Determinants of late stage diagnosis of breast and cervical cancer: the impact of age, race, social class, and hospital type

Determinants of Protective Healthcare Services Awareness among Female Syrian Refugees in Turkey

War-related migration may deprive people of access to a regular healthcare system and cause new diseases to be battled. Since refugee women are more vulnerable to diseases during this period, protective healthcare services awareness is critical for early disease diagnosis. Following the civil war that triggered the migration of millions of Syrians, an extensive survey was undertaken in coordination with the World Health Organization Country Office in Turkey to explore the health status of Syrian refugees in Turkey. Employing the survey data, we aimed to investigate the determinants of the awareness of protective health services (Pap smear test, mammogram, HIV test) among female Syrian refugees. Logit regression analysis was applied in order to investigate the determinants of the awareness of protective health services among the female refugee population. The results revealed a notably low rate of awareness of protective health services among female Syrian refugees. Furthermore, the association of explanatory variables, including socioeconomic factors, healthcare use, and health literacy with the protective health services awareness, was found to be significant.

Relative importance of individual insurance status and hospital payer mix on survival for women with cervical cancer

OBJECTIVE

To assess the relative contributions of individual insurance status and hospital payer mix (safety net status) to quality of care and survival for patients with cervical cancer.

METHODS

We used the National Cancer Database to identify patients with cervical cancer diagnosed from 2004 to 2017. Patients were classified by insurance (uninsured/Medicaid/private/Medicare/other) and hospitals were grouped into quartiles based on the proportion of uninsured/Medicaid patients (payer mix) (top quartile defined as safety-net hospital (SNHs) and lowest as Q1 hospitals). Quality-of-care was assessed by adherence to evidence-based metrics. Individual contributions of insurance status and payer mix to survival was assessed with a proportional hazards Cox model.

RESULTS

A total of 124,339 patients including 11,338 uninsured (9.1%) and 27,281 Medicaid (21.9%) recipients treated at 1156 hospitals were identified. Quality-of-care was not significantly different across hospital quartiles. Adjusting for patients' clinical/demographic characteristics, treatment at a SNH was associated with a 14% higher mortality (HR = 1.14; 95% CL, 1.08-1.20) than at Q1 hospitals. Testing for individual insurance, uninsured patients had 32% increased mortality (HR = 1.32; 95% CI,1.26-1.38) and Medicaid recipients 40% increased (HR = 1.40; 95%CI,1.35-1.44) compared to privately insured patients. Examining both payer mix and insurance, only individual insurance retained a significant impact on mortality.

CONCLUSIONS

Individual insurance may be a more important predictor of survival than site-of-care and hospital payer mix for women with cervical cancer. There is substantial variation in outcomes within hospitals based on individual insurance, regardless of hospital payer mix.

Elevated breast cancer mortality among highly educated Asian American women

Background

Postmenopausal breast cancer (PMBC) is the most commonly diagnosed and the second leading cause of cancer death among women in the US. Research examining the association between PMBC and education level has been inconsistent; no study in the US has examined how educational level impacts PMBC mortality in Asian American women, a largely immigrant population with above-average educational attainment.

Methods

California Vital Statistics data from 2012–2017 were analyzed to derive age-adjusted mortality rate ratios (MRRs) by education level (associates degree or above referred to as “higher education”, high school, less than high school) and race [Non-Hispanic White (NHW), Asian/Pacific Islander (Asian), and its two largest subpopulations: Chinese and Filipino] from negative binomial regression models.

Results

PMBC mortality for both NHWs and Asians was greater among women with higher education compared to those who did not complete high school: NHWs had 22% higher PMBC mortality (MRR 1.22; 95% CI: 1.14–1.31) and Asians had 2.6 times greater PMBC mortality (MRR 2.64; 95% CI: 2.32–3.00) than their counterparts who did not complete high school. Asians in the lowest education level had 70% lower mortality than NHWs (MRR 0.30; 95% CI: 0.27–0.34). This mortality advantage among Asians was greatly reduced to only 27% lower among the highest educated (MRR 0.73; 95% CI: 0.68–0.78). For higher educated Filipina women, no mortality advantage was evident compared to NHWs (MRR 0.96; 95% CI: 0.88–1.05).

Conclusion

PMBC mortality for higher educated Asian women is elevated in comparison to their counterparts with less education. Given that PMBC survival is greater among those with higher education, our findings strongly suggest an excess in the incidence of PMBC (more than double) among higher educated Asian women; this warrants more research into potentially modifiable causes of PMBC in this burgeoning population.

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

Background

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

Methods

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

Results

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

Conclusions

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

Prevalência e fatores associados ao diagnóstico de câncer de mama em estágio avançado

Resumo Este estudo transversal investigou a prevalência e os fatores associados ao diagnóstico de câncer de mama em estágio avançado entre 18.890 mulheres assistidas em hospital especializado da capital do Rio de Janeiro, Brasil, entre os anos 1999 e 2016. Utilizou-se regressão de Poisson com variância robusta para estimar razões de prevalência e respectivos intervalos de 95% de confiança. Apresentaram maiores prevalências de diagnóstico nessa condição mulheres com idade entre 20-39 e 40-49 anos, de raça/cor da pele preta e parda, que viviam sem companheiro(a), procedentes de outros municípios do estado do Rio de Janeiro, que tiveram o Sistema Único de Saúde como origem do encaminhamento e que foram diagnosticadas nos sexênios 1999-2004 e 2005-2010. Em contrapartida, mulheres com idade entre 60-69 e 70-99 anos, que cursaram algum nível de escolaridade, com histórico familiar de câncer e que chegaram ao hospital com diagnóstico e sem tratamento apresentaram menores prevalências de diagnóstico em estágio avançado. Esses resultados podem ser considerados no planejamento de ações de prevenção secundária, a fim de antecipar o diagnóstico de câncer de mama dos grupos mais vulneráveis e assim colaborar para a redução da prevalência do diagnóstico em estágio avançado.

Machine learning-based statistical analysis for early stage detection of cervical cancer

Cervical cancer (CC) is the most common type of cancer in women and remains a significant cause of mortality, particularly in less developed countries, although it can be effectively treated if detected at an early stage. This study aimed to find efficient machine-learning-based classifying models to detect early stage CC using clinical data. We obtained a Kaggle data repository CC dataset which contained four classes of attributes including biopsy, cytology, Hinselmann, and Schiller. This dataset was split into four categories based on these class attributes. Three feature transformation methods, including log, sine function, and Z-score were applied to these datasets. Several supervised machine learning algorithms were assessed for their performance in classification. A Random Tree (RT) algorithm provided the best classification accuracy for the biopsy (98.33%) and cytology (98.65%) data, whereas Random Forest (RF) and Instance-Based K-nearest neighbor (IBk) provided the best performance for Hinselmann (99.16%), and Schiller (98.58%) respectively. Among the feature transformation methods, logarithmic gave the best performance for biopsy datasets whereas sine function was superior for cytology. Both logarithmic and sine functions performed the best for the Hinselmann dataset, while Z-score was best for the Schiller dataset. Various Feature Selection Techniques (FST) methods were applied to the transformed datasets to identify and prioritize important risk factors. The outcomes of this study indicate that appropriate system design and tuning, machine learning methods and classification are able to detect CC accurately and efficiently in its early stages using clinical data.

