with treatment choice, where non-English speakers were less likely to choose treatment as recommended by the Tumor Board. Lower mean distance from the hospital (37.38 [48.31] vs. 16.92 [19.10], p < 0.0001) and a county-based higher mean percentage of bachelor degree or higher education (42.16 [8.82] vs. 44.95 [6.19], p < 0.0003) were associated with treatment selection.

CONCLUSION

Language, distance from the hospital, and education affected treatment selection in this study and may be useful in understanding how to counsel patients on treatment selection for HNC.

Older cancer survivors living with financial hardship in China: A qualitative study of family perspectives

OBJECTIVE

Financial hardship among older cancer survivors has not been well-studied, despite its debilitating effects on their health and well-being. The purpose of this study was to describe the lived experiences of Chinese older cancer survivors who have experienced financial hardship following a cancer diagnosis.

METHODS

A qualitative study was conducted. Data was collected using in-depth interviews with 21 older cancer survivors (aged ≥ 60) with financial hardship and 20 family caregivers in Shandong Province, China between August 2020 and January 2021. Data were analyzed using Colaizzi's phenomenological method.

RESULTS

Four main themes emerged: (1) older survivors have insufficient ability to address cancer-related costs; (2) financial transfers from adult children to older parents became prevalent after a cancer diagnosis; (3) cancer-related financial worries and stress extended into children's families; (4) coping and adjustment strategies were used by the extended family. Traditional Confucian culture and the Chinese health care system considerably impacted the interpretation of financial hardship.

CONCLUSION

Both older cancer survivors and their adult children experienced financial distress impacted by filial piety in China. Strategies adapted to Confucian family values and the health care system are needed to address cancer-related financial hardships.

Racial and socioeconomic disparities in urgent transcatheter mitral valve repair: A National Inpatient Sample analysis

BACKGROUND

Cardiac interventions performed urgently are known to be associated with poor outcomes compared with electively performed procedures. Transcatheter edge-to-edge mitral valve repair (TMVr) has developed as a reasonable alternative to mitral valve surgery in certain patient populations. We aimed to leverage a national database to identify predictors of urgent versus elective TMVr, as well as the association between urgency and outcomes.

METHODS

The National Inpatient Sample (NIS) was queried to identify patients who underwent TMVr from 2016 to 2017. Hospitalizations were identified within the database as elective versus nonelective. Univariate and multivariable analyses were performed to identify patient characteristics associated with urgent procedures. In-hospital outcomes were assessed.

RESULTS

There were 10,195 cases of TMVr in this cohort, 24.2% of which were performed urgently. In multivariable analysis, Hispanic race, Medicaid insurance, and low income were associated with increased likelihood of urgent hospital admission and TMVr. Additionally, small hospital size and Northeast region were associated with increased likelihood of urgent admission and procedure. Urgent TMVr was associated with increased mortality (4.5% vs. 1.6%, p < .001), prolonged length of stay (6.0 vs. 2.0, p < .001), and increased cost ($71,451.90 vs. $44,981.20, p < .001).

CONCLUSIONS

Racial and socioeconomic disparities exist in the utilization of TMVr as an urgent versus elective procedure, suggesting differences in access to surveillance and preventive care. Urgent TMVr is associated with increased morbidity and mortality, prolonged length of stay, and increased hospital costs. Priority should be placed on mitigating such disparities to improve outcomes.

Survival Disparities in Multiple Myeloma by Health Insurance Status among US Non-Elderly Adults: A SEER-Based Comparative Analysis

BACKGROUND/AIM

The impacts of health insurance status on survival outcomes in multiple myeloma (MM) have not been addressed in depth. The present study was conducted to identify definite relationships of cancer-specific survival (CSS) and overall survival (OS) with health insurance status in MM patients.

METHODS

MM patients aged 18-64 years and with complete insurance records between January 1, 2007, and December 31, 2016, were identified from 18 Surveillance, Epidemiology, and End Results (SEER) Database registries. Health insurance condition was categorized as uninsured, any Medicaid, insured, and insured (no specifics). Relationships of health insurance condition with OS/CSS were identified through Kaplan-Meier, and uni-/multivariate Cox regressions using the hazard ratio and 95% confidence interval. Potential baseline confounding was adjusted using multiple propensity score (mPS).

