Real-world use of antiretroviral therapy and risk of cancer among people with HIV in Texas

BACKGROUND

Combination antiretroviral therapy (cART) may reduce cancer risk among people with HIV (PWH), but cancer-specific associations are incompletely understood.

METHODS

We linked HIV and cancer registries in Texas to a national prescription claims database. cART use was quantified as the proportion of days covered (PDC). Cox proportional hazards models assessed associations of cancer risk with cART usage, adjusting for demographic characteristics, AIDS status, and time since HIV report.

RESULTS

We evaluated 63 694 PWH followed for 276 804 person-years. The median cART PDC was 21.4% (interquartile range: 0.0-59.8%). cART use was associated with reduced risk of Kaposi sarcoma [adjusted hazard ratio (aHR) 0.48, 95% confidence interval (CI) 0.34-0.68 relative to unexposed status] and non-Hodgkin lymphoma (aHR 0.41, 95% CI 0.31-0.53), liver cancer (aHR 0.61, 95% CI 0.39-0.96), anal cancer (aHR 0.65, 95% CI 0.46-0.92), and a miscellaneous group of 'other' cancers (aHR 0.80, 95% CI 0.66-0.98). In contrast, cART-exposed status was not associated with risk for cervical, lung, colorectal, prostate or breast cancers.

CONCLUSION

In a large HIV cohort incorporating data from prescription claims, cART was associated with greatly reduced risks of Kaposi sarcoma and non-Hodgkin lymphoma, and to a lesser degree, reduced risks of liver and anal cancers. These associations likely reflect the beneficial effects of HIV suppression and improved immune control of oncogenic viruses. Efforts to increase cART use and adherence may further decrease cancer incidence among PWH.

Positive association between adiposity and inflammation in US adults: A cross-sectional study

Identification of biomarkers involved in multifaceted obesity-related inflammatory processes paired with reliable anthropometric measures of visceral adiposity is important for developing epidemiologic screening tools. This retrospective observational study used linear regression models to examine the association between inflammation and visceral fat in a nationally representative sample of 10 655 US adults. Inflammation was measured using a cumulative inflammation index (CII) generated from white blood cell ratios and uric acid. Intra-abdominal adiposity was assessed using sagittal abdominal diameter (SAD). Overall, 67.7%, 18.3%, and 13.9% of adults sampled were normoglycemic, prediabetic, and diabetic, with mean SAD of 21.7 ± 0.11 cm, 24.2 ± 0.14 cm, 26.0 ± 0.18 cm and CII of 4.3 ± 0.05, 4.7 ± 0.09, 5.1 ± 0.09, respectively. For each unit increase in SAD, CII was 0.12 higher (95% CI 0.10, 0.14) in US adults who were normoglycemic, 0.09 higher (95% CI 0.07, 0.12) in prediabetics and 0.10 higher (95% CI 0.07, 0.14) in diabetics. The association between SAD and CII was independent of diabetes status. These findings demonstrate an independent association between adiposity and inflammation, supporting increased visceral fat is associated with increased visceral-associated inflammation. Future studies are needed to define and characterise obesity-related inflammatory mediators and their role in chronic disease risk such as diabetes.

Cumulative Exposure to E-Cigarette Coupons and Changes in E-Cigarette Use Among U.S. Adults

INTRODUCTION

Coupons are an effective, frequently used tobacco marketing strategy. This study examined prospective associations between cumulative exposure to e-cigarette coupons and changes in e-cigarette use among U.S. adults.

METHODS

Data were from a representative U.S. adult cohort (n=19,824) in the Population Assessment of Tobacco and Health Study (waves [W] 2, 3, 4, and 5), collected from October 2014 to November 2019. Analysis was conducted in 2022. Four logistic regression models examined associations of a number of waves for which participants received e-cigarette coupons during W2-W4 with changes in e-cigarette use: W2 never use to W5 current use (initiation); W2 current nondaily use to W5 daily use (progression); W2 current use to W5 former use (cessation), and W2 former use to W5 current use (return-to-use).

RESULTS

Overall, 66.1% of U.S. adults never used e-cigarettes, 10.6% currently used e-cigarettes, and 23.4% formerly used e-cigarettes at W2. The average number of waves for which participants received e-cigarette coupons during W2-W4 was 0.13: 0.10 among W2 individuals who never used e-cigarettes, 0.30 among individuals who currently used e-cigarettes on a nondaily basis, 0.50 among individuals who currently used e-cigarettes, and 0.17 among individuals who formerly used e-cigarettes. Receiving coupons at increased waves was associated with (1) greater odds of initiation (AOR=1.58, 95% CI=1.26-1.97); (2) lower odds of cessation (AOR=0.78, 95% CI=0.67-0.91); and (3) increased odds of return-to-use (AOR=1.39, 95% CI=1.14-1.69). Findings did not differ by W2 cigarette smoking status.