The Impact of Residential Racial Segregation on Non-Small Cell Lung Cancer Treatment and Outcomes

BACKGROUND

Despite decreases in lung cancer incidence, racial disparities in diagnosis and treatment persist. Residential segregation and structural racism have effects on socioeconomic status for black people, affecting healthcare access. This study aims to determine the impact of residential segregation on racial disparities in non-small cell lung cancer (NSCLC) treatment and mortality.

METHODS

Patient data were obtained from Surveillance, Epidemiology, and End Results Program (SEER) database for black and white patients diagnosed with NSCLC from 2004-2016 in the 100 most populous counties. Regression models were built to assess outcomes of interest - stage at diagnosis and surgical resection of disease. Predicted margins assessed impact of index of dissimilarity (IoD) on these disparities. Competing risk regressions for black and white patients in highest and lowest quartiles of IoD were used to assess cancer-specific mortality.

RESULTS

Our cohort had 193,369 white and 35,649 black patients. Black patients were more likely to be diagnosed at advanced stage than white patients with increasing IoD. With increasing IoD, black patients were less likely to undergo surgical resection than white. Disparities were eliminated at low IoD. Black patients at high IoD had lower cancer-specific survival.

CONCLUSIONS

Black patients were more likely to present at advanced disease, were less likely to receive surgery for early stage, and had higher cancer-specific mortality at higher IoD. Our findings highlight the impact of structural racism and residential segregation on NSCLC outcomes. Solutions to these disparities must come from policy reforms to reverse residential segregation and deleterious socioeconomic effects of discriminatory policies.

Supervised Algorithms of Machine Learning for the Prediction of Cervical Cancer

Background

Compared to other genital cancers, cervical cancer is the most prevalent and the main cause of mortality in females in third-world countries, affected by different factors, including smoking, poor nutritional status, immune-deficiency, long-term use of contraceptives and so on.

Objective

The present study was conducted to predict cervical cancer and identify its important predictors using machine learning classification algorithms.

Material and Methods

In a cross-sectional study, the data of 145 patients with 23 attributes, which referred to Shohada Hospital Tehran, Iran during 2017-2018, were analyzed by machine learning classification algorithms which included SVM, QUEST, C&R tree, MLP and RBF. The criteria measurement used to evaluate these algorithms included accuracy, sensitivity, specificity and area under the curve (AUC).

Results

The accuracy, sensitivity, specificity and AUC of Quest and C&R tree were, respectively 95.55, 90.48, 100, and 95.20, 95.55, 90.48, 100, and 95.20, those of RBF 95.45, 90.00, 100 and 91.50, those of SVM 93.33, 90.48, 95.83 and 95.80 and those of MLP 90.90, 90.00, 91.67 and 91.50 percentage. The important predictors in all the algorithms were found to comprise personal health level, marital status, social status, the dose of contraceptives used, level of education and number of caesarean deliveries.

Conclusion

This investigation confirmed that ML can enhance the prediction of cervical cancer. The results of this study showed that Decision Tree algorithms can be applied to identify the most relevant predictors. Moreover, it seems that improving personal health and socio-cultural level of patients can be causing cervical cancer prevention.

Do poor patients suffer from inaccurate diagnoses more than well-to-do patients? A randomized control trial

BACKGROUND

Poor patients have greater morbidity and die up to 10 years earlier than patients who have higher socio-economic status. These findings are often attributed to differences in life-style between groups. The present study aimed at investigating the extent to which physicians contribute to the effect by providing relative poorer care, resulting in relative neglect in terms of time spent with a poor patient and more inaccurate diagnoses.

METHODS

A randomised experiment with 45 internal medicine residents. Doctors diagnosed 12 written clinical vignettes that were exactly the same except for the description of the patients' socio-economic status. Each participant diagnosed four of the vignettes in a poor-patient version, four in a rich-patient version, and four in a version that did not contain socio-economic markers, in a balanced within-subjects incomplete block design. Main measurements were: diagnostic accuracy scores and time spent on diagnosis.

RESULTS

Mean diagnostic accuracy scores (range 0-1) did not significantly differ among the conditions of the experiment (for poor patients: 0.48; for rich patients: 0.52; for patients without socio-economic markers: 0.54; p > 0.05). While confronted with patients not presenting with socio-economic background information, the participants spent significantly less time-to-diagnosis ((for poor patients: 168 s; for rich patients: 176 s; for patients without socio-economic markers: 151 s; p < 0.01), however due to the fact that the former vignettes were shorter.

CONCLUSION

There is no reason to believe that physicians are prejudiced against poor patients and therefore treat them differently from rich patients or patients without discernible socio-economic background.

Travel time to provider is associated with advanced stage at diagnosis among low income head and neck squamous cell carcinoma patients in North Carolina

OBJECTIVE

There is considerable variation in the travel required for a patient with head and neck squamous cell carcinoma (HNSCC) to receive a diagnosis. The impact of this travel on the late diagnosis of cancer remains unexamined, even though presenting stage is the strongest predictor of mortality. Our aim is to determine whether travel time affects HNSCC stage at diagnosis independently of other risk factors, and whether this association is affected by socioeconomic status.

MATERIALS AND METHODS

Cases were obtained from the CHANCE database, a population-based case-control study in North Carolina (n = 808). The mean age was 59.6 and 72% were male. Stage at diagnosis was categorized as early (T1-T2) or advanced (T3-T4) T stage and the presence or absence of nodal metastasis. Multivariate logistic regression models were used to estimate odds ratios for stage-at-diagnosis based on travel time, after adjustment for variables including demographics, income, insurance status, alcohol, and tobacco use.

RESULTS

The adjusted odds ratio (OR) of advanced T-stage at diagnosis was 1.97 for each hour driven (95% CI 1.36-2.87). There was no association with nodal metastases. There was a significant interaction between travel time and income (p = 0.026) with a pattern of higher ORs for increased distance among lower income (<$20,000) patients compared to the ORs for higher income (>$20,000) patients.

DISCUSSION

Travel time was an independent contributor to advanced T stage at diagnosis among low income patients. This suggests travel burden may be a barrier to early diagnosis of HNSCC for impoverished patients.

Patterns of Care of Breast Cancer Patients in a Rural Cancer Center in Western India

Breast cancer is an emerging public health problem in low- and middle-income countries. The main objective is to describe the clinical characteristics and patterns of care of breast cancer patients diagnosed and treated in a rural cancer hospital in Barshi, Western India. The results from a cross-sectional study of 99 consecutive breast cancer patients diagnosed and treated between February 2012 and November 2014 in Nargis Dutt Memorial Cancer Hospital is reported. The case records of the patients were scrutinized and reviewed to abstract data on their clinical characteristics, diagnostic, and treatment details. The mean age at diagnosis of the patients was 52.8 ± 11.6 years; 83.5% of women were married, and 60.6% were illiterate. Sixty percent of patients had tumors measuring 5 cm or less. Almost half of the patients (46.4%) had stage I or II A disease and a third (36.0%) had axillary lymph node metastasis. Estrogen, progesterone, and human epidermal growth factor receptor2 receptor status were investigated in 41 (41.4%) of patients only. The median interval between diagnosis and initiation of treatment was 11 days. Modified radical mastectomy was done in 91% of patients, and nearly a third of patients who were prescribed chemotherapy did not complete treatment. The rural-based tertiary cancer care center has made treatment more accessible to breast cancer patients and has reduced the interval between diagnosis and treatment initiation. However, there are still many challenges like non-compliance to and incomplete treatments and poor follow-up that need to be addressed.