RESULTS

Totally 17,981 patients were included, including 68.3% with private insurance and only 4.9% with uninsurance. Log-rank test uncovered significant difference between health insurance status and OS/CSS among MM patients. Patients with non-insurance or Medicaid coverage in comparison with private insurance tended to present poorer OS/CSS both in multivariate Cox regression and in mPS-adjusted model (non-insurance vs. private insurance [OS/CSS]: 1.33 [1.20-1.48]/1.13 [1.00-1.28] and 1.45 [1.25-1.69]/1.18 [1.04-1.33], respectively; Medicaid coverage vs. private insurance [OS/CSS]: 1.67 [1.56-1.78]/1.25 [1.16-1.36] and 1.76 [1.62-1.90]/1.23 [1.13-1.35], respectively).

CONCLUSIONS

Our observational study of exposure-outcome associations suggests that insufficient or no insurance is moderately linked with OS among MM patients aged 18-64 years. Wide insurance coverage and health-care availability may strengthen some disparate outcomes. In the future, prospective cohort research is needed to further clarify concrete risks with insurance type, owing to the lack of definite division of insurance data in SEER.

Associations of insurance, urbanity, and comorbidity with types of palliative care received by patients with head and neck cancer

BACKGROUND

Our study examined some of the social and medical factors associated with receiving pain palliation alone over more aggressive cytoreductive palliative measures, such as surgery, chemotherapy, or radiation among patients with head and neck cancer.

METHODS

This retrospective study used the National Cancer Database 2016 for data analysis. Patient and tumor characteristics were examined using bivariate analysis and logistic regression to identify their association with receiving pain palliation alone versus cytoreductive palliation treatment.

RESULTS

Using multivariate logistic regression analysis, insurance status (odds ratio [OR]: 0.27, 95% confidence interval [CI]: 0.15-0.50, p < 0.001), urbanity (OR: 1.73, 95%CI: 1.21-2.46, p = 0.002), and Charlson-Deyo scores greater than 3 (OR: 2.49, 95%CI: 1.38-4.47, p = 0.002) were significantly associated with receipt of pain palliation alone.

CONCLUSIONS

Clinicians should be aware of non-health-related factors, such as insurance status, that may influence patients' receipt of treatments in head and neck cancer.

Changes in cannabis use according to socioeconomic status among Finnish adolescents from 2000 to 2015

BACKGROUND

Despite reduced sanctions and more permissive attitudes toward cannabis use in the USA and Europe, the prevalences of adolescent cannabis use have remained rather stable in the twenty-first century. However, whether trends in adolescent cannabis use differ between socioeconomic groups is not known. The aim of this study was to examine trends in cannabis use according to socioeconomic status among Finnish adolescents from 2000 to 2015.

METHODS

A population-based school survey was conducted biennially among 14-16-year-old Finns between 2000 and 2015 (n = 761,278). Distributions for any and frequent cannabis use over time according to socioeconomic adversities were calculated using crosstabs and chi-square test. Associations between any and frequent cannabis use, time, and socioeconomic adversities were studied using binomial logistic regression results shown by odds ratios with 95% confidence intervals.

RESULTS

At the overall level, the prevalences of lifetime and frequent cannabis use varied only slightly between 2000 and 2015. Cannabis use was associated with socioeconomic adversities (parental unemployment in the past year, low parental education, and not living with both parents). The differences in any and frequent cannabis use between socioeconomic groups increased significantly over the study period.

CONCLUSIONS

Although the overall changes in the prevalence of adolescent cannabis use were modest, cannabis use increased markedly among adolescents with the most socioeconomic adversities. Socioeconomic adversities should be considered in the prevention of adolescent cannabis use.

Socioeconomic and health care coverage disparities in children, adolescents, and young adults with sarcoma

BACKGROUND

Socioeconomic and health care coverage disparities are established as poor prognostic markers in adults with sarcoma, but few studies examine these differences among pediatric, adolescents and young adults (AYA). This study examines the association between socioeconomic status (SES), insurance status, and disease presentation among children and AYA patients with sarcoma.

METHODS

This is a retrospective cohort study of patients aged 0-25 years with bone or soft tissue sarcoma from the National Cancer Database. SES assignments were based on estimated median income and education level. Patient demographics and clinical factors were compared by SES and insurance status. Multivariate logistic regression models were fitted to determine adjusted odds ratios of SES and insurance status on metastatic disease or tumor size ≥5 cm at time of presentation.