CONCLUSIONS

E-cigarette coupons may encourage and sustain e-cigarette use. Policies restricting e-cigarette coupons may curb e-cigarette use.

Associations of depression with hypertension and citizenship among U.S. adults: A cross-sectional study of the interactions of hypertension and citizenship

With the increasing prevalence of hypertension-related cardiovascular deaths and depression, this study examined the associations of depression with hypertension, citizenship status, and interaction of hypertension and citizenship status among U.S. adults. Data from the 2015-2018 National Health Interview Survey (NHIS), including 63,985 individuals, were analyzed. Depression status was the outcome, with hypertension and U.S. citizenship status as the main independent variables. Using odds ratio (OR) estimates, we evaluated the associations between hypertension and depression, and citizenship status. The result indicates that a higher proportion of U.S. adults with hypertension reported depression compared to those who did not have hypertension (42.9 % vs. 37.5 %). In terms of U.S. citizenship status, a higher proportion of U.S. citizens reported depression than non-citizens (39.6 % vs. 31.6 %). However, non-citizens with hypertension were more likely to report depression compared to U.S. citizens without hypertension (OR = 1.46; 95 % CI = 1.15, 1.86). While hypertension marginally increased the odds of depression among the general U.S. population, being a non-U.S. citizen with hypertension significantly increased the risk of depression by 46 %. The findings imply that the healthy immigrant paradox, in the context of hypertension-depression prevention and control, may not apply to non-citizens with hypertension. We therefore recommend community-based screenings and more tailored interventions to address these health disparities while taking into consideration the unique cultural norms, behaviors and healthcare barriers encountered by specific immigrant communities.

Association of Patient Experience of Care and Radiation Therapy Initiation Among Women With Early-Stage Breast Cancer

PURPOSE

For women diagnosed with early-stage breast cancer, lumpectomy followed by radiation therapy (RT) has been a guideline-recommended treatment. However, lumpectomy followed by hormonal therapy is also an approved treatment for certain women. It is unclear what patient-driven factors are related to decisions to receive RT. This study examined relationships between patient-reported experience of care, an important dimension of health care quality, and receipt of RT after lumpectomy.

METHODS AND MATERIALS

We used National Cancer Institute Surveillance, Epidemiology, and End Results data linked to the CMS Medicare Consumer Assessment of Healthcare Providers and Systems patient surveys (SEER-CAHPS) to examine experiences of care among women diagnosed with local/regional stage breast cancer 2000 to 2017 who received lumpectomy, were enrolled in fee-for-service Medicare, completed a CAHPS survey ≤18 months after diagnosis, and survived for this study period. Experience of care was assessed by patient-provided scores for physicians, doctor communication, care coordination, and other aspects of care. Multivariable logistic regression models assessed associations of receipt of external beam RT with care experience and patient sociodemographic and clinical characteristics.

RESULTS

The study population included 824 women; 655 (79%) received RT. Women with higher experience of care scores for their personal doctor were significantly more likely to have received any RT (odds ratio [OR], 1.18; P = .033). Nonsignificant trends were observed for associations of increased RT with higher CAHPS measures of doctor communications (OR, 1.15; P = .055) and care coordination (OR, 1.24; P = .051). In contrast, women reporting higher scores for Part D prescription drug plans were significantly less likely to have received RT (OR, 0.78; P = .030).

CONCLUSIONS

Patient experience of care was significantly associated with receipt of RT after lumpectomy among women with breast cancer. Health care organization leaders may want to consider incorporating experience of care into quality improvement initiatives and other activities that aim to improve patient decision-making, care, and outcomes.

Cumulative cigarette discount coupon exposure and trajectories of cigarette smoking: a longitudinal analysis in US adults

INTRODUCTION

Exposure to cigarette discount coupons is associated with short-term increase in cigarette smoking; however, long-term impact is unclear. This study examined associations of cumulative exposure to cigarette coupons with trajectories of cigarette smoking in US adults.

METHODS

Data were from the US Population Assessment of Tobacco and Health Study Adult Surveys (n=19 824; waves 2-5). We examined the number of waves participants received cigarette discount coupons/promotions during waves 2-4 and smoking behaviours at wave 5. Weighted logistic multivariable regression models were used, adjusting for wave 2 demographics and stratified by wave 2 smoking status.