Concurrent Chemoradiotherapy or Radiotherapy Alone for Locally Advanced Cervical Cancer in Elderly Women

Aims and background

To evaluate the efficacy and toxicity of concurrent chemoradiotherapy or radiotherapy alone in elderly patients with locally advanced cervical carcinoma (stage IB2-IVA).

Methods and study design

We retrospectively reviewed the medical records of 105 women aged ≥65 years who received radiotherapy (group I, n = 61) or concurrent chemoradiotherapy (group II, n = 44). Patients received a median dose of 76.4 Gy to point A, including 30-35 Gy of high-dose intracavity brachytherapy. The concurrent chemoradiotherapy group received platinum-based chemotherapy.

Results

The median follow-up was 65 months for surviving patients. There was no significant difference in compliance to radiotherapy between the two groups. Most acute toxicities were hematologic; acute hematologic and gastrointestinal toxicity were significantly more common in group II. Five-year overall survival and cancer-specific survival rates were, respectively, 53.5% and 66.6% in group I and 61.8% and 68.8% in group II. Performance status, comorbidity index, tumor size, and stage were independent prognostic factors for overall survival, whereas stage was the only prognostic factor for cancer-specific survival.

Conclusions

The analysis showed no benefit of concurrent chemoradiotherapy with respect to overall survival and cancer-specific survival in elderly women. A prospective study is needed to determine the role of concurrent chemoradiotherapy in this population. Free full text available at www.tumorionline.it

Impact of Widespread Cervical Cancer Screening: Number of Cancers Prevented and Changes in Race-specific Incidence

OBJECTIVES

With recent approval of standalone HPV testing and increasing uptake of HPV vaccination, some have postulated that we are moving toward a "post-Pap" era of cervical cancer prevention. However, the total number cases that have been prevented by Pap smear screening as well as its impact on racial disparities are unknown.

METHODS

We estimated national cervical cancer incidence from 1976 to 2009 using the Surveillance, Epidemiology, and End Result database. Screening data were obtained from the literature and National Cancer Institute Progress Reports. We examined early, late, and race-specific trends in cancer incidence, and calculated the estimated number of cancers prevented over the past 3 decades.

RESULTS

From 1976 to 2009, there was a significant decrease in the incidence of early-stage cervical cancer, from 9.8 to 4.9 cases per 100,000 women (P<0.001). Late-stage disease incidence also decreased, from 5.3 to 3.7 cases per 100,000 women (P<0.001). The incidence among black women decreased from 26.9 to 9.7 cases per 100,000 women (P<0.001), a greater decline compared with that of white women and women of other races. After adjusting for "prescreening era" rates of cervical cancer, we estimate that Pap smears were associated with a reduction of between 105,000 and 492,000 cases of cervical cancer over the past 3 decades in the United States.

CONCLUSIONS

A large number of early-stage and late-stage cervical cancers were prevented and racial disparity in cancer rates were reduced during an era of widespread Pap smear screening.

Availability and accessibility of subsidized mammogram screening program in peninsular Malaysia: A preliminary study using travel impedance approach

Access to healthcare is essential in the pursuit of universal health coverage. Components of access are availability, accessibility (spatial and non-spatial), affordability and acceptability. Measuring spatial accessibility is common approach to evaluating access to health care. This study aimed to determine the availability and spatial accessibility of subsidised mammogram screening in Peninsular Malaysia. Availability was determined from the number and distribution of facilities. Spatial accessibility was determined using the travel impedance approach to represent the revealed access as opposed to potential access measured by other spatial measurement methods. The driving distance of return trips from the respondent's residence to the facilities was determined using a mapping application. The travel expenditure was estimated by multiplying the total travel distance by a standardised travel allowance rate, plus parking fees. Respondents in this study were 344 breast cancer patients who received treatment at 4 referral hospitals between 2015 and 2016. In terms of availability, there were at least 6 major entities which provided subsidised mammogram programs. Facilities with mammogram involved with these programs were located more densely in the central and west coast region of the Peninsula. The ratio of mammogram facility to the target population of women aged 40-74 years ranged between 1: 10,000 and 1:80,000. In terms of accessibility, of the 3.6% of the respondents had undergone mammogram screening, their mean travel distance was 53.4 km (SD = 34.5, range 8-112 km) and the mean travel expenditure was RM 38.97 (SD = 24.00, range RM7.60-78.40). Among those who did not go for mammogram screening, the estimated travel distance and expenditure had a skewed distribution with median travel distance of 22.0 km (IQR 12.0, 42.0, range 2.0-340.0) and the median travel cost of RM 17.40 (IQR 10.40, 30.00, range 3.40-240.00). Higher travel impedance was noted among those who lived in sub-urban and rural areas. In summary, availability of mammogram facilities was good in the central and west coast of the peninsula. The overall provider-to-population ratio was lower than recommended. Based on the travel impedance approach used, accessibility to subsidised mammogram screening among the respondents was good in urban areas but deprived in other areas. This study was a preliminary study with limitations. Nonetheless, the evidence suggests that actions have to be taken to improve the accessibility to opportunistic mammogram screening in Malaysia in pursuit of universal health coverage.

Assessing Factors Associated With Survival Among Cervical Cancer Patients in Kenya: A Retrospective Follow-up Study

Background:

Cervical cancer ranks as the fourth most commonly diagnosed cancer and the fourth leading cause of cancer death in women worldwide. In Kenya, cervical cancer is the second most commonly diagnosed cancer after breast cancer and the leading cause of cancer death in women. It is estimated that by the end of 2018, cervical cancer will be responsible for 5,250 (11%) new cases and 3,286 (11.84%) deaths in Kenya.

Methods:

We conducted a retrospective follow-up study to estimate the overall survival of women treated for cervical cancer in Kenya. Medical records were reviewed to extract information for generating a quantitative data set, and the chi-square test was used to test for associations between patient outcomes and various sociodemographic and clinical factors. To estimate overall survival after treatment, we used Kaplan–Meier survival analysis, the logrank test, and Cox proportional hazards regression.

Results:

A total of 481 patient records were included in this study. From the bivariate analysis, 4 factors demonstrated a statistically significant association with survival: access to care (P=.049), stage of disease at diagnosis (P<.001), type of treatment received (P<.001), and whether or not treatment was initiated and completed (P<.001). The overall 5-year survival estimate for women with cervical cancer was 59%. However, 396 (82.3%) women were lost to follow-up; with no deaths observed after the first year, the overall survival estimate is only accurate for the first year.

Conclusion:

The high rate of loss to follow-up appears to be characteristic of cancer care in Kenya and highlights the difficulties in conducting survival studies in low-resource settings with low coverage of vital registration and a lack of centralised national administrative systems. Despite the study's limitations, the results support evidence whereby late-stage diagnosis, deficiencies in cancer management, and limited cancer care services, in particular, have been found to contribute to poor patient outcomes in sub-Saharan Africa.

Genetic alterations and PIK3CA gene mutations and amplifications analysis in cervical cancer by racial groups in the United States

INTRODUCTION

A number of studies indicated racial differences in cervical cancer outcomes and several factors are associated with it such as stage, comorbidities, treatment pattern, and socioeconomic status. However, the associations of tumor genomic patterns such as phosphatidylinositol 3-kinase catalytic subunit alpha (PIK3CA) gene mutations and amplifications with cervical cancer racial disparities are largely unexplored.