RESULTS

In a cohort of 9112 patients, 2932 (32.1%) had low, 2084 (22.8%) middle, and 4096 (44.9%) high SES. For insurance status, 5864 (64.3%) had private, 2737 (30.0%) public, and 511 (5.6%) were uninsured. Compared to high SES, patients with low SES were more likely to have metastatic disease (OR = 1.16, P = .03) and tumors ≥5 cm (OR = 1.29, P < .01). Compared to private insurance, public and no insurance were associated with metastatic disease (OR = 1.35, P < .01 and OR = 1.32, P = .02) and increased tumors ≥5 cm (OR = 1.28, P < .01 and OR = 1.67, P < .01).

CONCLUSIONS

SES disparities exist among children and AYA patients with sarcoma. Low SES and public or no insurance are associated with advanced disease at presentation. Further studies are needed to identify interventions to improve earlier detection of sarcomas in at-risk children and young adults.

SCAP Mediated GDF15-Induced Invasion and EMT of Esophageal Cancer

Background: GDF15 is a potential biomarker for patients with esophageal cancer (EC). However, the mechanistic role of GDF15 in the invasion and metastasis of EC remains poorly understood.

Methods: We determined the expression and function of GDF15 in esophageal cancer cells (ESCCs) and in patient tissue samples using western blotting, migration, and invasion assays, immunohistochemistry, Co-IP assays, and quantitative real-time-PCR. In addition, a pulmonary metastatic nude mouse model was used to determine the function of GDF15. We then supplemented our experimental results with database analysis to validate our findings.

Results: GDF15 was upregulated in EC, and was associated with poor differentiation, high metastasis rates, and worse prognosis. GDF15 knock-down reduced the migration and invasion of ESCCs. Co-IP assays demonstrated its association with SCAP, while GDF15 knock-down decreased SCAP levels. SCAP overexpression reversed the migration, invasion and EMT in GDF15-siRNA ESCCs. However, after incubation with β-cyclodextrin (β-CD), the ability of migration and invasion was weakened, EMT was reversed again. Migration, invasion, and EMT were enhanced in GDF15-siRNA ESCCs cultured in the presence of cholesterol and were similar to GDF15-siRNA ESCCs overexpressing SCAP. In vivo, knockdown of GDF15 inhibited lung metastasis of ESCCs and was reversed by SCAP overexpression or high cholesterol diet. Increased lung metastasis after SCAP overexpression was partially suppressed by intraperitoneal injection of β-CD. In addition, we determined that GDF15 was a direct target of miR-1324, miR-1324 was down-regulated in EC tissues. MiR-1324 upregulation resulted in decreased GDF15 expression and metastasis in ESCCs.

Conclusions: We demonstrated that SCAP mediated GDF15-induced the invasion and metastasis of EC by regulating cholesterol metabolism. In addition, GDF15 was shown to be a direct target of miR-1324.

Assessment of patients' understanding of and adherence to oral anticancer medication (OAM): Results of a cross-sectional institutional pilot study

BACKGROUND

Although oral anticancer medications (OAM) provide opportunity for treatment at home, challenges include prescription filling, monitoring side effects, safe handling, and adherence. We assessed understanding of and adherence to OAM in vulnerable patients.

METHODS

This 2018 pilot study defined vulnerable patients based on Chinese language, older age (≥65 years), and subsidized insurance. All participants had a cancer diagnosis and were taking an OAM filled through the hospital's specialty pharmacy. Participants reported on OAM taking (days per week, times per day, special instructions) and handling (handling, storage, disposal). The specialty pharmacist classified patient-reported responses about OAM taking and handling as adequate or inadequate. OAM regimens were classified by complexity.

RESULTS

Of 61 eligible patients, 55 participated. Mean age was 68 years (standard deviation [SD] = 12) and 53% were female. Patient subgroups were: 27% Chinese, 64% ≥65 years, and 9% subsidized insurance. Forty-nine percent were on frontline therapy and median time on OAM was 1 year (Quartile 1 = 0.4, Quartile 3 = 1.7). Adequacy of OAM taking (30%) and handling (15%) were low; 15% had adequacy in both. Adequacy of OAM taking and handling did not vary by patient subgroup or regimen complexity. Mean patient-reported adherence was high (5.4, SD = 1, possible range 1-6) and did not vary by adequacy of OAM taking or handling.