RESULTS

Among wave 2 adults who never smoked, each increment wave of exposure to cigarette discount coupons was associated with greater odds of wave 5 current smoking (adjusted OR (aOR)=2.09, 95% CI 1.24-3.52). Among wave 2 adults who smoked daily, each wave of coupon exposure was associated with lower odds of quitting smoking at wave 5 (aOR=0.67, 95% CI 0.62-0.73). Among wave 2 adults who had quit smoking, each increment wave of exposure was associated with greater odds of wave 5 current smoking (aOR=1.61, 95% CI 1.41-1.85). Additionally, women (vs men) and adults with lower socioeconomic status (SES) (vs higher SES) were more frequently exposed to cigarette coupons for a higher number of waves (p<0.05).

DISCUSSION

Exposure to cigarette coupons exhibited a dose-response relationship with changes in cigarette smoking behaviours over time, promoting smoking progression and hindering smoking cessation especially among women and people with lower SES. Prohibiting these coupons can be an important tobacco control strategy.

Mortality Relative Risks by Smoking, Race/Ethnicity, and Education

INTRODUCTION

The impact of cigarette smoking on mortality is well studied, with estimates of the relative mortality risks for the overall population widely available. However, age-specific mortality estimates for different sociodemographic groups in the U.S. are lacking.

METHODS

Using the 1987-2018 National Health Interview Survey Linked Mortality Files through 2019, all-cause mortality relative risks (RRs) were estimated for current smokers or recent quitters and long-term quitters compared with those for never smokers. Stratified Cox proportional hazards regression models were used to estimate RRs by age, gender, race/ethnicity, and educational attainment. RRs were also assessed for current smokers or recent quitters by smoking intensity and for long-term quitters by years since quitting. The analysis was conducted in 2021-2022.

RESULTS

All-cause mortality RRs among current smokers or recent quitters were generally highest for non-Hispanic White individuals than for never smokers, followed by non-Hispanic Black individuals, and were lowest for Hispanic individuals. RRs varied greatly by educational attainment; generally, higher-education groups had greater RRs associated with smoking than lower-education groups. Conversely, the RRs by years since quitting among long-term quitters did not show clear differences across race/ethnicity and education groups. Age-specific RR patterns varied greatly across racial/ethnic and education groups as well as by gender.

CONCLUSIONS

Age-specific all-cause mortality rates associated with smoking vary considerably by sociodemographic factors. Among high-education groups, lower underlying mortality rates for never smokers result in correspondingly high RR estimates for current smoking. These estimates can be incorporated in modeling analyses to assess tobacco control interventions' impact on smoking-related health disparities between different sociodemographic groups.

Trends in Education-Related Smoking Disparities Among U.S. Black or African American and White Adults: Intersections of Race, Sex, and Region

INTRODUCTION

Despite its overall decline in the United States, trends in cigarette smoking could vary by intersection with demographic characteristics. We explored trends in education-related disparities in current smoking among U.S. adults by race (Black or African American and White), sex, and U.S. census region.

AIMS AND METHODS

Data were from U.S. civilian non-institutionalized adults (aged ≥18 years) who self-identified as Black or African American and White and participated in the 1995-2019 Tobacco Use Supplement to the Current Population Survey. We estimated average annual percent changes in current cigarette smoking by the intersections of race, sex, census region, and educational attainment. We calculated educated-related prevalence differences in current cigarette smoking by subtracting the prevalence of bachelor's degrees from that of

RESULTS

Education-related disparities in current cigarette smoking increased over time, especially among Black or African American male (PD1995-1996 = 22.8%; PD2018-2019 = 27.2%) and female adults (PD1995-1996 = 12.1%; PD2018-2019 = 16.5%). By region, Black or African American male adults in the Midwest showed the largest increase in education-related current cigarette smoking disparities, followed by Black or African American male and female adults in the South, and White male and female adults in the Midwest. These findings were because of small to no declines in the prevalence of current cigarette smoking among those with

CONCLUSION AND RELEVANCE

The gap in the prevalence of current cigarette smoking by education widened over time, especially among Black or African American adults in certain regions.