OBJECTIVES

Therefore, the present investigation aimed to identify genetic alterations (mutations and copy number variations) in cervical cancer and determine whether the PIK3CA gene mutations and amplifications in cervical cancer differ across racial/ethnic groups in the United States.

METHODS

This study made use of The Cancer Genome Atlas (TCGA) database. TCGA database is a publicly available database that was created by a joint effort between the National Cancer Institute and the National Human Genome Research Institute. The two-tailed Fisher's exact test was used to test for associations between the categorical variables, race, and PIK3CA gene mutation as well as PIK3CA gene amplification using the "Fisher test" function in R.

RESULTS

There were 309 cervical cancer samples, and of these, 194 samples had gene mutations and 295 samples had copy number alteration data. The top five mutated genes in TCGA dataset were PIK3CA, MUC4, KMT2C, SYNE1, and KMT2D. The top five amplified genes in TCGA dataset were MECOM, TP63, PRKCI, PIK3CA, and TRFC. The PIK3CA gene had the highest number of mutations with 53 mutation counts. The mutation rates were 62.5%, 31.3%, 25.4%, and 21.1% for American Indian, African American, White, and Asian, respectively. The amplification rates were 28.6%, 21.1%, 18.9%, and 12.5% for African American, Asian, White, and American Indian.

CONCLUSIONS

There are many significantly mutated or amplified genes implicated in cervical cancer. Some of them are not grouped with the already known genes in relation to cervical cancer. For example, the KMT2C, SYNE1, KMT2D, EP300, RYR2, FLG, DMD, FBXW, MECOM, TRFC, RPL35A, LPP, TBL, FGF12, and SOX2 genes. They can be explored as therapeutic targets to improve cervical cancer treatment.

Patient Navigation Improves Subsequent Breast Cancer Screening After a Noncancerous Result: Evidence from the Patient Navigation in Medically Underserved Areas Study

BACKGROUND

Past efforts to assess patient navigation on cancer screening utilization have focused on one-time uptake, which may not be sufficient in the long term. This is partially due to limited resources for in-person, longitudinal patient navigation. We examine the effectiveness of a low-intensity phone- and mail-based navigation on multiple screening episodes with a focus on screening uptake after receiving noncancerous results during a previous screening episode.

METHODS

The is a secondary analysis of patients who participated in a randomized controlled patient navigation trial in Chicago. Participants include women referred for a screening mammogram, aged 50-74 years, and with a history of benign/normal screening results. Navigation services focused on identification of barriers and intervention via shared decision-making processes. A multivariable logistic regression intent-to-treat model was used to examine differences in odds of obtaining a screening mammogram within 2 years of the initial mammogram (yes/no) between navigated and non-navigated women. Sensitivity analyses were conducted to explore patterns across subsets of participants (e.g., navigated women successfully contacted before the initial appointment; women receiving care at Hospital C).

RESULTS

The final sample included 2,536 women (741 navigated, 1,795 non-navigated). Navigated women exhibited greater odds of obtaining subsequent screenings relative to women in the standard care group in adjusted models and analyses including women who received navigation before the initial appointment.

CONCLUSIONS

Our findings suggest that low-intensity navigation services can improve follow-up screening among women who receive a noncancerous result. Further investigation is needed to confirm navigation's impacts on longitudinal screening.

Socioeconomic and Racial/Ethnic Disparities in Cancer Mortality, Incidence, and Survival in the United States, 1950-2014: Over Six Decades of Changing Patterns and Widening Inequalities

We analyzed socioeconomic and racial/ethnic disparities in US mortality, incidence, and survival rates from all-cancers combined and major cancers from 1950 to 2014. Census-based deprivation indices were linked to national mortality and cancer data for area-based socioeconomic patterns in mortality, incidence, and survival. The National Longitudinal Mortality Study was used to analyze individual-level socioeconomic and racial/ethnic patterns in mortality. Rates, risk-ratios, least squares, log-linear, and Cox regression were used to examine trends and differentials. Socioeconomic patterns in all-cancer, lung, and colorectal cancer mortality changed dramatically over time. Individuals in more deprived areas or lower education and income groups had higher mortality and incidence rates than their more affluent counterparts, with excess risk being particularly marked for lung, colorectal, cervical, stomach, and liver cancer. Education and income inequalities in mortality from all-cancers, lung, prostate, and cervical cancer increased during 1979-2011. Socioeconomic inequalities in cancer mortality widened as mortality in lower socioeconomic groups/areas declined more slowly. Mortality was higher among Blacks and lower among Asian/Pacific Islanders and Hispanics than Whites. Cancer patient survival was significantly lower in more deprived neighborhoods and among most ethnic-minority groups. Cancer mortality and incidence disparities may reflect inequalities in smoking, obesity, physical inactivity, diet, alcohol use, screening, and treatment.

Lung Cancer in Homeless People: Clinical Outcomes and Cost Analysis in a Single Institute

Introduction. To characterize the demographic and clinical features, outcomes, and treatment costs of lung cancer in homeless people. Methods. Medical records of 22 homeless patients with lung cancer at Seoul National University Boramae Medical Center in Seoul, South Korea, were retrospectively analyzed. Results. All patients were men (median age, 62 years). Most patients (78%) had advanced disease (stage IIIB, n = 2; stage IV, n = 15). Seven died during initial hospitalization (median survival, 1.5 months). Six were lost to follow-up after initial outpatient visits or discharges from initial admission (median follow-up, 13 days). Only 4 received appropriate treatment for their disease and survived for 1, 15, 19, and 28 months, respectively. Conversely, 4 of 5 patients with early stage disease (stage I, n = 4; stage IIA, n = 1) received curative surgery (median follow-up 25.5 months). The median treatment cost based on 29 days of hospitalization and 2 outpatient visits was $12,513, constituting 47.3% of the 2013 per capita income. Inpatient treatment accounted for 90% of the total costs. The National Health Insurance Service paid 82% of the costs. Conclusion. Among the homeless, lung cancer seems to be associated with poor prognosis and substantial costs during a relatively short follow-up and survival period.

What Predicts an Advanced-Stage Diagnosis of Breast Cancer? Sorting Out the Influence of Method of Detection, Access to Care, and Biologic Factors

BACKGROUND

Multiple studies have yielded important findings regarding the determinants of an advanced-stage diagnosis of breast cancer. We seek to advance this line of inquiry through a broadened conceptual framework and accompanying statistical modeling strategy that recognize the dual importance of access-to-care and biologic factors on stage.

METHODS

The Centers for Disease Control and Prevention-sponsored Breast and Prostate Cancer Data Quality and Patterns of Care Study yielded a seven-state, cancer registry-derived population-based sample of 9,142 women diagnosed with a first primary in situ or invasive breast cancer in 2004. The likelihood of advanced-stage cancer (American Joint Committee on Cancer IIIB, IIIC, or IV) was investigated through multivariable regression modeling, with base-case analyses using the method of instrumental variables (IV) to detect and correct for possible selection bias. The robustness of base-case findings was examined through extensive sensitivity analyses.

