Area Deprivation Index is Associated with Variation in Quality of Life and Psychosocial Well-being Following Breast Cancer Surgery

Using the Area Deprivation Index to Assess the Role of Social Factors in Shaping Access and Utilization of Breast Reconstruction

INTRODUCTION

Although access to post-breast cancer reconstructive surgeries continues to improve, inequities remain. This study uses Area Deprivation Index (ADI) to assess the impact of sociodemographic factors on access and utilization of breast reconstruction (BR).

METHODS

This was a retrospective cohort of patients who underwent breast cancer surgery from 2014 to 2019. Patients were stratified by ADI, race, age, median household income, geography, and distance from the hospital. Summary statistics were computed, and multivariate regression was used to calculate odds ratios (OR).

RESULTS

A total of 2060 patients underwent mastectomy, of which 737 (36%) underwent immediate BR. For every one-unit increase in ADI, the odds of having BR decreased by 1.2% (OR, 0.988; CI, 0.985-0.992; P < 0.001). African American and Asian patients were significantly less likely to undergo reconstruction than other racial groups (OR, 0.669; CI, 0.456-0.963; P = 0.034 and OR, 0.341; CI, 0.114-0.819; P = 0.028, respectively). For every 1-year increase in age, the odds of receiving BR decreased by 5.6% (OR, 0.944; CI, 0.936-0.951; P < 0.001). For every $10 increase in median annual household income, the odds of having BR increased by 7.2% (OR, 1.007; CI, 1.005-1.009; P < 0.001). Rural patients were significantly more likely to receive reconstruction (OR, 1.391l; CI, 1.049-1.838; P = 0.021) than urban patients. As patients' distance from the hospital increased, White patients were more likely to receive BR (OR, 1.035; CI, 1.0003-1.0713; P = 0.048), whereas non-White patients were less likely to receive BR (OR, 0.965; CI, 0.933-0.999; P = 0.048). There were varying relationships between each measure of disparity and BR types.

CONCLUSIONS

Disparities in BR exist due to a sum of system-wide issues putting individual neighborhoods at highest risk.

The Effect of Race and Area Deprivation on Symptom Profiles Over the Course of Early-Stage Breast Cancer

CONTEXT

Limited research has examined racial disparities in symptom burden prior to chemotherapy initiation, during and at the chemotherapy completion.

OBJECTIVE

To describe and compare the symptom burden (fatigue, pain, and physical functioning) and change over time between Black and White women receiving Early-Stage Breast Cancer (ESBC) chemotherapy while considering social determinants of health.

METHODS

A longitudinal, repeated measures comparative design was employed. Time points of symptom measurement (PROMIS domains) at baseline, mid and end point were adjusted as per patient chemotherapy schedule. Linear mixed models were applied.

RESULTS

There were 149 patients, 36% Black 64% White (54 ± 12 years) recommended to receive ESBC chemotherapy with adequate data for symptom analysis. PAIN: Main effect of race was significant (F(1, 390) = 29.43, P < .001) for pain.Black patients experienced significantly higher pain scores compared to White patients at pretherapy (Mean Difference; MD = 3.7, P = .034), midpoint (MD = 5.8, P = .002), and endpoint (MD = 7.8, P < .001). In the adjusted model, Black race and higher BMI were significant predictors of higher pain scores. Black patients experienced significant deterioration in pain over time.

FATIGUE

The scores for fatigue increased significantly from baseline for Black patients by endpoint (MDT1-T3 = 8.7, P < .001) and for White patients at midpoint (MDT1-T2 = 5.7) and at endpoint (MDT1-T3 = 10.1, P < .001). In the adjusted model, higher BMI predicted worse fatigue scores.

PHYSICAL FUNCTION

Black patients had significantly lower physical function scores compared to White patients at midpoint (MD = 4.0, P = .027). Physical function decreased by endpoint in Black (MDT1-T3 = 7.8, P < .001), and White patients (MDT1-T3 = 7.7, P < .001). In the adjusted model, only higher BMI and cardiopulmonary comorbidities significantly predicted worse physical function.

CONCLUSION

Symptom burden significantly increased over the course of chemotherapy for all patients. Scores for pain and physical function were higher overall for Black patients and deteriorated at a greater rate for Black vs. White women over the course of chemotherapy. BMI was a significant predictor of pain, fatigue, and physical function, this assessment holds implications for proactive assessment and mitigation strategies.

Neighborhood socioeconomic deprivation and patient-reported outcomes in symptom management trials for women with breast cancer

PURPOSE

Neighborhood socioeconomic deprivation (NSD) is associated with worse outcomes among patients with cancer, but little is known about NSD-related disparities in patient-reported outcomes (PRO) in clinical trials. We examined the relationship between PROs and NSD in symptom management trials among women with breast cancer.

METHODS

We pooled data from three SWOG randomized trials to examine four outcomes: physical and functional wellbeing (PWB, FWB), average pain, and pain interference. NSD was measured using participants' zip code linked to the area deprivation index (ADI) score, categorized into tertiles. Multivariable linear regression adjusted for sociodemographic and clinical characteristics was used to analyze baseline PROs. Linear mixed models were used to examine if trajectory of PROs from baseline through 24 weeks varied by ADI.

RESULTS

We examined 761 participants, of whom 51% were from least deprived neighborhoods. Participants in the most deprived neighborhoods had worse average pain at baseline (β = .38, 95% CI = .03 to .72, p = .03) while participants in somewhat deprived areas also had worse FWB (β = -1.07, 95% CI = -1.95 to -.20, p = .02) and pain interference (β = 0.42, 95% CI = .09 to .75, p = .01) compared to those from least deprived areas. Hispanic ethnicity and having Medicaid/no insurance were associated with worse outcomes. After adjusting for baseline score, ADI was not associated with any outcome over time.

CONCLUSIONS

Breast cancer patients living in areas with NSD had worse FWB, joint pain, and pain interference at baseline. Clinical trial participants should be screened for community-level needs. Implementing interventions to address those needs could help mitigate disparities.