IMPLICATIONS

Despite the decline in the prevalence of current cigarette smoking in the U.S. population overall, such public health gain may not benefit all individuals equally. Using the data from a U.S. representative serial cross-sectional survey study during 1995-2019, we found that disparities in current cigarette smoking prevalence between those with Collapse

Key Words Collapse

MESH Headings

• Adult
• Female
• Humans
• Male
• Black or African American
• Cigarette Smoking/epidemiology
• Cross-Sectional Studies
• Educational Status
• Prevalence
• Surveys and Questionnaires
• United States/epidemiology
• White
• Health Status Disparities

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Grants

• FDA HHS
• NIMHD NIH HHS
• National Institute on Minority Health and Health Disparities
• U.S. Food and Drug Administration

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Affiliation(s)

Kelvin Choi Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA
Jamal T Jones Office of Science, Center for Tobacco Products, U.S. Food and Drug Administration, Beltsville, Maryland, USA
Andrea L Ruybal Office of Science, Center for Tobacco Products, U.S. Food and Drug Administration, Beltsville, Maryland, USA
Timothy S McNeel Information Management Services, Inc., Calverton, Maryland, USA
Danielle A Duarte Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA
Monica Webb Hooper Office of the Director, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA

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Association of exposure to environmental tobacco smoke at home and risk of mortality among US never smokers by race/ethnicity, education, and income

Environmental tobacco smoke (ETS) increases the risk of mortality among nonsmokers. Yet, few studies have examined this association among racial/ethnic minorities or among people with less education or income. We assessed self-reported ETS exposure at home among never smoking participants (n = 110,945) of the 1991-2010 National Health Interview Surveys. Deaths through 2015 were identified by the National Death Index. Hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cause-specific mortality were estimated using Cox proportional hazards regression models with age as the underlying time metric and adjusted for sex, race/ethnicity, education, household income, body mass index, region of residence, and survey year. We further stratified all-cause mortality analyses by race/ethnicity, household income, and education. Relative to no ETS at home, every day exposure was associated with higher risk of all-cause mortality (HR = 1.33, 95%CI: 1.23, 1.45), with similar HRs observed across strata of education and income. HRs were similar among non-Hispanic Black (HR = 1.28, 95%CI: 1.08, 1.53) and non-Hispanic White adults (HR = 1.34, 95%CI: 1.21, 1.48) although somewhat higher among Hispanic adults (HR = 1.65, 95%CI: 1.29, 2.10; P for pairwise comparison = 0.04). ETS exposure at home is an important contributor to mortality across strata of race/ethnicity, education, and income in the US.

Acculturation and depression are associated with short and long sleep duration among Mexican Americans in NHANES 2005-2018

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Length of time in the US was associated with long sleep duration.

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Individuals who speak majority English had higher odds of short sleep duration.

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Depression severity was linked to short and long sleep duration.

Acculturation and depression are linked to poor sleep quality and sleep problems that may explain ongoing health disparities for Hispanics/Latinos. We examined the associations of acculturation, depression, and sleep duration among the Mexican American population. We used a multinomial logistic regression model on cross-sectional data from the 2005–2018 National Health and Nutrition Examination Survey on 4,700 Mexican American adults aged ≥18 years old. The outcome of sleep duration was operationalized as short (≤6 h), optimal (7–8 h), and long (≥9 h). Acculturation was constructed using years living in the U.S. and language(s) spoken at home (majority Spanish, English and Spanish equally, majority English). Depression severity was assessed using the 9-item Patient Health Questionnaire. Covariates included gender, age, marital status, income, and U.S. citizenship. Speaking majority English (Adjusted Odds Ratio (AOR) = 1.23; 95% Confidence Interval (CI) = 1.00–1.52) and mild (AOR = 1.63; 95%CI = 1.32–2.01), moderate (AOR = 1.94; 95%CI = 1.43–2.63), and moderately severe/severe (AOR = 2.58; 95%CI = 1.72–3.88) levels of depression were significantly associated with short sleep duration. Living in the U.S. for ≥10 years (AOR = 1.61; 95%CI = 1.17–2.23) and moderately severe/severe depression (AOR = 2.30; 95%CI = 1.34–3.93) were significantly associated with long sleep duration. Our results provide additional evidence of a link between acculturation, depression, and short and long sleep duration among the Mexican American population. Understanding the sleep health of this population is important for informing future public health interventions and research. Additional investigation into the relationship between acculturation/depression and other sleep health measures among this population is warranted.

Is patient experience of care associated with treatment choices for women with early-stage breast cancer?