CONCLUSIONS

Understanding of OAM taking and handling in this group of vulnerable patients was low and did not align with patient-reported adherence. Future interventions should ensure that patients understand how to safely take and handle OAM, thereby optimizing their therapeutic potential.

Lower Socioeconomic Status is Associated With Adverse Urinary Markers and Surgical Complexity in Kidney Stone Patients

OBJECTIVE

To determine if socioeconomic status (SES) correlates with severity of kidney stone disease and 24-hour urine parameters.

MATERIALS AND METHODS

An IRB approved prospectively maintained database for nephrolithiasis was retrospectively analyzed for both 24-hour urine results and surgical procedures performed from 2009 to 2019. Severely distressed communities (SDC) were categorized as those with a Distressed Communities Index (DCI), a composite measure of SES, score in the top quartile (lowest for SES). Univariate and multivariate analyses were performed to evaluate the strength of the association of DCI on: stone size at presentation, need for and type of surgical procedure, need for staged surgery and specific stone risk factors in 24-hour urine collections.

RESULTS

Surgical procedures were performed on 3939 patients (1978 women) who were not from SDC and 200 (97 women) from SDC. Patients from SDC were older (57.1 years vs 54.2 years; P = .009). Patients from SDC were more likely to undergo proportionally more invasive procedures (17.5% vs 11.6%; P = .011) and require staged surgery at a higher rate (13.0% vs 8.5%; P = .028). Men from SDC had larger stones (12.5 mm vs 9.7 mm; P = .001). Among 24-hour urine results from 2454 patients (1187 women), DCI was not correlated with sodium, calcium, magnesium, volume, oxalate, phosphate, and pH levels. Higher DCI (lower SES) correlated with lower urine citrate (P = .001) and lower urine potassium (P = .002).

CONCLUSION

SES correlates with larger stone burden at the time of urologic intervention, requires proportionally more invasive procedures and more staged procedures. Lower SES correlated with lower urine citrate and potassium.

External validation of OroGrams as a predictive model for overall and progression-free survival in Scottish patients with oropharyngeal squamous cell carcinoma: a retrospective cohort study

The aims of this study were to externally validate the OroGrams (oropharyngeal cancer survival calculator) nomogram in a Scottish cohort with high endemic smoking rates, and to compare survival rates with the original validation cohort. A retrospective cohort study in Greater Glasgow and Clyde ENT and OMFS departments was performed to investigate survival outcomes of patients with oropharyngeal squamous cell carcinoma (OPSCC) from January 2012 - December 2017. The main outcome measures were progression-free (PFS) and overall survival (OS), and Kaplan Meier curves. The predictive accuracy of OroGrams was investigated for survival probabilities at one, three, and five years. Smoking and HPV-negative cancer rates were significantly higher in Scottish patients than in the UK consortium cohort. A greater proportion of Scottish patients had advanced UICC8 stages. PFS in patients with HPV-negative cancer appeared better in the Scottish cohort than in the original cohort. Calculated mean standardised Brier scores for PFS and OS were below 0.2 at all three follow-up points, suggesting good overall prognostic accuracy, but there was wide variation between predictive accuracy in individual patients. OroGrams shows prognostic accuracy at one-year follow up in Scotland. The accuracy decreases with longer follow-up periods.

Financial hardship in Chinese cancer survivors

BACKGROUND

The purpose of this study was to estimate the proportion of Chinese cancer survivors experiencing financial hardship and then examine the relationship between material and behavioral financial hardship.

METHODS

This study surveyed 964 cancer survivors who were 30 to 64 years old and 644 survivors who were 65 years old or older during 2015-2016 (1608 survivors in all). Material financial hardship was measured by whether they had borrowed money because of cancer, its treatment, or the lasting effects of treatment, and behavioral financial hardship was measured by whether they had forgone some cancer-related medical care because of cost. Multivariable logistic regression models were used to examine factors associated with material financial hardship by age group.

RESULTS

Approximately 44% of the cancer survivors who were 65 years old or older borrowed money or went into debt because of cancer, and 54% of younger patients (P < .01) reported cancer-related debts. Among these survivors with cancer care debt, survivors aged 65 years old or older had a lower proportion of borrowing more than 50,000 Chinese yuan (CNY; approximately US $7700) than survivors aged 30 to 64 years (14% vs 20%). In both age groups, approximately 10% of cancer survivors reported that they had experienced behavioral financial hardship. After adjustments for covariates, cancer survivors who reported material financial problems were more likely to report behavioral financial hardship (odds ratio [OR] for those aged 30-64 years, 3.72; 95% confidence interval [CI], 2.13-6.50; OR for those aged 65 years or older, 5.48; 95% CI, 2.69-11.15).