Impacts of neighborhood deprivation on septic and aseptic revision total knee arthroplasty outcomes: A comprehensive analysis using the area deprivation index

BACKGROUND

Community deprivation has been linked to poor health outcomes following primary total knee arthroplasty (pTKA), but few studies have explored revision TKA (rTKA). The present study analyzed implications of neighborhood deprivation on rTKA outcomes by characterizing relationships between Area Deprivation Index (ADI) and (1) non-home discharge disposition (DD), (2) hospital length of stay (LOS), (3) 90-day emergency department (ED) visits, (4) 90-day hospital readmissions, and (5) the effect of race on these healthcare outcomes.

METHODS

A total of 1,434 patients who underwent rTKA between January 2016 and June 2022 were analyzed. Associations between the ADI and postoperative healthcare resource utilization outcomes were evaluated using multivariate logistic regression. Mediation effect was estimated using a nonparametric bootstrap resampling method.

RESULTS

Greater ADI was associated with non-home DD (p < 0.001), LOS ≥ 3 days (p < 0.001), 90-day ED visits (p = 0.015), and 90-day hospital readmission (p = 0.002). Although there was no significant difference in ADI between septic and aseptic patients, septic patients undergoing rTKA were more likely to experience non-home discharge (p < 0.001), prolonged LOS (p < 0.001), and 90-day hospital readmission (p = 0.001). The effect of race on non-home DD was found to be mediated via ADI (p = 0.038). Similarly, results showed the effect of race on prolonged LOS was mediated via ADI (p = 0.01).

CONCLUSION

A higher ADI was associated with non-home discharge, prolonged LOS, 90-day ED visits, and 90-day hospital readmissions. The impacts of patient race on both non-home discharge and prolonged LOS were mediated by ADI. This index allows clinicians to better understand and address disparities in rTKA outcomes.

Exploring Socioeconomic Disparities in Mandibular Trauma: A Retrospective Cohort Analysis of Patient Profiles and Treatment Outcomes

Study Design

Retrospective Chart Review.

Objective

Mandible fracture is a life-altering event, and its complications can have devastating consequences for patients. Patients are therefore well-served if providers can identify their risk factors and engage strategies to reduce complication risk. The present study examines mandible trauma in an urban tertiary hospital serving an economically disadvantaged population.

Methods

This review identified all patients undergoing operative repair of traumatic mandible fractures from January 2015 to December 2020. Patient risk factors, operative technique, and surgical complications (including infection, hardware failure, malunion, and mandible nonunion) were analyzed.

Results

Two hundred and seventy-two patients were identified with mandible fractures; 78.3% of these injuries were related to interpersonal violence; 83.4% of patients were male, and 55.5% were African American. Based on multivariable logistic regression models, increased rates of postoperative complications were observed in patients with increasing Area Deprivation Index (Odds Ratio 1.02), mandible body fracture (OR 3.11), tobacco use disorder (OR 3.75), history of hepatitis C infection (OR 7.35), and discharge to drug and alcohol rehabilitation (OR 23.42).

Conclusions

For providers treating patients with mandible fractures, the effects of comorbid substance use-including tobacco use-and inadequate discharge disposition (a reflection of financial means and insurance status) should be identified early, and steps to mitigate their consequences should be taken. Providers must recognize that patients with these comorbidities require more patience, support, and attention than patients without these risk factors. Increased engagement with multidisciplinary services such as psychiatry, addiction medicine, primary care, and social work may improve outcomes for these vulnerable patients.

Greater Socioeconomic Deprivation Is Associated With Increased Complication Rates and Lower Patient-Reported Outcomes Following Open Reduction and Internal Fixation of Humeral Shaft Fractures

OBJECTIVES

This study explored the hypothesis that social determinants of health, including racial and economic differences, may impact orthopaedic trauma outcomes in patients undergoing open reduction and internal fixation of humeral shaft fractures.

METHODS

DESIGN

Retrospective.

SETTING

Single, academic, tertiary level I trauma center.

PATIENT SELECTION CRITERIA

Adults with midshaft humerus fractures (Orthopaedic Trauma Association/Association of Osteosynthesis 12) were treated operatively with plate fixation from May 2011 to May 2021 with a minimum follow-up of 9 months.

OUTCOME MEASURES AND COMPARISONS

Radiographic fracture healing, complication rates, and patient-reported outcomes were investigated. Social determinants of health were assessed using the Area Deprivation Index (ADI). Demographics, complication rates, and patient-reported clinical outcomes were compared between the first and fourth ADI quartiles.

RESULTS

One hundred ninety-six patients fit the study criteria. The average age of the cohort was 47 years with 100 women (51%). Comparisons of the least deprived quartile (n = 49) with the most deprived quartile (n = 49) yielded similar sex distribution (59% vs. 43% females, P = 0.15), fewer non-White patients (8% vs. 51%, P < 0.01), older average age (51 vs. 43 years, P = 0.05), similar body mass index (30.5 vs. 31.8, P = 0.45), and higher Charlson Comorbidity Index (2.2 vs. 1.1, P = 0.03). While nonunion rates were similar ( P = 0.20) between groups, the most deprived quartile had 2.3 times greater odds of postoperative complications ( P = 0.04). Patients in the most deprived group exhibited higher Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference scores ( P < 0.01) and PROMIS Depression (D) scores ( P = 0.01), with lower PROMIS Physical Function scores ( P < 0.01) at 6-month follow-up than the least deprived cohort. The most deprived cohort had 3 times higher odds of missing scheduled appointments within the first postoperative year ( P < 0.01), resulting in a significantly higher no-show rate ( P < 0.01) than the least deprived cohort. Regression analysis including several demographic and injury factors identified that ADI was significantly associated with the occurrence of any missed appointments ( P < 0.01), no-show rates ( P = 0.04), and experiencing one of the following postoperative complications during recovery: nonunion, radial nerve injury, or dysfunction ( P = 0.03).