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Background: For women diagnosed with early stage breast cancer, lumpectomy followed by radiation therapy is a guideline-recommended treatment. However, lumpectomy followed by hormonal therapy is also an approved treatment regimen for certain women. It is unclear what patient-driven factors are related to the decision to receive radiation therapy. This study examined the relationship between patient-reported experience of care, an important dimension of health care quality, and receipt of radiation therapy following lumpectomy among women with breast cancer. Methods: We used the SEER-CAHPS data resource (NCI Surveillance Epidemiology and End Results [SEER] data linked to Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses) to examine experiences of care among women diagnosed with local or regional stage breast cancer in 2000-2017 who received lumpectomy, were enrolled in fee-for-service Medicare, completed a CAHPS survey within 18 months of diagnosis, and survived for this study period. Experience of care was assessed by patient-provided numeric scores for overall care, health plan, physicians, customer service, doctor communication, care coordination, and other aspects of care. Multivariable logistic regression models assessed associations of receipt of radiation therapy with care experience and patient sociodemographic and clinical characteristics. Results: The study population included 825 women; 651 (79%) received radiation therapy. Approx. 84% were diagnosed with localized (vs. regional) breast cancer. Women with higher experience scores for their personal doctor or for care coordination were significantly more likely to have received any radiation therapy. In contrast, among women enrolled in Medicare Part D plans, those who reported higher scores for their prescription drug plan were significantly less likely to have received radiation therapy. Conclusions: Patient experience of care was significantly associated with receipt of radiation therapy following lumpectomy among women with breast cancer. While these results do not show causality, future quality improvement initiatives may want to explore the role of patient experience of care in facilitating patient decision making and improving quality of care.

U.S. Trends in Age of Cigar Smoking Initiation by Race/Ethnicity and Education

INTRODUCTION

Younger age of initiating cigar smoking is associated with greater nicotine dependence and current use. Age of initiating cigarette smoking has increased over time, whereas trends in age of initiating cigar smoking remain understudied. These trends were examined by race/ethnicity, by education, and at their intersection.

METHODS

The analytic sample included U.S. Hispanic, Black, and White cigar-ever-smokers aged 24‒25 years (n=29,715) from the 2002‒2019 National Survey on Drug Use and Health. Participants reported their age, race/ethnicity, sex, education (≤high school; some college; ≥bachelor's degree), age of initiating cannabis use, and cigar smoking. Weighted multivariable linear regressions adjusted for sex and age of cannabis use initiation were used to examine trends in age of initiating cigar smoking by race/ethnicity, education, and education Χ year interactions within racial/ethnic groups. Age of initiating cigar smoking comparisons across race/ethnicity and education were examined using the most recent 2019 data.

RESULTS

During 2002‒2019, across education, White cigar-ever-smokers started smoking cigars at an older age, whereas it remained unchanged among Hispanic cigar-ever-smokers. Among Black cigar-ever-smokers, age of initiating cigar smoking did not change among those with ≤high school and some college, and was older among those with ≥bachelor's degree. In 2019, age of initiating cigar smoking did not vary by educational level among Hispanic and White cigar-ever-smokers. Black cigar-ever-smokers with ≥bachelor's degree initiated cigar smoking at older ages than their White counterparts.

CONCLUSIONS

Black individuals experienced widening education-related disparities, and Hispanic individuals had no progress in delaying age of initiating cigar smoking. Regulatory action banning cigar flavors may impact these trends.

Awareness of Alcohol and Cancer Risk and the California Proposition 65 Warning Sign Updates: A Natural Experiment

In 1986, California enacted Proposition 65 (P65), requiring businesses to display warning signs informing consumers that specific chemicals and alcohol exposure increase the risk of cancer and reproductive harm. In 2018, the P65 alcohol warning signs were updated to include an informational P65 website link, and the update was associated with media coverage and increased enforcement of warning requirements. This study examines knowledge of the association between alcohol use and cancer risk in California compared to the rest of the US before and after the 2018 P65 update. We analyzed state-level data on alcohol and cancer knowledge from the Health Information National Trends Survey from 2017 (n = 3285), 2019 (n = 5438), and 2020 (n = 3865). We performed multinomial logistic regressions to examine knowledge levels by survey year and location (California vs. all other states) and reported the predicted marginals of knowledge by survey year and location. The adjusted prevalence of respondents who reported an association between alcohol and cancer risk was higher in California (41.6%) than the remaining states (34.1%) (p = 0.04). However, knowledge levels decreased significantly over survey years, and there was no evidence for an effect of the P65 update on knowledge in California compared to other states based on the testing of an interaction between state and year (p = 0.32). The 1986 warning signs may have had an enduring effect on awareness, though the update, so far, has not. Further efforts are needed to determine how to increase alcohol and cancer knowledge to address the burden of alcohol-attributable cancers.

Black New Yorkers with Type 2 Diabetes: Afro-Caribbean Immigrants Have Lower BMI and Lower Waist Circumference than African Americans

OBJECTIVE

Using the 2013/2014 New York City (NYC) Health and Nutrition Examination Survey (NYCHANES) data, this exploratory study examined whether (a) type 2 diabetes (diabetes) prevalence differed between NYC Afro-Caribbeans and African Americans; (b) anthropometric, biochemical, and sociodemographic diabetes profiles differed between and within groups; and (c) diabetes odds differed between and within groups.

