Health System Practices and Perspectives of Social Risk Screening in Oncology

PURPOSE/OBJECTIVE(S)

Social risks (e.g., food insecurity) are adverse social/economic conditions associated with poor health outcomes. Among patients with cancer, presence of social risks is associated with increased late-stage diagnoses, care delays, and mortality. The purpose of this project was to assess the perspectives and practices regarding social risk screening within a large NCI-designated cancer center.

MATERIALS/METHODS

Email invitations to complete a secure, online survey were distributed to oncology healthcare staff (e.g., oncologists, nurses, pharmacists, medical assistants, social workers, and patient navigators) at Moores Cancer Center between June 1, 2022 and July 31, 2022. The 6-item survey collected information on clinical role, current practices and perceived barriers to screening for social risks as part of routine care. Respondents were categorized as MD-trained providers versus non-MD clinical staff. Descriptive statistics were used, including Fisher's exact test to compare responses by respondent type (MD vs non-MD). All analyses were conducted using data management and decision management software. This project was approved by the UCSD Institutional Review Board.

RESULTS

A total of 59 respondents completed the survey, including 20 MDs (34%) and 39 non-MD staff (66%). Overall, most respondents reported asking patients about their social risks (75%) and communicating information about patients' social risks with other healthcare staff when clinically relevant (84%). MDs were significantly more likely to agree that they ask patients about social risks when clinically relevant than non-MDs (95% vs 64%, p = 0.024). MDs were also more likely to communicate, review and use social risk information than their non-MD colleagues. The most reported barriers to integrating social risk information into clinical care, overall, included insufficient time (73%), uncertainty about who is responsible (70%), and lack of knowledge about existing tools (75%) for asking patients about social risks, as well as lack of resources to address social risks (76%). Non-MDs were more likely to cite concern that patients and families will feel uncomfortable answering questions about social risks (67% vs 20% of MDs, p = 0.003) as a barrier. Only 30% of MDs and 46% of non-MDs agreed that "asking about social risks is outside of the scope of my role" was a barrier.

CONCLUSION

Most oncology providers and staff agree that obtaining social risk information is important for patient care. Developing clinic-based solutions that integrate social risk screening and referral workflows within the oncology setting is imperative to reduce cancer health disparities. Future efforts that leverage the use of electronic health records to conduct social risk screening and streamline referrals to community-based resources in oncology may improve cancer health equity.

Association of Transgender or Gender Non-Binary Identity on Disease Characteristics and Survival Outcomes in Prostate Cancer

PURPOSE/OBJECTIVE(S)

While it is becoming increasingly common for people to identify as transgender or gender-non-binary, our understanding of the influence of gender identity on disease severity of hormone-sensitive malignancies, including prostate cancer (PC) is limited. The goal of this study is to compare the aggressiveness of disease and survival outcomes between transgender or gender non-binary (TG) and cis-gender (CG) patients with PC.

MATERIALS/METHODS

The cohort included patients diagnosed with PC between 1999 and 2022 within the Veterans Health Administration (VHA) Database. TG patients were identified with an ICD 9 or 10 diagnosis code that occurred prior to PC diagnosis. Treatment information and baseline disease characteristics were ascertained through the VHA electronic health records. Multivariable logistic regressions were performed to estimate the association between TG status and presenting with Gleason > = 8, PSA > 20 ng/mL, and metastatic disease at diagnosis. Covariates in these models included age at diagnosis, race, ethnicity, marital status, and smoking status. Metastases were identified through natural language processing from cancer or radiology documents. Time to metastases was defined as the time from PC diagnosis to metastases, with other causes of death considered as competing risks. The association between TG identity status and metastatic disease was calculated with a Cox regression model. The difference in overall survival was assessed with the Kaplan-Meier method and log-rank test.

RESULTS

The final cohort was composed of 282,264 individuals, 219 (0.08%) of which were identified as TG. TG patients have similar odds of presenting with presenting with Gleason Score ≥8 (Odds Ratio (OR) 1.18, p = 0.31), PSA >20 ng/mL (OR 0.78, p = 0.59), and metastasis at diagnosis (OR 0.47, p = 0.29). There were 34,918 patients who develop metastatic disease at any time, 24 of which were TG. The 10-year cumulative incidence of metastases for TG and CG individuals was 11.5% (95% Confidence Interval (CI): 6.6-16.1%) and 13.9% (CI: 13.7-14.0%), respectively. There was no significant difference between TG status and risk of developing metastases (Hazard Ratio (HR) 0.93, p = 0.71). The 10-year overall survival for TG and CG was 73.4% (CI: 66.5-80.9%) and 65.0% (CI: 64.8-65.2%), respectively. There was no significant difference between TG status and overall survival (Hazard Ratio (HR) 0.83, p = 0.13).