CONCLUSIONS

Patients experiencing greater resource deprivation faced increased odds of complications, missed appointments, and poorer PROMIS outcomes following humeral shaft fracture fixation. These findings suggest that baseline socioeconomic disparities predict unfavorable postoperative outcomes even given favorable baseline health status according to the Charlson Comorbidity Index score.

LEVEL OF EVIDENCE

Prognostic, Level III. See Instructions for Authors for a complete description of levels of evidence.

Neighborhood-level Disparities in Achievement of Social Continence Among School-aged Children With Anorectal Malformations: A Single-center Retrospective Study

BACKGROUND

Fecal incontinence is a common problem for children with repaired anorectal malformations (ARM) and has significant implications for initiating school. While sex, anatomy, and medical comorbidities are known to influence continence outcomes, the impact of socioeconomic factors and neighborhood-level disadvantage are less well understood.

METHODS

We performed a single-center retrospective review of all school-aged (5-18 years) children with ARM at a longitudinal pediatric surgery clinic. Demographic, clinical, and socioeconomic variables were abstracted via chart review and geocoding was performed to obtain Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) scores. Statistical analyses assessed for associations between the primary outcome of social continence (defined as no diaper usage and infrequent fecal accidents at age 5) and these variables.

RESULTS

72 patients were included; of these, 45.8% were socially continent. On bivariate analysis, social continence was significantly associated with state ADI score as well as the SVI Housing characteristics score. These associations remained significant when adjusting for sex and medical comorbidities in separate multiple logistic regression models.

CONCLUSION

The relative disadvantage of the neighborhood in which a child with ARM lives may play a role in their ability to achieve continence by school age. Efforts are warranted to identify and develop targeted interventions to for this pediatric population.

LEVEL OF EVIDENCE

IV.

Neighborhood Deprivation is Associated With Increased Postoperative Complications After Implant-Based Breast Reconstruction

PURPOSE

The Area Deprivation Index (ADI) ranks neighborhoods by deprivation based on US Census data. This study utilizes ADI scores to investigate the impact of neighborhood deprivation on complication rates following breast reconstruction.

PATIENTS AND METHODS

Patients who received implant-based reconstruction from 2019 to 2023 were identified at a single institution in New York. Patients were linked to a state-specific ADI score and categorized into groups: "High ADI" (6-10) and "Low ADI" (1-5). Patient characteristics and complication rates were compared between the ADI groups with Chi-Square analysis and t-tests. The predictive value of ADI scores on complication rates was assessed using logistic regression models.

RESULTS

In total, 471 patients were included, of which 16% (n = 73) were in the High ADI group, and 84% (n = 398) were in the Low ADI group. There were no baseline differences between the 2 groups, except that there were more patients of Hispanic descent in the High ADI group (30% vs. 15%, P < .01). The High ADI group had a higher overall complication rate than the Low ADI group (34% vs. 21%, P < .01), as well as higher individual rates of hematoma (12% vs. 3%, P < .01) and unexpected reoperations (18% vs. 7%, P < .01). After adjusting for differences in race, High ADI scores predicted hematoma, reoperations, and any complication (P < .05).

CONCLUSION

Patients living in neighborhoods with high ADI had a higher incidence of postoperative complications, independent of comorbidities and race. This measure of disparity should be considered when counselling patients about their risk of complications following procedures like implant-based breast reconstruction.

The use of complementary and alternative medicine and approaches to coping with stress in women with breast cancer: a cross-sectional study

OBJECTIVE

The study aimed to reveal the approaches to coping with stress of women with breast cancer and the factors predicting these approaches, to determine the prevalence and characteristics of Complementary and Alternative Medicine (CAM), and to examine the relationship between use of CAM and approaches to coping with stress.

METHODS

A descriptive and cross-sectional study was conducted among 328 women with breast cancer at a training and research hospital in Türkiye. Data were collected with the "Descriptive Information Form" and the "Stress Coping Styles Scale (SCSS)".

RESULTS

Women's SCSS score was 47.26±6.39 (effective) and 37.76±6.33 (ineffective). The SCSS score were not significantly different between CAM users and non-CAM users (p>0.05). The prevalence of CAM use was 36%, the most common types of CAM were herbal products (55.1%) and prayer (33.8%) and the reasons for using CAM were for relaxation (symptomatic) (43.2%). As a result of multivariate logistic regression analysis, level of income, working, number of living children, receiving chemotherapy, receiving surgery, having a family history of cancer, and the interest of their partner after the disease were associated with effective coping with stress (p<0.05, adjusted R2=0.08, 0.05, and 0.33 respectively). Working, receiving chemotherapy, receiving surgery, stage of cancer, and having a history of cancer in a social environment were associated with ineffective coping with stress (p<0.05, adjusted R2=0.14 and 0.11 respectively).

CONCLUSIONS

One-third of women were using CAM and had a good level of approaches to coping with stress. Healthcare providers, especially gynecology-oncology nurses, should provide counseling on CAMs and develop strategies for coping with stress for women with breast cancer.

The Impact of Neighborhood and Socioeconomic Disparities on Distal Radius Fracture Follow-Up Adherence

BACKGROUND

The aims of this retrospective cohort study were (1) to assess whether the Area Deprivation Index (ADI), a novel neighborhood-level socioeconomic disparities metric, is associated with follow-up nonadherence, and (2) to determine the individual-level socioeconomic factors associated with follow-up nonadherence after treatment of distal radius fractures (DRFs).

METHODS

The authors included all patients who underwent nonoperative or operative management of DRFs at an academic level I trauma center between 2019 and 2021. A manual chart review was performed to collect data on ADI, sociodemographic factors, injury characteristics, conservative and surgical interventions, and health care utilization.