RESULTS

Advanced-stage disease was negatively associated with detection by mammography (P < 0.001) and with age < 50 (P < 0.001), and positively related to black race (P = 0.07), not being privately insured [Medicaid (P = 0.01), Medicare (P = 0.04), uninsured (P = 0.07)], being single (P = 0.06), body mass index > 40 (P = 0.001), a HER2 type tumor (P < 0.001), and tumor grade not well differentiated (P < 0.001). This IV model detected and adjusted for significant selection effects associated with method of detection (P = 0.02). Sensitivity analyses generally supported these base-case results.

CONCLUSIONS

Through our comprehensive modeling strategy and sensitivity analyses, we provide new estimates of the magnitude and robustness of the determinants of advanced-stage breast cancer.

IMPACT

Statistical approaches frequently used to address observational data biases in treatment-outcome studies can be applied similarly in analyses of the determinants of stage at diagnosis. Cancer Epidemiol Biomarkers Prev; 25(4); 613-23. ©2016 AACR.

The effects of navigation and types of neighborhoods on timely follow-up of abnormal mammogram among black women

BACKGROUND

Despite the availability of relatively simple and inexpensive screening tools, minority women are more often diagnosed at a late stage of breast cancer, in part due to delays in follow-up of abnormal screening result. One of the key factors for timely follow-up of abnormal mammogram may be neighborhood characteristics. Patient Navigation (PN) programs aim to diminish barriers, but its differential effects by neighborhood have not been fully examined. The current study examines the effect of types of neighborhoods on time to follow-up of abnormal mammogram, and the differential effects of PN by neighborhood characteristics.

METHODS

We examined data from a total of 1,696 randomized patients from a randomized controlled trial, "the Patient Navigation in Medically Underserved Areas" study that explored the effect of navigation on breast health outcomes. We categorized participants' neighborhoods into three categories and compared the effect of navigation between these neighborhood types.

RESULTS

Navigated women in mixed race neighborhoods had a shorter time to follow-up compared with non-navigated women in the neighborhoods. Black women living in mixed neighborhoods had a significant longer time to follow-up of abnormal mammogram, compared with black women living in middle class black neighborhoods.

CONCLUSION

Patient navigation interventions improve timely follow-up of abnormal mammogram. Patient navigation may be particularly beneficial for minority women who reside in racially heterogeneous neighborhoods which may be less likely to have access to affordable health clinics and social services. Health policies concerning breast cancer early detection for minority women need to pay further attention to those who might potentially be excluded from health services due to the characteristics of neighborhoods. Socioeconomic conditions of neighborhood may affect individual health through multiple interlinked mechanisms. Neighborhood characteristics, such as poverty, segregation, access to resources, and social cohesion, cannot be fully understood with simplistic measures of neighborhood disadvantage.

Psychosocial interventions addressing the needs of Black women diagnosed with breast cancer: a review of the current landscape

BACKGROUND

Poorer health outcomes and lower survival rates have been well documented among African American/Black (Black) women diagnosed with breast cancer. Black women are 41% more likely to die from breast cancer than White women despite a lower incidence rate. Apart from pharmacotherapy, psychosocial interventions are recommended by the Institute of Medicine as standard medical care for breast cancer patients at all phases of treatment. The current review is the first attempt to systematically evaluate the literature on the influence of psychosocial interventions for Black women diagnosed with breast cancer.

METHODS

This systematic review aimed to adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A comprehensive computerized literature search of CINAHL, PsycINFO, PubMed, and Web of Science was conducted to obtain relevant studies.

RESULTS

Interventions demonstrated improved mood, decreased distress, increased ability to cope with intrusive thoughts and cancer-related stress, personal growth, and improved social well-being. However, aspects unique to this population require additional scientific inquiry. Over 80% of empirical interventions focused on Black women diagnosed with breast cancer have been concentrated on the posttreatment phase. There is a paucity of work at the time of diagnosis and during treatment.

CONCLUSIONS

To address gaps in the scientific literature, more work is needed to better understand how psychosocial interventions can improve the health trajectory for Black women diagnosed with breast cancer particularly in the areas of seeking help and support, identifying culturally acceptable methods for engaging support networks, and identifying best practices for enhancing coping skills.

Female preventive practices: breast and smear tests

Breast cancer and cervical cancer are the most common female cancers in Spain and in many developed countries. The main goal of this paper is to identify the determinants of individual decisions on breast screening and smear testing, that is to say, the decision to take a test for the first time and the decision to test with suitable regularity. To that end, we have combined analyses of micro and macro data (the Spanish National Health Survey and Spanish Regional Social Indicators) and employed multilevel estimation models. Among the main results, we highlight the fact that regional public screening programmes improve individual decisions on screening (more women testing for the first time and more women testing regularly) and, furthermore, they generate positive synergies; for example, regional public programmes for smear testing improve individual decisions on both cervical and breast cancer screening. In addition, we conclude that it is not only important to know if the numbers of women undergoing breast screening and smear testing are increasing, it is also important to know if they are testing regularly.

Factors associated with delayed diagnosis of breast cancer in northeast Thailand

BACKGROUND

We identified factors associated with delayed first consultation for breast symptoms (patient delay), delayed diagnosis after first consultation (doctor delay), and advanced pathologic stage at presentation among 180 women with breast cancer in Thailand.

METHODS

In this cross-sectional study 180 patients with invasive breast cancer were interviewed about potential risk factors and markers of delayed presentation. Patient delay was defined as time from onset of symptoms to first consultation with a health care provider, and doctor delay was defined as time from first consultation with a health care provider to diagnosis of breast cancer. Linear regression and logistic regression were used for the data analyses.

RESULTS

Among the 180 patients, 17% delayed seeking consultation for longer than 3 months, and 42% reported a doctor delay of longer than 3 months. In multivariate linear analysis, a significant increase in patient delay was associated with higher family income and smoking; factors associated with increased doctor delay were previous breast symptoms, self-treatment, and travel time to the hospital. In multiple logistic regression, doctor delay was related to age at first birth (P = 0.003), previous breast symptoms (P = 0.01), and number of consultations with a surgeon before diagnosis (P = 0.007). Regarding stage of breast cancer, there were significant associations with age at diagnosis (P for trend = 0.04), education (P for trend = 0.01), family income (P for trend = 0.02), time to referral (P = 0.01), and number of consultations with a surgeon before diagnosis (P < 0.01).

CONCLUSIONS

Hospital referral from a health care provider was a major contributor to delayed diagnosis. Breast cancer awareness campaigns in Thailand should target individuals in low- and high-income groups, as well as practitioners.

The challenge of follow-up in a low-income colposcopy clinic: characteristics associated with noncompliance in high-risk populations

OBJECTIVE

The study aimed to identify sociodemographic and disease-specific factors associated with follow-up in an inner-city multiethnic colposcopy clinic.

MATERIALS AND METHODS

All charts of patients referred to colposcopy clinic for abnormal cervical cytology and/or high-risk human papillomavirus infections to the University of California, Irvine, Colposcopy Clinic in Santa Ana from November 2006 to December 2007 were reviewed. Compliance was defined as at least 1 follow-up evaluation within 3 to 14 months from initial colposcopy appointment. To determine compliance, the following factors were evaluated in a multivariate analysis: race, age, spoken language, insurance status, annual income, marital status, referral cytology, histology, and pregnancy status.