METHODS

Diabetes was defined as prior diagnosis, HbA1c ≥ 6.5% (7.8 mmol/L), or fasting glucose ≥ 126 mg/dL. Weighted logistic regression estimated diabetes odds by nativity and either waist circumference (WC) (cm) or BMI (kg/m²). All regression models controlled for age, hypertension, gender, education, income, marital status, physical activity, and smoking.

RESULTS

Among Afro-Caribbeans (n = 81, 65% female, age (mean ± SE) 49 ± 2 years, BMI 29.2 ± 0.7 kg/m²) and African Americans (n = 118, 50% female, age 47 ± 2 years, BMI 30.3 ± 0.9 kg/m²), Afro-Caribbeans with diabetes had lower BMI (29.9 ± 0.8 kg/m² vs. 34.6 ± 1.7 kg/m², P = 0.01) and lower WC (102 ± 2 cm vs. 114 ± 3 cm, P = 0.002) than African Americans with diabetes. Afro-Caribbeans with diabetes had lower prevalence of obesity (33.2% vs. 74.7%) and higher prevalence of overweight (57.2% vs. 13.5%) (P = 0.02) than African Americans with diabetes. Odds of diabetes did not differ between Afro-Caribbeans and African Americans. In models predicting the effect of WC, diabetes odds increased with WC (OR = 1.07 (95% CI 1.02, 1.11), P = 0.003) and age (OR = 1.09 (95% CI 1.03-1.15), P = 0.003) for African Americans only. In models predicting the effect of BMI, diabetes odds increased for Afro-Caribbeans with age (OR = 1.06 (1.01, 1.11)*, P = 0.04) and hypertension (OR = 5.62 (95% CI 1.04, 30.42), P = 0.045), whereas for African Americans, only age predicted higher diabetes odds (OR = 1.08 (95% CI 1.03, 1.14), P = 0.003).

CONCLUSIONS

In NYC, Afro-Caribbeans with diabetes have lower BMI and lower WC than African Americans with diabetes, but odds of diabetes do not differ. Combining African-descent populations into one group obscures clinical differences and generalizes diabetes risk.

Examining the relationship of sociodemographic factors, neighborhood cohesion and abnormal sleep duration among U.S. foreign-born subpopulations in the National Health Interview Survey

Background

Limited studies have examined the relationship of neighborhood cohesion and sleep duration between U.S. foreign-born Hispanics/Latinos and non-Hispanics/Latinos.

Methods

We conducted a multinomial logistic regression using the 2013-2018 National Health Interview Survey on U.S. foreign-born adults ≥18 (N = 27,253). The outcome variable, sleep duration, was categorized as short sleep (≤6 hours), normal sleep (7 to 8 hours), and long sleep (≥9 hours). Neighborhood cohesion was categorized using tertiles (low, medium, high) from self-reported Likert scores. Our model included sociodemographic factors (i.e., age, marital status), socioeconomic status (i.e., education, employment status), health risk behaviors (i.e., body mass index, smoking status, alcohol drinking status), ethnic identity (i.e., Mexican, Puerto Rican, Cuban, Dominican, Central or South American, other/multiple Hispanic/Latino, and non-Hispanic/Latino), and acculturation factors (i.e., years lived in the U.S.; the language of interview).

Results

Participants reporting low and medium neighborhood cohesion compared to high neighborhood cohesion had 45% (95% confidence interval [CI]:1.33-1.58) and 15% (95%CI:1.05-1.26) increased odds of short sleep (≤6 hours), compared to normal average sleep. Mexican participants had decreased odds of experiencing short sleep (adjusted odds ratio [AOR] = 0.82, 95%CI:0.73-0.92), while Puerto Ricans had increased odds of experiencing short sleep (AOR = 1.25, 95%CI:1.03-1.51) compared to non-Hispanics/Latinos.

Conclusion

Neighborhood cohesion was associated with increased odds of short sleep duration. Social determinants, acculturation, and behavioral risk factors in the context of neighborhood cohesion are critical to understand U.S. foreign-born Hispanic/Latino sleep duration, as these factors may negatively synergize to exacerbate risk, worsening mental and physical health outcomes.

Point-of-sale cigarette pricing strategies and young adult smokers' intention to purchase cigarettes: an online experiment

BACKGROUND

Point-of-sale tobacco marketing has been shown to be related to tobacco use behaviours; however, specific influences of cigarette price discounts, price tiers and pack/carton availability on cigarette purchasing intention are less understood by the tobacco control community.