RESULTS

There was a significant weak negative Spearman-ranked correlation between ADI state deciles and clinic attendance rates ( rs [220] = -0.144 [95% CI, -0.274 to -0.009]; P = 0.032). Socioeconomic factors associated with significant differences in clinic attendance rates were having a spouse or partner (protective) ( P = 0.007), Medicaid insurance ( P = 0.013), male sex ( P = 0.023), and current smoking ( P = 0.026). Factors associated with differences in no-show rates were having a spouse or partner (odds ratio [OR], 0.326 [95% CI, 0.123 to 0.867]; P = 0.025), Medicaid insurance (OR, 7.78 [95% CI, 2.15 to 28.2]; P = 0.002), male sex (OR, 4.09 [95% CI, 1.72 to 9.74]; P = 0.001), and cigarette use (OR, 5.07 [95% CI, 1.65 to 15.6]; P = 0.005).

CONCLUSIONS

ADI has a weak, negative correlation with clinic attendance rates after DRF treatment. Significant disparities in clinic follow-up adherence exist between patients on the basis of marital status, insurance, sex, and cigarette use.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Assessing the Relationship Between Neighborhood Socioeconomic Disadvantage and Telemedicine Use Among Patients With Breast Cancer and Examining Differential Provisions of Oncology Services Between Telehealth and In-Person Visits: Quantitative Study

BACKGROUND

Since the COVID-19 pandemic began, we have seen rapid growth in telemedicine use. However, telehealth care and services are not equally distributed, and not all patients with breast cancer have equal access across US regions. There are notable gaps in existing literature regarding the influence of neighborhood-level socioeconomic status on telemedicine use in patients with breast cancer and oncology services offered through telehealth versus in-person visits.

OBJECTIVE

We assessed the relationship between neighborhood socioeconomic disadvantage and telemedicine use among patients with breast cancer and examined differential provisions of oncology services between telehealth and in-person visits.

METHODS

Neighborhood socioeconomic disadvantage was measured using the Area Deprivation Index (ADI), with higher scores indicating greater disadvantages. Telemedicine and in-person visits were defined as having had a telehealth and in-person visit with a provider, respectively, in the past 12 months. Multivariable logistic regression was performed to examine the association between ADI and telemedicine use. The McNemar test was used to assess match-paired data on types of oncology services comparing telehealth and in-person visits.

RESULTS

The mean age of the patients with breast cancer (n=1163) was 61.8 (SD 12.0) years; 4.58% (52/1161) identified as Asian, 19.72% (229/1161) as Black, 3.01% (35/1161) as Hispanic, and 72.78% (845/1161) as White. Overall, 35.96% (416/1157) had a telemedicine visit in the past 12 months. Of these patients, 65% (266/409) had a videoconference visit only, 22.7% (93/409) had a telephone visit only, and 12.2% (50/409) had visits by both videoconference and telephone. Higher ADI scores were associated with a lower likelihood of telemedicine use (adjusted odds ratio [AOR] 0.89, 95% CI 0.82-0.97). Black (AOR 2.38, 95% CI 1.41-4.00) and Hispanic (AOR 2.65, 95% CI 1.07-6.58) patients had greater odds of telemedicine use than White patients. Compared to patients with high school or less education, those with an associate's degree (AOR 2.67, 95% CI 1.33-5.35), a bachelor's degree (AOR 2.75, 95% CI 1.38-5.48), or a graduate or professional degree (AOR 2.57, 95% CI 1.31-5.04) had higher odds of telemedicine use in the past 12 months. There were no significant differences in providing treatment consultation (45/405, 11.1% vs 55/405, 13.6%; P=.32) or cancer genetic counseling (11/405, 2.7% vs 19/405, 4.7%; P=.14) between telehealth and in-person visits. Of the telemedicine users, 95.8% (390/407) reported being somewhat to extremely satisfied, and 61.8% (254/411) were likely or very likely to continue using telemedicine.

CONCLUSIONS

In this study of a multiethnic cohort of patients with breast cancer, our findings suggest that neighborhood-level socioeconomic disparities exist in telemedicine use and that telehealth visits could be used to provide treatment consultation and cancer genetic counseling. Oncology programs should address these disparities and needs to improve care delivery and achieve telehealth equity for their patient populations.

Associations of role, area deprivation index, and race with health behaviors and body mass index among localized prostate cancer patients and their partners

PURPOSE

To examine the associations of role (localized prostate cancer (PCa) patient vs. their intimate partner), area deprivation index (ADI-higher scores indicating higher neighborhood deprivation levels), and race (Black/African American (AA) vs. White) with health behaviors and body mass index (BMI) among PCa patients and partners. The behaviors include smoking, alcohol consumption, diet quality, sedentary behaviors, and physical activity (PA).

METHODS

This study used the baseline data collected in a clinical trial. Given the nested structure of the dyadic data, multi-level models were used.

RESULTS

Significant role-race interaction effects on smoking, ADI-race effects on alcohol consumption, and role-ADI effects on BMI were found. Meanwhile, patients smoked more cigarettes, decreased alcohol consumption, had less healthful diets, spent longer time watching TV, did fewer sedentary hobbies, had more confidence in PA, and had higher BMIs than their partners. High ADI was independently associated with lower odds of drinking alcohol, using computer/Internet, and doing non-walking PA, and higher BMI compared to low ADI controlling for role and race. Black/AA dyads had less smoking amount and alcohol consumption and higher sedentary time and BMI than White dyads when adjusted for role and ADI.

CONCLUSIONS

This study identified significant interaction and main effects of role, ADI, or race on health behaviors and BMI.

IMPLICATIONS FOR CANCER SURVIVORS

Future behavioral interventions should address divergent individual needs between patients and partners, social and neighborhood barriers, and cultural indicators of racial groups to promote healthful behaviors and improve the quality of survivorship for PCa patients and partners.