RESULTS

Among the 1,046 scheduled appointments, 50% were attended. Of the patients, 458 with a minimum of 14 months of follow-up were included. The mean (SD) age of these patients was 31.0 (10.7) years. 58% were white and 55% spoke Spanish. A total of 248 patients (54%) had appropriately timed repeat testing, whereas 210 (46%) failed to return within 14 months. In univariate analysis, women who were referred from outside the clinic, single, younger than 40 years, and with self-pay or government-funded insurance were more likely to be noncompliant although this was not statistically significant. In multivariate analysis, referral from outside the clinic, self-pay, or government-funded insurance, Spanish-speaking, and single marital status were all significantly associated with noncompliance. Although cervical intraepithelial neoplasia 2 or 3 was not associated with noncompliance, 45% of women with cervical intraepithelial neoplasia 2 or 3 still did not comply with recommendations.

CONCLUSIONS

This inner-city clinic is perhaps successful at maintaining compliance for women at highest risk for cervical cancer when the triage originates from within the clinic and when the patient is married, English-speaking, and privately insured. However, reasons for those patients at highest risk for noncompliance in this clinic may need to be better characterized.

Sociodemographic Characteristics, Distance to the Clinic, and Breast Cancer Screening Results

Timely detection and follow-up of abnormal cellular changes can aid in early diagnosis of breast cancer, thus leading to better treatment outcomes. However, despite substantial breast cancer screening initiatives, the proportion of female breast cancer cases diagnosed at late stages remains high. Distance to screening clinics may affect access to care, particularly for women living in impoverished areas with limited means of reliable transportation. Utilizing breast cancer screening data collected by the Illinois Breast and Cervical Cancer Program between 1996 and 2010, we examined the effect of travel distance to the clinic from which women received breast cancer screening tests on stage of diagnosis. The proportion of abnormal mammograms in White women (1.6%) was higher than in Black women (1.1%) or Hispanic women (0.5%). The average distance traveled to a clinic was also farthest among White women (6.7 mi) than for Hispanic (5.3 mi) or Black women (4.4 mi). Distance to a clinic was significantly associated with increased odds of having abnormal results. When distance to clinic was controlled for, the observed disparity in odds of having an abnormal mammogram between White and Black women was no longer statistically significant. Individual and neighborhood sociodemographic characteristics were significantly associated with distance to clinic, but were not associated with increased odds of having an abnormal mammogram, controlling for distance to the clinic. Findings showed that individual and neighborhood sociodemographic characteristics are directly and indirectly associated with abnormal mammogram results, and that distance to a clinic may mediate, in part, the effects of individual characteristics and neighborhood disadvantage on the probability of having an abnormal mammogram.

Disparities in late stage diagnosis, treatment, and breast cancer-related death by race, age, and rural residence among women in Georgia

The objectives of this study were to examine the outcomes of late stage breast cancer diagnosis, receiving first course treatment, and breast cancer-related death by race, age, and rural/urban residence in Georgia. The authors used cross-sectional and follow-up data (1992-2007) for Atlanta and Rural Georgia cancer registries that are part of the National Cancer Institute's Surveillance, Epidemiology, and End Results Program (N = 23,500 incident breast cancer cases in non-Hispanic whites or non-Hispanic African Americans). Multilevel modeling and Cox proportional hazard models revealed that compared to whites, African American women had significantly increased odds of late stage diagnosis (odds ratio [OR] = 2.08, p = 0.0001) and unknown tumor stage (OR = 1.27, p = 0.0001), decreased odds of receiving radiation (OR = 0.93, p = 0.041) or surgery (OR = 0.50, p = 0.0001), and increased risk of death following breast cancer diagnosis (hazard rate ratio [HR] = 1.50, p = 0.0001). Increased age was significantly associated with the odds of late/unknown stage at diagnosis, worse treatment, and survival. Women residing in rural areas had significantly decreased odds of receiving radiation and surgery with radiation (OR = 0.59, p = 0.0001), and for receiving breast-conserving surgery compared to mastectomy (OR = 0.73, p = 0.005). Factors affecting each level of the breast cancer continuum are distinct and should be examined separately. Efforts are needed to alleviate disparities in breast cancer outcomes in hard-to-reach populations.

Patterns of cervical cancer screening, diagnosis, and follow-up treatment in a state Medicaid fee-for-service population

Despite being a screening-amenable cancer, cervical cancer is the third most common genital cancer among white women and the most common among African American women. The study objective was to use administrative claims data for CC disease surveillance among recipients enrolled in a state Medicaid fee-for-service (FFS) program. West Virginia (WV) Medicaid FFS administrative claims data for female recipients aged 21-64 years from 2003 to 2008 were used for this study. All medical and prescription claims were aggregated to reflect each recipient's medical care and prescription drug utilization. The yearly prevalence of Pap smear testing declined from 23.9% in 2003 to 15.8% in 2008 in the Medicaid FFS population. During the 6-year study period, persistence with Pap smear testing was low; 41.8% of recipients received no Pap smear testing. Only 73.1% of recipients received Pap smear testing during the year prior to their CC or precancerous cervical lesions (PCL) diagnosis. The likelihood of a CC diagnosis increased with a decrease in Pap smear testing persistence. Only 10.1% of recipients received appropriate follow-up care following a diagnosis of high-grade PCL; only 31.5% of the recipients received appropriate follow-up care for low-grade PCL diagnosis. Although CC preventive services such as screening and PCL follow-up care are covered under Medicaid programs, underutilization of these services by recipients in the Medicaid FFS population is a concern. Results of this study emphasize the need to address disparities in screening and appropriate PCL follow-up care among recipients in the Medicaid FFS population.

Association of insurance status and age with cervical cancer stage at diagnosis: National Cancer Database, 2000-2007

OBJECTIVES

We examined the relationship of age at diagnosis and insurance status with stage among cervical cancer patients aged 21 to 85 years.

METHODS

We selected data on women (n = 69 739) diagnosed with invasive cervical cancer between 2000 and 2007 from the National Cancer Database. We evaluated the association between late stage (stage III/IV) and both insurance and age, with adjustment for race/ethnicity and other sociodemographic and clinical factors. We used multivariable log binomial models to estimate risk ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

The proportion of late-stage disease increased with age: from 16.53% (21-34 years) to 42.44% (≥ 70 years). The adjusted relative risk of advanced-stage disease among women aged 50 years and older was 2.2 to 2.5 times that of patients aged 21 to 34 years. Uninsured (RR = 1.44; 95% CI = 1.40, 1.49), Medicaid (RR = 1.37, 95% CI = 1.34, 1.41), younger Medicare (RR = 1.12, 95% CI = 1.06, 1.19), and older Medicare (RR = 1.20, 95% CI = 1.15, 1.26) patients had a higher risk of late-stage disease than did privately insured patients.

CONCLUSIONS

Screening should be encouraged for women at high risk for advanced-stage disease.

Timeliness of cervical cancer diagnosis and initiation of treatment in the National Breast and Cervical Cancer Early Detection Program

OBJECTIVES

To examine time intervals from cervical cancer screening to diagnosis and treatment initiation among low-income and uninsured women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) during two consecutive time periods.

METHODS

We analyzed NBCCEDP data for women with abnormal Pap tests (n=100,167), from which 1,417 invasive cervical cancers were diagnosed. We examined two time intervals for this study: diagnostic interval (time from abnormal Pap test to the date of definitive diagnosis) and treatment initiation interval (time from definitive diagnosis to treatment initiation) for two time periods: 1996-2002 and 2003-2009. We compared median time intervals for diagnostic and treatment initiation using the Kruskal-Wallis test. Adjusted proportions (predicted marginals) were calculated using logistic regression to examine diagnosis and treatment within program benchmarks (≤60 days).