CONCLUSIONS

Older cancer survivors in China experience significant material financial hardship, but it is not as noticeable as younger patients' hardship. The results highlight the importance of identifying cancer survivors who are more likely to experience financial hardship and improving the affordability of cancer care in China.

Refusal of cancer-directed treatment by colon cancer patients: Risk factors and survival outcomes

AIM

Surgery with or without chemotherapy represent the only curative option for patients with colon cancer. However, some patients refuse treatment despite the recommendation. This study aims to identify the incidence, risk factors and impact on survival associated with refusal.

METHODS

A National Cancer Data Base (NCDB) analysis between 1998 and 2012 was performed. We identified 924,290 patients with potentially treatable colon cancer. Patients who underwent treatment were compared with patients that refused.

RESULTS

7152 patients refused surgery. On multivariable analysis, patients were more likely to refuse if they were older (OR = 1.14; 95% CI 1.14-1.15), female (OR = 1.20; 95% CI 1.12-1.28), African American (vs White, OR = 2.30; 95% CI 2.10-2.51) or on Medicaid (vs private, OR = 3.06; 95% CI 2.49-43.77). Overall survival was worse in patients that refused surgery [median survival 6.8 vs 24 months, Cox hazard ratio (HR) 3.41; 95%CI 3.12-3.60]. Furthermore, 11,334 patients with path. stage III disease refused adjuvant chemotherapy.

CONCLUSIONS

Refusal of treatment affects survival and is independently associated with several variables (gender, race, insurance status), therefore raising the concern that socioeconomic factors may drive decisions.

Margin Positivity in Resectable Esophageal Cancer: Are there Modifiable Risk Factors?

BACKGROUND

Patients with esophageal cancer have poor overall survival, with positive resection margins worsening survival. Margin positivity rates are used as quality measures in other malignancies, but modifiable risk factors are necessary to develop actionable targets for improvement. Our objectives were to (1) evaluate trends in esophageal cancer margin positivity, and (2) identify modifiable patient/hospital factors associated with margin positivity.

METHODS

Patients who underwent esophagectomy from 2004 to 2015 were identified from the National Cancer Database. Trends in margin positivity by time and hospital volume were evaluated using Cochrane-Armitage tests. Associations between patient/hospital factors and margin positivity were assessed by multivariable logistic regression.

RESULTS

Among 29,706 patients who underwent esophagectomy for cancer, 9.37% had positive margins. Margin positivity rates decreased over time (10.62% in 2004 to 8.61% in 2015; p < 0.001). Older patients (≥ 75 years) were more likely to have positive margins [odds ratio (OR) 2.04, 95% confidence interval (CI) 1.42-2.92], as were patients with a Charlson-Deyo Index ≥ 3 (OR 1.84, 95% CI 1.08-3.12). Patients who received neoadjuvant therapy were less likely to have positive margins (OR 0.37, 95% CI 0.29-0.47), while laparoscopic surgical approach was associated with increased margin positivity (OR 1.70, 95% CI 1.40-2.06). As the hospital annual esophagectomy volume increased, margin positivity rates decreased (7.76% in the fourth quartile vs. 11.39% in the first quartile; OR 0.70, 95% CI 0.49-0.99).

CONCLUSIONS

Use of neoadjuvant therapy, surgical approach, and hospital volume are modifiable risk factors for margin positivity in esophageal cancer. These factors should be considered in treatment planning, and margin positivity rates could be considered as a quality measure in esophageal cancer.

Influence of Sociodemographic Factors on Treatment Decisions in Non-Small-Cell Lung Cancer

INTRODUCTION

In stage IV non-small-cell lung cancer (NSCLC), survival has significantly improved. Despite such trends, it has been noted that patients frequently refuse treatment. Therefore, we explored the factors associated with treatment refusal in NSCLC.

PATIENTS AND METHODS

Utilizing the National Cancer Data Base (NCDB), we identified all stage IV NSCLC cases from 2004 to 2014. Patients who received cancer treatment outside of the reporting facility were excluded. Multivariable logistic regression models were used to determine associations with treatment refusal.