Allostatic load as a predictor of postoperative complications in patients with breast cancer

Allostatic load (AL) is a biological measure of cumulative exposure to socioenvironmental stressors (e.g., poverty). This study aims to examine the association between allostatic load (AL) and postoperative complications (POC) among patients with breast cancer. Females ages 18+ with stage I-III breast cancer who received surgical management between 01/01/2012-12/31/2020 were identified in the Ohio State Cancer registry. The composite AL measure included biomarkers from the cardiovascular, metabolic, immune, and renal systems. High AL was defined as composite scores greater than the cohort's median (2.0). POC within 30 days of surgery were examined. Univariable and multivariable regression analysis examined the association between AL and POC. Among 4459 patients, 8.2% had POC. A higher percentage of patients with POC were unpartnered (POC 44.7% vs no POC 35.5%), government-insured (POC 48.2% vs no POC 38.3%) and had multiple comorbidities (POC 32% vs no POC 20%). Patients who developed POC were more likely to have undergone sentinel lymph node biopsy followed by axillary lymph node dissection (POC 51.2% vs no POC 44.6%). High AL was associated with 29% higher odds of POC (aOR 1.29, 95% CI 1.01-1.63). A one-point increase in AL was associated with 8% higher odds of POC (aOR 1.08, 95% CI 1.02-1.16) and a quartile increase in AL was associated with 13% increased odds of POC (aOR 1.13, 95% CI 1.01-1.26). Among patients undergoing breast cancer surgery, increased exposure to adverse socioenvironmental stressors, operationalized as AL, was associated with higher odds of postoperative complications.

Cannabis Use Reported by Patients Receiving Primary Care in a Large Health System

Importance

Despite the changing legal status of cannabis and the potential impact on health, few health systems routinely screen for cannabis use, and data on the epidemiology of cannabis use, and especially medical cannabis use among primary care patients, are limited.

Objective

To describe the prevalence of, factors associated with, and reasons for past-3 month cannabis use reported by primary care patients.

Design, Setting, and Participants

This cross-sectional study used electronic health record data from patients aged 18 years and older who had an annual wellness visit between January 2021 and May 2023 from a primary care clinic within a university-based health system in Los Angeles, California.

Exposures

Factors of interest included age, race and ethnicity, sex, employment status, and neighborhood Area Deprivation Index (ADI).

Main Outcomes and Measures

Cannabis use was assessed using the Alcohol Substance Involvement Screening Test (ASSIST). Patients were also asked about reasons for use, symptoms for which they used cannabis, and mode of use.

Results

Among the 175 734 patients screened, the median (range) age was 47 (18-102) years; 101 657 (58.0%) were female; 25 278 (15.7%) were Asian, 21 971 (13.7%) were Hispanic, and 51 063 (31.7%) were White. Cannabis use was reported by 29 898 (17.0%), with 10 360 (34.7%) having ASSIST scores indicative of moderate to high risk for cannabis use disorder (CUD). Prevalence of cannabis use was higher among male patients than female patients (14 939 [20.0%] vs 14 916 [14.7%]) and younger patients (18-29 years, 7592 [31.0%]; ≥60 years, 4200 [8.5%]), and lower among those who lived in the most disadvantaged neighborhoods (ADI decile 9-10, 189 [13.8%]; ADI decile 1-2, 12 431 [17.4%]). The most common modes of use included edibles (18 201 [61.6%]), smoking (15 256 [51.7%]), and vaporizing (8555 [29.0%]). While 4375 patients who reported using cannabis (15.6%) did so for medical reasons only, 21 986 patients (75.7%) reported using cannabis to manage symptoms including pain (9196 [31.7%]), stress (14 542 [50.2%]), and sleep (16 221 [56.0%]). The median (IQR) number of symptoms managed was 2 (1-4), which was higher among patients who were at moderate to high risk for CUD (4 [2-6] symptoms).

Conclusions and Relevance

In this study, cannabis use and risk of CUD were common, and more than three-quarters of patients who reported any cannabis use reported doing so to manage a health-related symptom. These findings suggest that integration of information regarding cannabis use for symptom management could help provide a crucial point-of-care opportunity for clinicians to understand their patients' risk for CUD.

Higher area deprivation index is associated with poorer local control and overall survival in non-metastatic nasopharyngeal carcinoma

BACKGROUND

Neighborhood socioeconomic deprivation impacts outcomes in various cancers. We examined this association in nasopharyngeal carcinoma (NPC) patients using the area deprivation index (ADI).

METHODS

We conducted a single-institution retrospective cohort study on NPC patients treated with definitive radiotherapy from 1980 to 2023. ADI was used as the primary exposure measure. Higher ADI indicates higher levels of socioeconomic deprivation.

RESULTS

Of 561 patients, those with higher ADI (6-10 vs. 1-5) presented more commonly with AJCC stage III/IV compared to I/II (87% vs. 76%, p = 0.03). Increasing ADI decile score correlated with poorer overall survival (HR 1.14, 95% CI 1.01-1.28, p = 0.04). Local control was worse in patients from the most deprived quartile in the cohort ADI 5-10 (HR 2.11, 95% CI 1.01-4.41, p = 0.05).

CONCLUSIONS

NPC patients from more disadvantaged neighborhoods undergoing radiotherapy had worse local control and survival outcomes. Interventions to address structural determinants of health and neighborhood disparities may improve these outcomes.

Liver transplantation access and outcomes: Impact of variations in liver-specific specialty care

BACKGROUND

We sought to characterize the impact access to gastroenterologists/hepatologists has on liver transplantation listing, as well as time on the liver transplantation waitlist and post-transplant outcomes.

METHODS

Liver transplantation registrants aged >18 years between January 1, 2004 and December 31, 2019 were identified from the Scientific Registry of Transplant Recipients Standard Analytic Files. The liver transplantation registration ratio was defined as the ratio of liver transplant waitlist registrations in a given county per 1,000 liver-related deaths.