METHODS

We conducted discrete choice experiments among an online sample of US young adult smokers (aged 18-30 years; n=1823). Participants were presented scenarios depicting their presence at a tobacco retail outlet with varying availability of cigarette price discounts, price tiers and pack/carton. At each scenario, participants were asked whether they would purchase cigarettes. Generalised linear regression models were used to examine the associations between of cigarette price discounts, price tiers and pack/carton with intention to purchase cigarettes overall and stratified by educational attainment.

RESULTS

Participants chose to purchase cigarettes in 70.9% of the scenarios. Offering price discounts were associated with higher odds of choosing to purchase cigarettes. Reducing the number of cigarette price tiers available in the store was associated with lower odds of choosing to purchase cigarettes. Stratified analysis showed that offering discounts on high-tier cigarette packs increased odds of choosing to purchase cigarettes among young adult smokers with at least some college education, while offering discounts on medium-tier cigarette packs increased odds of choosing to purchase cigarettes among those with some college education or less (eg, with a 10% discount, adjusted odds ratio [AOR]some college=1.62, 95% confidence interval [CI] 1.21 to 2.16; AOR≤high school=1.44, 95% CI 1.08 to 1.93).

CONCLUSIONS

Availability of cigarette price discounts, price tiers and pack/carton could potentially influence cigarette purchasing behaviours among young adult smokers. Regulating these marketing strategies may, therefore, reduce education-related smoking disparities.

Mortality Risks Associated With Dual- and Poly-Tobacco-Product Use in the United States

Increasing numbers of adults in the United States use more than 1 tobacco product. Most use cigarettes in combination with other tobacco products. However, little is known about the all-cause and cancer-specific mortality risks of dual- and poly-tobacco-product use. We examined these associations by pooling nationally representative data from the 1991, 1992, 1998, 2000, 2005, and 2010 National Health Interview Surveys (n = 118,144). Mortality information was obtained through linkage to the National Death Index. Cigarette smokers who additionally used other tobacco products smoked as many if not more cigarettes per day than exclusive cigarette smokers. Furthermore, cigarette smokers who additionally used other tobacco products had mortality risks that were as high as and sometimes higher than those of exclusive cigarette smokers. As tobacco use patterns continue to change and diversify, investigators in future studies need to carefully assess the impact of noncigarette tobacco products on cigarette use and determine associated disease risks.

Prevalence of current large cigar versus little cigar/cigarillo smoking among U.S. adults, 2018-2019

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Prevalence of cigar use varied by type, age, and race/ethnicity in the U.S.

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Current large cigar smoking was more prevalent among non-Hispanic White adults.

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Little cigar/cigarillo (LCC) smoking was more common in non-Hispanic Black adults.

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LCC smoking varied significantly depending on both age and race/ethnicity.

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LCC smoking was most prevalent among non-Hispanic Black young adults (18–30 years).

Cigar smoking is increasing among non-Hispanic Black adults in the U.S. However, the prevalence of large and little cigar/cigarillo (LCC) smoking varying jointly by age and race/ethnicity has not been reported. We analyzed data from the 2018–2019 Tobacco Use Supplement to the Current Population Survey (n = 134,900) to fill this knowledge gap. Participants reported the type of cigar they used most often in the past 30 days (either large cigars, little cigars, or cigarillos). We estimated the prevalence of current large cigar and LCC smoking by sociodemographic characteristics. We then examined sociodemographic correlates of large cigar and LCC smoking in comparison to non-cigar smoking using a multivariable multinomial logistic regression model, and sociodemographic correlates of LCC smoking compared to large cigar smoking using a multivariable logistic regression model. Age*race/ethnicity interaction on cigar smoking was tested. Age-stratified multivariable multinomial logistic regression and logistic regression models were used to examine associations between race/ethnicity and large cigar and LCC smoking by age, adjusting for other sociodemographic variables. Overall, 1.1% and 0.8% of U.S. adults currently smoked large cigars and LCCs, with younger adults more likely to smoke both types of cigars and non-Hispanic Black adults more likely than non-Hispanic White adults to smoke LCCs. Prevalence of currently smoking LCCs varied greatly by age and race/ethnicity, with the highest prevalence of current LCC smoking being among 18–30 year-old non-Hispanic Black adults. Cigar smoking prevention and cessation efforts should prioritize non-Hispanic Black young adults who are most at risk for cigar smoking health effects.