RESULTS

A total of 341,993 patients were identified; 5.4% of patients refused radiotherapy and 10.3% refused chemotherapy despite provider recommendations. The proportion of patients refusing radiotherapy and chemotherapy increased over time from 4.2% to 7.3% and 7.9% to 15%, respectively (P < .001). In multivariable analysis, men were less likely to refuse treatment compared to women (respectively, odds ratio = 0.80; 95% confidence interval, 0.76-0.84; P < .001; odds ratio = 0.82; 95% confidence interval, 0.80-0.85; P < .001, respectively). Factors associated with radiotherapy refusal included: Medicaid or Medicare as primary insurance, uninsured status, low household median income, and lower educational level. Regarding chemotherapy, uninsured patients, Medicaid patients, and patients with a high comorbidity index were more likely to refuse chemotherapy. Asians had lower rates of chemotherapy refusal relative to non-Hispanic whites. Non-Hispanic whites, Hispanics, and Asians had increasing chemotherapy refusal rates over time, while non-Hispanic blacks had less pronounced trends over time.

CONCLUSION

Socioeconomic factors rather than race/ethnicity appear to influence the refusal of cancer treatment in patients with stage IV NSCLC. Assessing socioeconomic challenges should be an essential part of patient evaluation when discussing treatment options.

Comparative study of esophagectomy, endoscopic therapy, and radiotherapy for cT1N0M0 esophageal cancer in elderly patients: A SEER database analysis

BACKGROUND

The number of patients diagnosed with early stage disease (T1a or T1b) has been increasing. This study was conducted to investigate the effect of esophagectomy (ES), endoscopic therapy (ET), and radiotherapy (RT) on long-term survival in elderly patients with cT1N0M0 esophageal cancer.

METHODS

We searched the Surveillance, Epidemiology, and End Results (SEER) database to identify the records of elderly patients (≥ 75 years) with cT1N0M0 esophageal cancer between 2004 and 2014. Patient demographics and esophageal cancer parameters were compared among ES, ET, and RT groups. The Kaplan-Meier method and Cox proportional hazard modeling were used to compare long-term survival.

RESULTS

Data from 954 esophageal cancer patients (ES: n = 196; ET: n = 224; RT: n = 534) were identified. Multivariate Cox regression analysis showed that five-year survival in the ET and ES groups was significantly higher than in the RT group. After propensity score matching, we found no difference in five-year survival between ES and ET.

CONCLUSION

Using SEER data, we identified a significant survival advantage with the use of ES and ET compared to RT in patients with cT1N0M0 esophageal cancer aged > 75 years, while the long-term survival of patients after ET and ES was not significantly different.

Survey of Surgical Oncology Fellowship Graduates 2005-2016: Insight into Initial Practice

BACKGROUND

Despite burgeoning interest in Complex General Surgical Oncology (CGSO) fellowship training, little is reported about postgraduate employment. The goal of this study was to characterize CGSO graduates' first employment and to identify factors that influenced this decision.

METHODS

The National Cancer Institute (NCI) and Society of Surgical Oncology developed and distributed an electronic survey to CGSO fellows who graduated from 2005 to 2016.

RESULTS

The survey response rate was 47% (237/509). Fifty-seven percent of respondents were first employed as faculty surgeons at a university-based/affiliated hospital, with 15% returning to their residency institution. The distribution of respondents' current employment across the United States mirrored the locations of their hometowns. Eighty-five percent of respondents care for patients across at least three disease types, most commonly hepatopancreatobiliary (81%), esophagus/gastric (75%), and sarcoma (74%). Twenty-seven percent of respondents spend the majority of their time in one area of surgical oncology; melanoma, breast, and head/neck were the most common. Two-thirds of respondents (67%) reported that they performed either clinical or basic science research as part of their current position. Multiple factors influenced the decision of first faculty position.

CONCLUSIONS

Most CGSO graduates are employed at academic medical centers across the country in proximity to NCI-designated centers, treat a variety of disease types, and spend a percentage of their time dedicated to clinical research.

[Influence of Insurance Status on Survival of Surgically Treated Esophageal Cancer Patients]

Background/Aims

Socioecomomic factor is an important determinant of access to healthcare and is one of the potential causes of disparities in esophageal cancer care outcomes. The aim of the study was to clarify the association between National health Insurance status (health insurance vs. medicare) as a socioeconomic factor and survival of patients with esophageal cancer who underwent surgical resection.