RESULTS

A total of 150,679 liver transplantation registrants were included. Access to liver transplantation centers and liver-specific specialty physicians varied markedly throughout the United States. Of note, the liver transplantation registration ratio was lower in counties with poor access to liver-specific care versus counties with adequate access (poor access 137.2, interquartile range 117.8-163.2 vs adequate access 157.6, interquartile range 127.3-192.2, P < .001). Among patients referred for liver transplantation, the cumulative incidence of waitlist mortality and post-transplant graft survival was comparable among patients with poor versus adequate access to liver-specific care (both P > .05). Among liver transplantation recipients living in areas with poor access, after controlling for recipient and donor characteristics, cold ischemic time, and model for end-stage liver disease score, the area deprivation index predicted graft survival (referent, low area deprivation index; medium area deprivation index, hazard ratio 1.52, 95% confidence interval 1.03-12.23; high area deprivation index, 1.45, 95% confidence interval 1.01-12.09, both P < .05).

CONCLUSION

Poor access to liver-specific care was associated with a reduction in liver transplantation registration, and individuals residing in counties with high social deprivation had worse graft survival among patients living in counties with poor access to liver-specific care.

Allostatic Load as a Predictor of Postoperative Complications in Patients with Breast Cancer

BACKGROUND

Allostatic load (AL) is a biological measure of cumulative exposure to socioenvironmental stressors (e.g., poverty). This study aims to examine the association between allostatic load (AL) and postoperative complications (POC) among patients with breast cancer.

METHODS

Assigned females at birth ages 18 + with stage I-III breast cancer who received surgical management between 01/01/2012-12/31/2020 were identified in the Ohio State Cancer registry. The composite AL measure included biomarkers from the cardiovascular, metabolic, immune, and renal systems. High AL was defined as composite scores greater than the cohort's median (2.0). POC within 30 days of surgery were examined. Univariable and multivariable regression analysis examined the association between AL and POC.

RESULTS

Among 4,459 patients, 8.2% had POC. A higher percentage of patients with POC were unpartnered (POC 44.7% vs no POC 35.5%), government-insured (POC 48.2% vs no POC 38.3%) and had multiple comorbidities (POC 32% vs no POC 20%). Patients who developed POC were more likely to have undergone sentinel lymph node biopsy followed by axillary lymph node dissection (POC 51.2% vs no POC 44.6%). High AL was associated with 29% higher odds of POC (aOR 1.29, 95% CI 1.01-1.63). A one-point increase in AL was associated with 8% higher odds of POC (aOR 1.08, 95% CI 1.02-1.16) and a quartile increase in AL was associated with 13% increased odds of POC (aOR 1.13, 95% CI 1.01-1.26).

CONCLUSION

Among patients undergoing breast cancer surgery, increased exposure to adverse socioenvironmental stressors, operationalized as AL, was associated with higher odds of postoperative complications.

Relationship between area-level socioeconomic status and health-related quality of life among cancer survivors

Area-level socioeconomic status (SES) impacts cancer outcomes, such as stage at diagnosis, treatments received, and mortality. However, less is known about the relationship between area-level SES and health-related quality of life (HRQOL) for cancer survivors. To assess the additive value of area-level SES data and the relative contribution of area- and individual-level SES for estimating cancer survivors' HRQOL, we conducted a secondary analysis of data from a population-based survey study of cancer survivors (the Measuring Your Health [MY-Health] Study). Multilevel multinomial logistic regression models were used to examine the relationships between individual-level SES, area-level SES as measured by the Centers for Disease Control and Prevention's Social Vulnerability Index, and HRQOL group membership (high, average, low, or very low HRQOL). Area-level SES did not significantly increase model estimation accuracy compared to models using only individual-level SES. However, area-level SES could be an appropriate proxy when the individual-level SES is missing.

Association of Neighborhood Disadvantage with Short- and Long-Term Outcomes After Pancreatectomy for Pancreatic Ductal Adenocarcinoma

BACKGROUND

While lower socioeconomic status has been shown to correlate with worse outcomes in cancer care, data correlating neighborhood-level metrics with outcomes are scarce. We aim to explore the association between neighborhood disadvantage and both short- and long-term postoperative outcomes in patients undergoing pancreatectomy for pancreatic ductal adenocarcinoma (PDAC).

PATIENTS AND METHODS

We retrospectively analyzed 243 patients who underwent resection for PDAC at a single institution between 1 January 2010 and 15 September 2021. To measure neighborhood disadvantage, the cohort was divided into tertiles by Area Deprivation Index (ADI). Short-term outcomes of interest were minor complications, major complications, unplanned readmission within 30 days, prolonged hospitalization, and delayed gastric emptying (DGE). The long-term outcome of interest was overall survival. Logistic regression was used to test short-term outcomes; Cox proportional hazards models and Kaplan-Meier method were used for long-term outcomes.

RESULTS

The median ADI of the cohort was 49 (IQR 32-64.5). On adjusted analysis, the high-ADI group demonstrated greater odds of suffering a major complication (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.26-6.40; p = 0.01) and of an unplanned readmission (OR, 3.09; 95% CI, 1.16-9.28; p = 0.03) compared with the low-ADI group. There were no significant differences between groups in the odds of minor complications, prolonged hospitalization, or DGE (all p > 0.05). High ADI did not confer an increased hazard of death (p = 0.63).

CONCLUSIONS

We found that worse neighborhood disadvantage is associated with a higher risk of major complication and unplanned readmission after pancreatectomy for PDAC.

Increased Neighborhood Deprivation Is Associated with Prolonged Hospital Stays After Surgical Fixation of Traumatic Pelvic Ring Injuries

BACKGROUND

The purpose of this study was to understand the role of social determinants of health assessed by the Area Deprivation Index (ADI) on hospital length of stay and discharge destination following surgical fixation of pelvic ring fractures.

METHODS

A retrospective chart analysis was performed for all patients who presented to our level-I trauma center with pelvic ring injuries that were treated with surgical fixation. Social determinants of health were determined via use of the ADI, a comprehensive metric of socioeconomic status, education, income, employment, and housing quality. ADI values range from 0 to 100 and are normalized to a U.S. mean of 50, with higher scores representing greater social deprivation. We stratified our cohort into 4 ADI quartiles. Statistical analysis was performed on the bottom (25th percentile and below, least deprived) and top (75th percentile and above, most deprived) ADI quartiles. Significance was set at p < 0.05.