RESULTS

Median diagnostic intervals decreased overall by 6 days (54 vs. 48 days, p<0.001). This decrease in the median diagnostic interval was noted for all variables examined. The median treatment initiation intervals remained stable over the two time periods.

CONCLUSIONS

Women screened by the NBCCEDP receive diagnostic follow-up and initiate treatment within preestablished program guidelines.

Socioeconomic, Rural-Urban, and Racial Inequalities in US Cancer Mortality: Part I-All Cancers and Lung Cancer and Part II-Colorectal, Prostate, Breast, and Cervical Cancers

We analyzed socioeconomic, rural-urban, and racial inequalities in US mortality from all cancers, lung, colorectal, prostate, breast, and cervical cancers. A deprivation index and rural-urban continuum were linked to the 2003-2007 county-level mortality data. Mortality rates and risk ratios were calculated for each socioeconomic, rural-urban, and racial group. Weighted linear regression yielded relative impacts of deprivation and rural-urban residence. Those in more deprived groups and rural areas had higher cancer mortality than more affluent and urban residents, with excess risk being marked for lung, colorectal, prostate, and cervical cancers. Deprivation and rural-urban continuum were independently related to cancer mortality, with deprivation showing stronger impacts. Socioeconomic inequalities existed for both whites and blacks, with blacks experiencing higher mortality from each cancer than whites within each deprivation group. Socioeconomic gradients in mortality were steeper in nonmetropolitan than in metropolitan areas. Mortality disparities may reflect inequalities in smoking and other cancer-risk factors, screening, and treatment.

Spatial association of racial/ethnic disparities between late-stage diagnosis and mortality for female breast cancer: where to intervene?

Background

Over the past twenty years, racial/ethnic disparities between late-stage diagnoses and mortality outcomes have widened due to disproportionate medical benefits that different racial/ethnic groups have received. Few studies to date have examined the spatial relationships of racial/ethnic disparities between breast cancer late-stage diagnosis and mortality as well as the impact of socioeconomic status (SES) on these two disparities at finer geographic scales.

Methods

Three methods were implemented to assess the spatial relationship between racial/ethnic disparities of breast cancer late-stage diagnosis and morality. First, this study used rate difference measure to test for racial/ethnic disparities in both late-stage diagnosis and mortality of female breast cancer in Texas during 1995-2005. Second, we used linear and logistic regression models to determine if there was a correlation between these two racial/ethnic disparities at the census tract level. Third, a geographically-weighted regression analysis was performed to evaluate if this correlation occurred after weighting for local neighbors.

Results

The spatial association of racial disparities was found to be significant between late-stage diagnosis and breast cancer mortality with odds ratios of 33.76 (CI: 23.96-47.57) for African Americans and 30.39 (CI: 22.09-41.82) for Hispanics. After adjusting for a SES cofounder, logistic regression models revealed a reduced, although still highly significant, odds ratio of 18.39 (CI: 12.79-26.44) for African-American women and 11.64 (CI: 8.29-16.34) for Hispanic women. Results of the logistic regression analysis indicated that census tracts with low and middle SES were more likely to show significant racial disparities of breast cancer late-stage diagnosis and mortality rates. However, values of local correlation coefficients suggested that the association of these two types of racial/ethnic disparities varied across geographic regions.

Conclusions

This study may have health-policy implications that can help early detection of breast cancer among disadvantaged minority groups through implementing effective intervention programs in targeted regions.

Breast cancer in Latinas: gene expression, differential response to treatments, and differential toxicities in Latinas compared with other population groups

Disparities in clinical outcomes of breast cancer have been described among different racial and ethnic groups in the U.S. Convincing data exist showing that Latina women have a lower incidence of breast cancer but a higher breast cancer-related mortality rate compared with white women. Noticeable differences in breast cancer incidence are present even within different Latina subsets with a higher incidence in second- and third-generation women compared with foreign born. An increasing amount of data exists pointing to significant differences in the genetics and biology of breast cancer in Latinas as a significant contributor to the higher mortality, including a higher incidence of triple-negative breast cancers (which do not overexpress HER-2 protein and are negative for estrogen receptors and progesterone receptors). Other social and environmental factors are likely to play a significant role as well, including a lower rate of screening mammography, variable access to medical care, among others. Recent data are inconclusive regarding differences among racial/ethnic groups in the response to chemotherapy. Data on racial/ethnic variations in the pharmacogenomics of chemotherapy, endocrine treatments, and toxicity are more limited, with some data suggesting differences in frequencies of polymorphisms of genes involved in the metabolism of some of these agents. Further studies are needed on this subject.

Timeliness and follow-up patterns of cervical cancer detection in a cohort of medically underserved California women

INTRODUCTION

This study examines factors associated with timely follow-up after Pap test in a program providing cervical cancer detection services to medically underserved California women.

METHODS

Data between 01 January 1992 and 30 June 2007 were analyzed. Cox proportional hazard regression was used to identify subgroups of women with delayed time to diagnosis or treatment scheduling. The probability of being scheduled for final diagnosis and treatment was assessed using logistic regression analysis. Demographic and clinical characteristics of the women lost to follow up were examined.

RESULTS

Time from screening to final diagnosis scheduling differed according to age group, race/ethnicity, and Pap test result. Race/ethnicity and age were associated with whether treatment was scheduled or not. While loss to follow up among those scheduled for final diagnosis was associated with certain patients' characteristics, no such association was found among those who were scheduled for treatment.

CONCLUSIONS

Patient's demographic characteristics determine the odds of being scheduled for final diagnosis and treatment as well as timeliness of follow-up from screening to final diagnosis. Findings suggest that the dual goal of reducing health disparities and cost-effective detection and treatment of precancerous disease to prevent cervical cancers cannot be achieved without consideration of racial/ethnic differences and needs.

Healthcare access, socioeconomic factors and late-stage cancer diagnosis: an exploratory spatial analysis and public policy implication

Patients diagnosed with late-stage cancer have lower survival rates than those with early-stage cancer. This paper examines possible associations between several risk factors and late-stage diagnosis for four types of cancer in Illinois: breast cancer, prostate cancer, colorectal cancer, and lung cancer. Potential risk factors are composed of spatial factors and nonspatial factors. The spatial factors include accessibility to primary healthcare and distance or travel time to the nearest cancer screening facility. A set of demographic and socioeconomic variables are consolidated into three nonspatial factors by factor analysis. The Bayesian model with convolution priors is utilised to analyse the relationship between the above risk factors and each type of late-stage cancer while controlling for spatial autocorrelation. The results for breast cancer suggest that people living in neighbourhoods with socioeconomic disadvantages and cultural barriers are more likely to be diagnosed at a late stage. In regard to prostate cancer, people in regions with low socioeconomic status are also more likely to be diagnosed at a late stage. Diagnosis of late-stage colorectal or lung cancer is not significantly associated with any of the abovementioned risk factors. The results have important implications in public policy.