CONCLUSION

TG individuals do not appear to have a difference in disease characteristics at diagnosis or survival compared to CG individuals. Future research should be done to determine the effect of gender affirming treatment on these outcomes. Furthermore, it is unclear if diagnosis codes are accurately identifying TG individuals.

Association between National Area Deprivation Index Rank on Disease Characteristics in Prostate Cancer

PURPOSE/OBJECTIVE(S)

Social determinants of health (SDH) play a large role in an individual's health; in recent years, there has been a push to examine the impact of one's neighborhood or "place." Previous studies have showed that living in a disadvantage neighborhood is associated with worth health outcomes. We hypothesize that equal access care will diminish the effects of living in a disadvantaged neighborhood.

MATERIALS/METHODS

We identified non-Hispanic African American (AA) and White (NHW) men diagnosed with PC between 2012 and 2015 in the Veterans Health Administration (VHA). Patient SDH was measured using census tract level 2015 Area Deprivation Index (ADI) information. The ADI is a composite measure that includes factor such as housing quality, income, health care access etc. We measured both National and State ADI rank as a continuous variable from 1 to 10 with 10 being highest deprivation. Patient information was gathered at the census tract level while ADI is assigned at the census block group. In order to get all information on the same geographic level, we averaged the ADI to its corresponding census tract. Associations between ADI and disease characteristics at diagnosis were measured using multivariable logistic regression models including age, race, and marital status as covariates.

RESULTS

The final cohort was composed of 25,222 men (8,384 AA and 16,838 NHW.) At the national level, there was no significant association between ADI and Gleason Score ≥8 (Odds Rations (OR) 0.99 [95% Confidence Interval (CI):0.98 - 1.00]), PSA >20 ng/mL (OR 0.99 [95% CI: 0.98 - 1.01]), and metastasis at diagnosis (OR 1.01 [CI: 0.98-1.04]).

CONCLUSION

Our results are consistent with our hypothesis that equal access care diminishes the impacts of living within a disadvantaged neighborhood. Future research should investigate the interaction between health care access and social and demographic factors.

Cardiovascular Outcomes in Relation to Antihypertensive Medication Use in Women with and Without Cancer: Results from the Women's Health Initiative

BACKGROUND

Recent clinical trials have evaluated angiotensin-converting enzyme (ACE) inhibitors (ACEis), angiotensin receptor blockers (ARBs), and beta blockers (BBs) in relation to cardiotoxicity in patients with cancer, typically defined by ejection fraction declines. However, these trials have not examined long-term, hard clinical endpoints. Within a prospective study, we examined the risk of heart failure (HF) and coronary heart disease (CHD) events in relation to use of commonly used antihypertensive medications, including ACEis/ARBs, BBs, calcium channel blockers (CCB), and diuretics, comparing women with and without cancer.

MATERIALS AND METHODS

In a cohort of 56,997 Women's Health Initiative study participants free of cardiovascular disease who received antihypertensive treatment, we used multivariable-adjusted Cox regression models to calculate the hazard ratios (HRs) of developing CHD, HF, and a composite outcome of cardiac events (combining CHD and HF) in relation to use of ACEis/ARBs, CCBs, or diuretics versus BBs, separately in women with and without cancer.

RESULTS

Whereas there was no difference in risk of cardiac events comparing ACEi/ARB with BB use among cancer-free women (HR = 0.99 [0.88-1.12]), among cancer survivors ACEi/ARB users were at a 2.24-fold risk of total cardiac events (1.18-4.24); p-interaction = .06). When investigated in relation to CHD only, an increased risk was similarly observed in ACEi/ARB versus BB use for cancer survivors (HR = 1.87 [0.88-3.95]) but not in cancer-free women (HR = 0.91 [0.79-1.06]; p-interaction = .04). A similar pattern was also seen in relation to HF but did not reach statistical significance (p-interaction = .23).

CONCLUSION

These results from this observational study suggest differing risks of cardiac events in relation to antihypertensive medications depending on history of cancer. Although these results require replication before becoming actionable in a clinical setting, they suggest the need for more rigorous examination of the effect of antihypertensive choice on long-term cardiac outcomes in cancer survivors.

IMPLICATIONS FOR PRACTICE

Although additional research is needed to replicate these findings, these data from a large, nationally representative sample of postmenopausal women indicate that beta blockers are favorable to angiotensin-converting enzyme inhibitors in reducing the risk of cardiac events among cancer survivors. This differs from the patterns observed in a noncancer cohort, which largely mirrors what is found in the randomized clinical trials in the general population.

The effect of multiple recruitment contacts on response rates and patterns of missing data in a survey of bladder cancer survivors 6 months after cystectomy

PURPOSE

The Bladder Cancer Quality of Life Study collected detailed and sensitive patient-reported outcomes from bladder cancer survivors in the period after bladder removal surgery, when participation in survey research may present a burden. This paper describes the study recruitment methods and examines the response rates and patterns of missing data.