RESULTS

There were 134 patients who met the inclusion criteria. Patients in the most deprived group were significantly more likely to have a history of smoking, to self-identify as Black, and to have a lower mean household income (p = 0.001). The most deprived ADI quartile had a significantly longer mean length of stay (and standard deviation) (19.2 ± 19 days) compared with the least deprived ADI quartile (14.7 ± 11 days) (p = 0.04). The least deprived quartile had a significantly higher percentage of patients who were discharged to a resource-intensive skilled nursing facility or inpatient rehabilitation facility compared with those in the most deprived quartile (p = 0.04). Race, insurance, and income were not significant predictors of discharge destination or hospital length of stay.

CONCLUSIONS

Patients facing greater social determinants of health had longer hospital stays and were less likely to be discharged to resource-intensive facilities when compared with patients of lesser social deprivation. This may be due to socioeconomic barriers that limit access to such facilities.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

The Effect of Race and Area Deprivation on Symptom Profiles over the Course of Early-Stage Breast Cancer

Purpose

This study compared common symptoms (fatigue, pain), overall physical functioning and changes over time between Black and White women receiving early-stage breast cancer (ESBC) chemotherapy.

Methods

A longitudinal, repeated measures comparative design was employed. Time points of symptom measurement (PROMIS domains) at baseline, mid and end point were adjusted as per patient chemotherapy schedule.

Analyses

Linear mixed models were applied.

Results

There were 147 patients, 36% Black 64% White (54±12 years) recommended to receive early-stage breast cancer chemotherapy with adequate data for symptom analysis.

Pain

Main effect of race was significant (F(1, 390) = 29.43, p<.001) for pain with Black patients experiencing significantly higher pain scores compared to White patients at pretherapy (Mean Difference; MD=3.7, p=.034), midpoint (MD=5.8, p=.002), and endpoint (MD=7.8, p<.001).

Fatigue

Fatigue significantly increased (deteriorated) at endpoint (MDT1-T3= 8.7, p<.001) for Black patients. Among White patients, fatigue significantly increased at midpoint (MDT1-T2= 5.7) and at endpoint (MDT1-T3=10.1, p<.001; MDT2-T3=4.3, p= .017). Physical function: Black patients had significantly lower physical function scores compared to White patients at midpoint (MD=4.0, p=.027). Physical function decreased by endpoint in Black (MDT1-T3=7.8, p<.001), and White patients (MDT1-T3=7.7, p<.001).

Conclusion

Symptom burden significantly increased over the course of chemotherapy for all patients. Scores for pain and physical function were higher overall for Black patients and deteriorated at a greater rate for Black vs. White women over the course of chemotherapy. This assessment holds implication for proactive assessment and mitigation strategies.

Effects of neighborhood disadvantage on cortisol and interviewer-rated anxiety symptoms in breast cancer patients initiating treatment

PURPOSE

Shorter breast cancer (BC) survival outcomes persist by neighborhood disadvantage independent of patient, tumor, and treatment characteristics. This suggests unaccounted mechanisms by which neighborhood disadvantage "gets under the skin" to impact BC survival outcomes. Here, we evaluate the relationship between neighborhood disadvantage and clinical and neuroendocrine markers of stress in BC patients.

METHODS

Women with stage 0-III BC were enrolled 2-10 weeks post-surgery and before initiating adjuvant treatment in a study examining stress and stress management processes. Women provided an afternoon-evening (PM) serum cortisol sample and were administered the Hamilton Anxiety Rating Scale (HAM-A). Home addresses were used to determine the Area Deprivation Index (ADI), a validated measure of neighborhood disadvantage. Multiple regression assessed the relationship between ADI and PM serum cortisol and the presence of elevated HAM-A symptoms.

RESULTS

Our sample (n = 225) was predominately middle-aged (M = 50.4 years; range 23-70 years), non-Hispanic White (64.3%), with stage I (38.1%), or II (38.6%) disease. The majority (n = 175) lived in advantaged neighborhoods (ADI 1-3). After controlling for age, stage, and surgery type, women from high ADI (4-10) (vs low ADI) neighborhoods had higher PM cortisol levels (β = 0.19, 95% CI [0.24, 5.00], p = 0.031) and were nearly two times as likely to report the presence of elevated anxiety symptoms (OR = 1.96, 95% CI [1.00, 3.86], p = 0.050).

CONCLUSION

Neighborhood disadvantage is significantly associated with higher levels of PM cortisol and elevated anxiety symptoms suggesting stress pathways could potentially contribute to relationships between neighborhood disadvantage and BC survival.

Community Outreach in Breast Imaging: What Radiologists Can Do to Close the Gap for the Uninsured Population

After implementation of the Affordable Care Act in 2010, the uninsured population of the United States decreased significantly. As of 2022, there were approximately 26.4 million uninsured individuals in the United States. The lack of coverage and access to services disproportionally affect minority groups in the country, reflecting the influence of the social determinants of health in their uninsured status. Use of screening mammography, an effective modality that results in early detection of and decreased mortality from breast cancer, was delayed or postponed by women of all races due to lockdowns and fear during the COVID-19 pandemic. Since then, the return to mammographic screening has lagged among minorities, further increasing their disproportionate screening gap. Radiologists-and more specifically breast imagers-must recognize these issues, as people who are uninsured and part of minority groups are diagnosed with breast cancer at later stages and have higher mortality rates, less continuity of care, and overall lower survival. The purpose of this article is to familiarize radiologists with the uninsured population, explain how they are disproportionally affected by breast cancer, and propose strategies that breast imagers can pursue to improve screening access and decrease compliance gaps for this patient population. ©RSNA, 2023 See the invited commentary by Nguyen in this issue. Quiz questions for this article are available through the Online Learning Center.