Use of partnership strategies to build radiation oncology disparities research programs in five Western Pennsylvania communities: an organizational case study

Many cancer treatment and prevention trials as well as surveillance programs suffer from a disproportionately low rate of accrual and a high rate of noncompliance or dropouts of racial minorities and the poor. One suggested strategy to help remediate this trend is to directly involve those targeted populations within the development, implementation, and evaluation of these services. The Radiation Oncology Community Outreach Group (ROCOG) and Neighborhood Cancer Care Cooperative (NCCC) are designed based upon this type of highly collaborative organizational structure, consistent with the general principles of community-based participatory research. Funded by the National Cancer Institute Cancer Disparities Research Partnership program, ROCOG/NCCC provide oncology-focused, community hospital-based initiatives intended to help close the cancer disparities gap. This article presents a descriptive case study of the organizational and political process that preceded our grant proposal submission, the potential benefits and difficulties associated with our extensive collaborative model, and an example of how highly competitive health care organizations can become partners in narrowly focused initiatives aimed at a greater social good.

Impact of socioeconomic status on cancer incidence and stage at diagnosis: selected findings from the surveillance, epidemiology, and end results: National Longitudinal Mortality Study

BACKGROUND

Population-based cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute (NCI) are mainly based on medical records and administrative information. Individual-level socioeconomic data are not routinely reported by cancer registries in the United States because they are not available in patient hospital records. The U.S. representative National Longitudinal Mortality Study (NLMS) data provide self-reported, detailed demographic and socioeconomic data from the Social and Economic Supplement to the Census Bureau's Current Population Survey (CPS). In 1999, the NCI initiated the SEER-NLMS study, linking the population-based SEER cancer registry data to NLMS data. The SEER-NLMS data provide a new unique research resource that is valuable for health disparity research on cancer burden. We describe the design, methods, and limitations of this data set. We also present findings on cancer-related health disparities according to individual-level socioeconomic status (SES) and demographic characteristics for all cancers combined and for cancers of the lung, breast, prostate, cervix, and melanoma.

METHODS

Records of cancer patients diagnosed in 1973-2001 when residing 1 of 11 SEER registries were linked with 26 NLMS cohorts. The total number of SEER matched cancer patients that were also members of an NLMS cohort was 26,844. Of these 26,844 matched patients, 11,464 were included in the incidence analyses and 15,357 in the late-stage diagnosis analyses. Matched patients (used in the incidence analyses) and unmatched patients were compared by age group, sex, race, ethnicity, residence area, year of diagnosis, and cancer anatomic site. Cohort-based age-adjusted cancer incidence rates were computed. The impact of socioeconomic status on cancer incidence and stage of diagnosis was evaluated.

RESULTS

Men and women with less than a high school education had elevated lung cancer rate ratios of 3.01 and 2.02, respectively, relative to their college educated counterparts. Those with family annual incomes less than $12,500 had incidence rates that were more than 1.7 times the lung cancer incidence rate of those with incomes $50,000 or higher. Lower income was also associated with a statistically significantly increased risk of distant-stage breast cancer among women and distant-stage prostate cancer among men.

CONCLUSIONS

Socioeconomic patterns in incidence varied for specific cancers, while such patterns for stage were generally consistent across cancers, with late-stage diagnoses being associated with lower SES. These findings illustrate the potential for analyzing disparities in cancer outcomes according to a variety of individual-level socioeconomic, demographic, and health care characteristics, as well as by area measures available in the linked database.

Identification and characteristics of vaccine refusers

Background

This study evaluated the utility of immunization registries in identifying vaccine refusals among children. Among refusers, we studied their socioeconomic characteristics and health care utilization patterns.

Methods

Medical records were reviewed to validate refusal status in the immunization registries of two health plans. Racial, education, and income characteristics of children claiming refusal were collected based on the census tract of each child. Health care utilization was identified using both electronic medical record and insurance claims. Within the immunization registries of two HMOs in the study, some providers use refusal and medical contraindication interchangeably, and some providers tend to always use "ever refusal." Therefore, we combined medical contraindication and refusal together and treated them all as "refusal" in this study.

Results

The immunization registry, compared to chart review, had negative predictive values of 85–92% and 90–97% for 2- and 6-year olds, and positive predictive values of only 52–74% and 59–62% to identify vaccine refusals. Refusers were more likely to reside in well-educated, higher income areas than non-refusers. Refusers had not opted out of health care system and continued, although less frequently for the age 2 and under group, to use services.

Conclusion

Without enhancements to immunization registries, identifying children with immunization refusal would be time consuming. Since communities where refusers live are well educated, interventions should target these communities to communicate vaccine adverse events and consequences of vaccine preventable diseases.

Economic, racial and ethnic disparities in breast cancer in the US: towards a more comprehensive model

Using cancer registry data, we focus on racial and ethnic disparities in stage of breast cancer diagnosis in Cook County, IL. The county health system is the "last resort" health-care provider for low-income persons. Socioeconomic status is measured using empirical Bayes estimates of tract-level poverty, specific to non-Hispanic whites, non-Hispanic blacks or Hispanics in one of three age groups. We use ordinal logistic regression with non-proportional odds to model stage. Blacks and Hispanics are at greater risk for regional and distant stage diagnosis, but the disparity declines with age. Women in high-poverty areas are at substantially greater risk for late-stage diagnosis. The effects of poverty do not differ by age or across racial and ethnic groups.

Contextual Analysis of Breast Cancer Stage at Diagnosis Among Women in the United States, 2004

BACKGROUND: To explore contextual effects and to test for interactions, this study examined how breast cancer stage at diagnosis among U.S. women related to individual- and county-level (contextual) variables associated with access to health care and socioeconomic status. METHODS: Individual-level incidence data were obtained from the National Program of Cancer Registries (NPCR) and the Surveillance, Epidemiology and End-Results (SEER) program. The county of residence of women with diagnosed breast cancer (n = 217,299) was used to link NPCR and SEER data with county-level measures of health care access from the 2004 Area Resource File (ARF). In addition to individual-level covariates such as age, race, and Hispanic ethnicity, we examined county-level covariates (residence in a Health Professional Shortage Area, urban/rural residence; race/ethnicity; and number of health centers/clinics, mammography screening centers, primary care physicians, and obstetrician-gynecologists per 100,000 female population or per 1000 square miles) as predictors of stage of breast cancer at diagnosis. RESULTS: Both individual-level and contextual variables are associated with later stage of breast cancer at diagnosis. Black women and women of "other race" had higher odds of receiving a diagnosis of regional or distant stage breast cancer (P <0.0001 and P = 0.02). With adjustment for age, Hispanics were more likely to receive a diagnosis of later stage breast cancer than non-Hispanics (P <0.0.001). Women living in areas with a higher proportion of black women had greater odds of receiving a diagnosis of regional or late stage breast cancer compared with women living in areas with the lowest proportion of black women. The same was noted for women living in areas with intermediate proportions of Hispanic women (age-adjusted odds ratio [OR], 0.94; 95% confidence interval [CI], 0.92-0.97]. Other important contextual variables associated with stage at diagnosis included the percentage of persons living below the poverty level and the number of office-based physicians per 100,000 women. Women living in counties with a higher proportion of persons living below the poverty level or fewer office-based physicians were more likely to receive a diagnosis of later stage breast cancer than those living in other counties (P < 0.001). In multivariable analysis, residence in areas with a higher proportion of non-Hispanic black women modified the associations of age and Hispanic ethnicity with later stage breast cancer (P = 0.0159 and P = 0.0002, respectively). CONCLUSIONS: This study found that county-level contextual variables related to the availability and accessibility of health care providers and health services can affect the timeliness of breast cancer diagnosis. This information could help public health officials develop interventions to reduce the burden of breast cancer among U.S. women.