METHODS

Detailed surveys focusing on quality of life, healthcare decision-making, and healthcare expenses were mailed to patients 5-7 months after cystectomy. We conducted up to 10 follow-up recruitment calls. We analyzed survey completion rates following each contact in relation to demographic and clinical characteristics, and patterns of missing data across survey content areas.

RESULTS

The overall response rate was 71% (n = 269/379). This was consistent across patient clinical characteristics; response rates were significantly higher among patients over age 70 and significantly lower among racial and ethnic minority patients compared to non-Hispanic white patients. Each follow-up contact resulted in marginal survey completion rates of at least 10%. Rates of missing data were low across most content areas, even for potentially sensitive questions. Rates of missing data differed significantly by sex, age, and race/ethnicity.

CONCLUSIONS

Despite the effort required to participate in research, this population of cancer survivors showed willingness to share detailed information about quality of life, health care decision-making, and expenses, soon after major cancer surgery. Additional contacts were effective at increasing participation. Response patterns differed by race/ethnicity and other demographic factors. Our data collection methods show that it is feasible to gather detailed patient-reported outcomes during this challenging period.

Spending for Advanced Cancer Diagnoses: Comparing Recurrent Versus De Novo Stage IV Disease

PURPOSE

Spending for patients with advanced cancer is substantial. Past efforts to characterize this spending usually have not included patients with recurrence (who may differ from those with de novo stage IV disease) or described which services drive spending.

METHODS

Using SEER-Medicare data from 2008 to 2013, we identified patients with breast, colorectal, and lung cancer with either de novo stage IV or recurrent advanced cancer. Mean spending/patient/month (2012 US dollars) was estimated from 12 months before to 11 months after diagnosis for all services and by the type of service. We describe the absolute difference in mean monthly spending for de novo versus recurrent patients, and we estimate differences after controlling for type of advanced cancer, year of diagnosis, age, sex, comorbidity, and other factors.

RESULTS

We identified 54,982 patients with advanced cancer. Before diagnosis, mean monthly spending was higher for recurrent patients (absolute difference: breast, $1,412; colorectal, $3,002; lung, $2,805; all P < .001), whereas after the diagnosis, it was higher for de novo patients (absolute difference: breast, $2,443; colorectal, $4,844; lung, $2,356; all P < .001). Spending differences were driven by inpatient, physician, and hospice services. Across the 2-year period around the advanced cancer diagnosis, adjusted mean monthly spending was higher for de novo versus recurrent patients (spending ratio: breast, 2.39 [95% CI, 2.05 to 2.77]; colorectal, 2.64 [95% CI, 2.31 to 3.01]; lung, 1.46 [95% CI, 1.30 to 1.65]).

CONCLUSION

Spending for de novo cancer was greater than spending for recurrent advanced cancer. Understanding the patterns and drivers of spending is necessary to design alternative payment models and to improve value.

Abstract A87: “I didn't know what to think. I thought I was going to die.” Latinas' understanding and attitudes toward an abnormal Pap test result

Background and purpose: There is a disproportionate burden of cervical cancer among Latinas compared with non-Latino White women. This is thought to be attributed to both low rates of screening and poor adherence to recommended diagnostic follow-up after an abnormal Pap test. The purpose of this study is to assess knowledge, attitudes, barriers and facilitators to follow up after an abnormal Pap test result in Latinas.

Study Design: We conducted 26 semi-structured interviews among Latinas aged 21 to 64 years old who had an abnormal Pap test result in rural Eastern Washington. Interviews were conducted in the participants' preferred language. Interviews were transcribed verbatim and uploaded into Atlas.ti for coding and analysis.

Results/Outcome: One of the main themes that emerged as a potential barrier to follow up was misconceptions and secrecy around an abnormal Pap test result. Upon receiving the result, all women instantly believed they had cancer, and many felt desperate and embarrassed to talk to close family and friends. Transportation, lack of insurance and pain from the procedures were also mentioned as very important barriers to follow up. For those participants who had shared their result, family support was mentioned as a key facilitator to follow up. Interestingly, trusting oneself and having faith in God were also mentioned by some as facilitators to follow up. Within our participants, unlike previous studies, “Fatalismo” did not emerge as a barrier.

Impact: Understanding the barriers and facilitators to follow up care after an abnormal Pap test as well attitudes and knowledge of the implications of an abnormal Pap test can help us improve the education and outreach strategies used in reaching the Latina population.

Discussion: Latinas seem to have misconceptions about the implications of having an abnormal Pap. There are important cultural barriers that derive from these misconceptions that may be affecting the uptake and follow up of cervical cancer screening in this population. Our results will inform an intervention to increase cervical cancer screening in Latinas in Eastern Washington.