Methods

Among the 66 patients who underwent surgical resection for esophageal cancer between January 2006 and December 2017, 17 patients (25.8%) were in the medicare group. The data were analyzed to identify clinical manifestations and to compare surgical and oncologic outcomes between the groups.

Results

There was no significant difference in the distribution of sex (p=0.13), age (p=0.24), and pathologic stage (p=0.61) between the groups. The length of median hospital stay was significantly shorter in the healthy insurance group (18 days vs. 25 days, p=0.04). In the medicare group, postoperative mortality rates and incidence of postoperative complication were non-significantly higher(11.8% vs. 6.1%, p=0.45, 64.7% vs. 46.7%, p=0.21, respectively). However, pulmonary complication rates, including pneumonia, acute respiratory distress syndorme, and prolonged air leakage was significantly higher in the medicare group (47.1% vs. 18.4%, p=0.02). Five-year disease free survival rate was not different between the two groups (61.0% vs. 54.5%, p=0.68); the 5-year overall survival rate was significantly lower in the medicare group (27.7% vs. 53.7%, p=0.03).

Conclusions

The medicare status of National health insurance could have a negative influence on the overall survival in patients with esophageal cancer who underwent surgery.

Nationwide population-based study reveals increased malignancy risk in taiwanese liver transplant recipients

Post-transplant malignancy is a major cause of late mortality for liver transplant recipients (LTRs). This nationwide population-based cohort study investigated the cancer type, incidence, and risk factors associated with post-transplant malignancies in 2938 Taiwanese LTRs who underwent transplantation between 1998 and 2012. Data from the National Health Insurance Research Database were extracted on the basis of the International Classification of Disease, Ninth Revision, Clinical Modification codes. Among these patients, 284 post-transplant malignancies were diagnosed. These included 99 de novo malignancies among 98 patients, yielding a standardized incidence ratio of 2.17 (95% CI, 1.76 to 2.64) compared to the general population. The most common malignancies were infection related liver cancer (19.39%), oropharyngeal cancer (19.39%), non-Hodgkin's lymphoma (9.18%), and esophageal cancer (5.10%), as well as non-infection-related prostate cancer (6.12%). Patients with recurrent malignancies had the highest mortality. Furthermore, 186 recurrent malignancies relapsed, and the commonly affected organs were the liver (83.33%), lung (4.84%), bone and bone marrow (4.30%), and intrahepatic bile ducts (2.69%). Old age, the male sex, liver cirrhosis, hepatitis B, peptic ulcer, diabetes mellitus, and pre-existing cancer were all risk factors associated with post-transplant malignancies. Recipients with biliary atresia or urea cycle metabolism disorders were protected from post-transplant malignancies. Our data revealed a significantly increased risk of malignancies in Taiwanese LTRs and suggest implementation of a careful malignancy-surveillance program and immunosuppression-minimizing strategy for high-risk patients.

Effects of socioeconomic status on esophageal adenocarcinoma stage at diagnosis, receipt of treatment, and survival: A population-based cohort study

The incidence of esophageal adenocarcinoma (EAC) is increasing worldwide and has overtaken squamous histology in occurrence. We studied the impact of socioeconomic status (SES) on EAC stage at diagnosis, receipt of treatment, and survival. A population-based retrospective cohort study was conducted using Ontario Cancer Registry-linked administrative health data. Multinomial logistic regression was used to examine the association between SES (income quintile) and stage at EAC diagnosis and EAC treatment. Survival times following EAC diagnosis were estimated using Kaplan-Meier method. Cox proportional-hazards regression analysis was used to examine the association between SES and EAC survival. Between 2003–2012, 2,125 EAC cases were diagnosed. Median survival for the lowest-SES group was 10.9 months compared to 11.6 months for the highest-SES group; the 5-year survival was 9.8% vs. 15.0%. Compared to individuals in the highest-SES group, individuals in the lowest-SES category experienced no significant difference in EAC treatment (91.6% vs. 93.3%, P = 0.314) and deaths (78.9% vs. 75.6%, P = 0.727). After controlling for covariates, no significant associations were found between SES and cancer stage at diagnosis and EAC treatment. Additionally, after controlling for age, gender, urban/rural residence, birth country, health region, aggregated diagnosis groups, cancer stage, treatment, and year of diagnosis, no significant association was found between SES and EAC survival. Moreover, increased mortality risk was observed among those with older age (P = 0.001), advanced-stage of EAC at diagnosis (P < 0.001), and those receiving chemotherapy alone, radiotherapy alone, or surgery plus chemotherapy (P < 0.001). Adjusted proportional-hazards model findings suggest that there is no association between SES and EAC survival. While the unadjusted model suggests reduced survival among individuals in lower income quintiles, this is no longer significant after adjusting for any covariate. Additionally, there is an apparent association between SES and survival when considering only those individuals diagnosed with stage 0-III EAC. These analyses suggest that the observed direct relationship between SES and survival is explained by patient-level factors including receipt of treatment, something that is potentially modifiable.