Ensuring Safety While Achieving Beauty: An Evidence-Based Approach to Optimizing Mastectomy and Autologous Breast Reconstruction Outcomes in Patients with Obesity

BACKGROUND

Although obesity has previously been associated with poor outcomes after mastectomy and breast reconstruction, its impact across the WHO obesity classification spectrum and the differential effects of various optimization strategies on patient outcomes have yet to be delineated. We sought to examine the impact of WHO obesity classification on intraoperative surgical and medical complications, postoperative surgical and patient-reported outcomes of mastectomy and autologous breast reconstruction, and delineate outcomes optimization strategies for obese patients.

STUDY DESIGN

This is a review of consecutive patients who underwent mastectomy and autologous breast reconstruction from 2016 to 2022. Primary outcomes were complication rates. Secondary outcomes were patient-reported outcomes and optimal management strategies.

RESULTS

We identified 1,640 mastectomies and reconstructions in 1,240 patients with mean follow-up of 24.2 ± 19.2 months. Patients with class II/III obesity had higher adjusted risk of wound dehiscence (odds ratio [OR] 3.20; p < 0.001), skin flap necrosis (OR 2.60; p < 0.001), deep venous thrombosis (OR 3.90; p < 0.033), and pulmonary embolism (OR 15.3; p = 0.001) than nonobese patients. Obese patients demonstrated significantly lower satisfaction with breasts (67.3 ± 27.7 vs 73.7 ± 24.0; p = 0.043) and psychological well-being (72.4 ± 27.0 vs 82.0 ± 20.8; p = 0.001) than nonobese patients. Unilateral delayed reconstructions were associated with independently shorter hospital stay (β -0.65; p = 0.002) and lower adjusted risk of 30-day readmission (OR 0.45; p = 0.031), skin flap necrosis (OR 0.14; p = 0.031), and pulmonary embolism (OR 0.07; p = 0.021).

CONCLUSIONS

Obese women should be closely monitored for adverse events and lower quality of life, offered measures to optimize thromboembolic prophylaxis, and advised on the risks and benefits of unilateral delayed reconstruction.

Long-term Surgical and Patient-Reported Outcomes Comparing Skin-Preserving, Staged Versus Delayed Microvascular Breast Reconstruction

BACKGROUND

Skin-preserving, staged, microvascular, breast reconstruction often is preferred in patients requiring postmastectomy radiotherapy (PMRT) but may lead to complications. We compared the long-term surgical and patient-reported outcomes between skin-preserving and delayed microvascular breast reconstruction with and without PMRT.

METHODS

We conducted a retrospective, cohort study of consecutive patients who underwent mastectomy and microvascular breast reconstruction between January 2016 and April 2022. The primary outcome was any flap-related complication. The secondary outcomes were patient-reported outcomes and tissue-expander complications.

RESULTS

We identified 1002 reconstructions (672 delayed; 330 skin-preserving) in 812 patients. Mean follow-up was 24.2 ± 19.3 months. PMRT was required in 564 reconstructions (56.3%). In the non-PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (β - 0.32, p = 0.045) and lower odds of 30-days readmission (odds ratio [OR] 0.44, p = 0.042), seroma (OR 0.42, p = 0.036), and hematoma (OR 0.24, p = 0.011) compared with delayed reconstruction. In the PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (β - 1.15, p < 0.001) and operative time (β - 97.0, p < 0.001) and lower odds of 30-days readmission (OR 0.29, p = 0.005) and infection (OR 0.33, p = 0.023) compared with delayed reconstruction. Skin-preserving reconstruction had a 10.6% tissue expander loss rate and did not differ from delayed reconstruction in terms of patient-reported satisfaction with breast, psychosocial well-being, or sexual well-being.

CONCLUSIONS

Skin-preserving, staged, microvascular, breast reconstruction is safe regardless of the need for PMRT, with an acceptable tissue expander loss rate, and is associated with improved flap outcomes and similar patient-reported quality of life to that of delayed reconstruction.

Impact of High Neighborhood Socioeconomic Deprivation on Access to Accredited Breast Imaging Screening and Diagnostic Facilities

PURPOSE

The aim of this study was to evaluate the presence or absence of accredited breast imaging facilities in ZIP codes with high or low neighborhood socioeconomic deprivation.

METHODS

A retrospective ecological study design was used. Neighborhood socioeconomic disadvantage rankings at the ZIP code level were defined by the University of Wisconsin Neighborhood Atlas Area Deprivation Index. Outcomes included the presence or absence of FDA- or ACR-accredited mammographic facilities, accredited stereotactic biopsy or breast ultrasound facilities, and ACR Breast Imaging Centers of Excellence. US Department of Agriculture rural-urban commuting area codes were used to define urban and rural status. Access to breast imaging facilities in high-disadvantage (≥97th percentile) and low-disadvantage (≤3rd percentile) ZIP codes was compared using χ2 tests, stratified by urban or rural status.

RESULTS

Among 41,683 ZIP codes, 2,796 were classified as high disadvantage (1,160 rural, 1,636 urban) and 1,028 as low disadvantage (39 rural, 989 urban). High-disadvantage ZIP codes were more likely rural (P < .001) and less likely to have FDA-certified mammographic facilities (28% versus 35%, P < .001), ACR-accredited stereotactic biopsy (7% versus 15%, P < .001), breast ultrasound (9% versus 23%, P < .001), or Breast Imaging Centers of Excellence (7% versus 16%, P < .001). Among urban areas, high-disadvantage ZIP codes were less likely to have FDA-certified mammographic facilities (30% versus 36%, P = .002), ACR-accredited stereotactic biopsy (10% versus 16%, P < .001), breast ultrasound (13% versus 23%, P < .001), and Breast Imaging Centers of Excellence (10% versus 16%, P < .001).

CONCLUSIONS

People living in ZIP codes with high socioeconomic disadvantage are less likely to have accredited breast imaging facilities within their ZIP codes, which may contribute to disparities in access to breast cancer care experienced by underserved groups living in these areas.