Citation Format: Elizabeth Carosso, Javiera Martinez, Matthew Banegas, Gloria Coronado, Beti Thompson. “I didn't know what to think. I thought I was going to die.” Latinas' understanding and attitudes toward an abnormal Pap test result. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A87.

Abstract B66: Breast cancer outcomes among Hispanic women by race

Introduction: Few studies have examined the distribution of breast cancer outcomes among Hispanics by race (i.e. Hispanic Black, Hispanic White). Understanding the diversity of breast cancer characteristics among Hispanic women is key to explaining the differences in breast cancer outcomes.

Purpose: To assess the distribution of tumor stage, joint estrogen receptor (ER)/progesterone receptor (PR) status, and breast cancer-specific mortality with race and ethnicity, among Hispanic Black, Hispanic White, non-Hispanic Black (NHB), non-Hispanic White (NHW) women using Surveillance, Epidemiology, and End Results (SEER) Program data.

Methods: We used data on 441,742 women aged 20–79 years who were diagnosed with primary invasive breast cancer between January 1992 and December 2008, with no prior history of cancer, and who were identified through the SEER 17 population-based registries. Women less than 20 and older than 79 years of age were excluded from the study. The primary outcomes of interest were: AJCC tumor stage, joint estrogen receptor (ER)/progesterone receptor (PR) status, and breast cancer-specific mortality. Our primary exposure of interest was race/ethnicity, which was categorized into four groups, based on SEER data: non-Hispanic White, non-Hispanic Black, Hispanic White, and Hispanic Black. Covariates included age at diagnosis, year of diagnosis, % population below poverty level, % population with less than a high school education, % foreign born, % non-English language, SEER registry, and treatment (surgery and/or radiation therapy).

Results: Hispanic Blacks had the highest risk of being diagnosed with stage III and IV tumors compared to NHWs (RRR=2.4 [95% CI:1.9-3.1] and RRR=2.0 [95% CI:1.4-2.8], respectively; p&lt;0.01). Both NHBs and Hispanic Blacks had 2.4-fold greater risk of being diagnosed with ER–/PR– breast cancer compared to NHW women (RRR=2.4 [95% CI:2.3-2.5] and RRR=2.4 [95% CI:2.0-2.9], respectively; p&lt;0.01). Hispanic White women had a significantly increased risk of being diagnosed with both ER–/PR– (64% increase) and ER+/PR– (24% increase) breast cancers compared to NHW women (RRR=1.6 [95% CI:1.6-1.7] and RRR=1.2 [95% CI:1.2-1.3], respectively; p&lt;0.01). Hispanic White and Hispanic Black women were at increased risk of breast cancer-specific mortality compared to NHW women (HR=1.2 [95% CI:1.2-1.3] and HR=1.5 [95%:1.2-1.80, respectively, p&lt;0.01).

Conclusion: Hispanic Black women have disproportionately higher rates of late stage invasive breast cancer diagnoses, ER–/PR– breast disease, and breast cancer-specific mortality compared to non-Hispanic White women. Furthermore, RRR estimates suggest that the increased risk associated with late stage and ER–/PR– may be greater than or equal to those estimates observed for non-Hispanic Black and Hispanic White women. The findings from this study will be among the first studies to present information on breast cancer characteristics and outcomes in both Hispanic Black and Hispanic White.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B66.

Pilot Study

The human papillomavirus (HPV) is one of the most common sexually transmitted infections (STI) in the world and it is associated with cervical cancer. The development of a prophylactic HPV vaccine has proven effective in clinical trials and it is now available to the public. The HPV vaccine represents a viable prevention strategy against cervical cancer. However, parental preferences, perceptions, and willingness to use the HPV vaccine are crucial, and if not assessed accurately, may threaten the successful implementation of a broad HPV vaccination program. This pilot study explored the views of 60 adult, Mexican women, all of who were mothers of female children between the ages of ten to 14 years old on the following four areas of interest: HPV knowledge; HPV vaccine knowledge and attitudes; barriers to HPV vaccine use; and potential uses and side effects of the HPV vaccine. Only 7% of respondents knew that HPV was a virus or STI. Eighty-six percent had not heard of the HPV vaccine, but 62% felt that the HPV vaccine would prevent HPV infection. However, 38% said the church would not approve of the HPV vaccine use for 10-14-year-old girls. Twenty-seven percent thought that promiscuous behavior would increase following HPV vaccination. Overall, respondents had very little knowledge of the HPV vaccine, were willing to be vaccinated themselves (83%), but were lesser willing to vaccinate their daughters (63%). Ultimately, understanding the beliefs about and identifying the barriers of HPV vaccine use will influence the effectiveness of the vaccine and its potential impact in reducing cervical cancer incidence rates worldwide.