Potential factors associated with clinical stage of nasopharyngeal carcinoma at diagnosis: a case-control study

Background

In China, most patients with nasopharyngeal carcinoma (NPC) are diagnosed at a late stage and consequently have a poor prognosis. This study aimed to investigate potential factors associated with the clinical stage of NPC at diagnosis.

Methods

Data were obtained from 118 patients with early-stage NPC and 274 with late-stage NPC who were treated at Sun Yat-sen University Cancer Center between August 2014 and July 2015. Patients were individually matched by age, sex, and residence, and a conditional logistic regression model was applied to assess the associations of clinical stage at diagnosis with socioeconomic status indicators, knowledge of NPC, physical examinations, patient interval, and risk factors for NPC.

Results

Although knowledge of early NPC symptoms, smoking cessation, and patient interval were important factors, the number of cigarettes smoked per day, motorbike ownership, and physical examination exhibited the strongest associations with the clinical stage of NPC at diagnosis. Compared with smoking fewer than ten cigarettes a day, smoking 10–30 cigarettes [odds ratio (OR) 4.03; 95% confidence interval (CI) 1.11–14.68] or more than 30 cigarettes (OR 11.46; 95% CI 1.26–103.91) was associated with an increased risk of late diagnosis. Compared with not owning a motorbike, owning a motorbike (OR 0.38; 95% CI 0.23–0.64) was associated with early diagnosis. Subjects who underwent physical examinations were less likely to receive a late diagnosis than those who did not undergo examinations (OR 0.50; 95% CI 0.28–0.89). However, indicators of wealth were not significant factors.

Conclusions

Initiatives to improve NPC patient prognosis should aim to promote knowledge about early symptoms and detection, health awareness, and accessibility to health facilities among all patients, regardless of socioeconomic status.

Patterns of Care and Treatment Outcomes of Elderly Patients with Stage I Esophageal Cancer: Analysis of the National Cancer Data Base

INTRODUCTION

This study analyzes practice patterns, treatment-related mortality, survival, and predictors thereof in elderly patients with early-stage esophageal cancer (EC).

METHODS

The National Cancer Data Base was queried for cT1-2 N0 EC in patients 80 years of age and older. Patients were divided into four treatment groups: observation (Obs), chemoradiotherapy (CRT), local excision (LE), and esophagectomy (Eso). Patient, tumor, and treatment parameters were extracted and compared. Analyses were performed on overall survival (OS) and postoperative 30- and 90-day mortality.

RESULTS

A total of 923 patients from 2004 to 2012 were analyzed. Of these, 43% underwent clinical Obs, 22% underwent CRT, 25% underwent LE, and 10% underwent Eso. Patients undergoing Obs were older, had more comorbidities, were treated at nonacademic centers, and lived 25 miles or less from the facility. Patients receiving an operation (Eso or LE) were more often younger, male, white, and in the top income quartile. The postoperative 30-day mortality rates in the LE and Eso groups were 1.3% and 9.6%, respectively (p < 0.001) and increased to 2.6% and 20.2% at 90 days, respectively (p < 0.001). The 5-year OS rate was 7% for Obs, 20% for CRT, 33% for LE, and 45% for Eso (p < 0.001). Multivariate analyses showed improved OS with any local definitive therapy: CRT (hazard ratio [HR] = 0.42, 95% confidence interval [CI]: 0.34-0.52, p < 0.001), LE (HR = 0.3, 95% CI: 0.24-0.38, p < 0.001), and Eso (HR = 0.32, 95% CI: 0.23-0.44, p < 0.001).

CONCLUSIONS

There are noteworthy demographic, socioeconomic, and regional disparities influencing management of elderly patients with stage I EC. Despite high rates of Obs, careful consideration of all local therapy options is warranted, given the improved outcomes with treatment.