Trends of cigarette smoking and smokeless tobacco use among US firefighters and law enforcement personnel, 1992-2019

BACKGROUND

Previous studies indicate tobacco use was more prevalent among firefighters and law enforcement personnel than in the US adult population. Trends of smoking and smokeless tobacco (SLT) use among these first responders are unknown. We examined trends in current smoking and SLT use among US firefighters and law enforcement personnel and compared smoking and SLT use prevalence in firefighters and law enforcement personnel to US adults in non-first-responder occupations.

METHODS

Trends of smoking and SLT use prevalence among firefighters, law enforcement personnel, and adults in other occupations were assessed by fitting joinpoint regression models using the 1992-2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS). We used multivariable logistic regression models adjusted for demographics to examine associations between occupation and smoking and SLT use status using the 2018-2019 TUS-CPS data. Analyses were conducted in 2021.

RESULTS

From 1992 to 2019, the smoking prevalence declined overall (all p's < 0.01). Though SLT use prevalence among adults in non-first-responder occupations declined (annual percentage change [APC] = -1.2%; 95% confidence interval [CI] = -1.7% to -0.7%), no changes were shown among firefighters and law enforcement personnel which suggests SLT use may be increasing among firefighters over time. In 2018-2019, firefighters (adjusted odds ratio [AOR] = 3.4; 95% CI = 1.7 to 6.8) and law enforcement personnel (AOR = 3.2; 95% CI = 2.1 to 4.7) were more likely than adults in non-first-responder occupations to use SLT.

CONCLUSIONS

While smoking prevalence declined overall, SLT use is higher among firefighters and law enforcement personnel and may be increasing over time among firefighters. Research should examine reasons for SLT use by first responders. Comprehensive tobacco policies and SLT-specific cessation programs are needed for first responders.

E-cigarette initiation predicts subsequent academic performance among youth: Results from the PATH Study

Research shows cigarette smoking is associated with lower academic performance among youth. This study examines how initiating e-cigarette use is associated with subsequent academic performance. Data from Waves 2-4 youth and parent surveys of the Population Assessment of Tobacco and Health (PATH) Study were analyzed. Youth (12-15 years old) who reported never using any tobacco products at Wave 2 were included in the analysis (n = 4960). Initiation of e-cigarettes and cigarettes was assessed at Wave 3. Weighted multivariable linear regression models were tested to assess the association between e-cigarette and cigarette initiation at Wave 3 and academic performance at Wave 4, controlling for covariates at Wave 2. At Wave 3, 4.3% and 1.9% of youth initiated e-cigarette and cigarette use, respectively. Youth who initiated e-cigarette use at Wave 3 had lower academic performance at Wave 4, compared to those who did not initiate e-cigarette use (adjusted regression coefficient [ARC] -0.22, 95% confidence interval [CI] -0.43, -0.02). Initiating cigarettes was also associated with lower academic performance (ARC -0.51, 95% CI -0.84, -0.18). Results indicate that e-cigarette use initiation is associated with lower subsequent academic performance, independent from the association between cigarette use initiation and lower academic performance among U.S. youth. Future research needs to examine whether preventing youth e-cigarette and cigarette use can lead to improvement in academic performance.

Epidemiology of cervical adenocarcinoma and squamous cell carcinoma among women living with HIV compared to the general population in the United States

OBJECTIVES

Cervical cancer risk overall is elevated among women living with HIV (WLH). However, it is unclear whether risks of cervical cancer are similarly elevated across histologic subtypes.

METHODS

Data were utilized from the HIV/AIDS Cancer Match Study, a linkage of 12 US HIV and cancer registries during 1996-2016. Cervical cancers were categorized as adenocarcinoma (AC), squamous cell carcinoma (SCC) or other histologic type. Standardized incidence ratios were estimated to compare rates of AC and SCC in WLH compared to the general population. For WLH, risk factors for AC and SCC were evaluated using Poisson regression. All-cause 5-year survival was estimated by HIV status and histology.

RESULTS

Overall, 62,615 cervical cancers were identified, including 609 in WLH. Compared to the general population, incidence of AC was 1.47-times higher (95%CI: 1.03-2.05) and incidence of SCC was 3.62-times higher among WLH (95%CI: 3.31-3.94). Among WLH, there was no difference in AC rates by race/ethnicity or HIV transmission group, although SCC rates were lower among White women (vs. Black, adjusted rate ratio (aRR)=0.53; 95%CI: 0.38-0.73) and higher among women who inject drugs (vs. heterosexual transmission; aRR=1.44; 95%CI: 1.17-1.78). Among WLH, 5-year overall survival was similar for AC (46.2%) and SCC (43.8%), but notably lower than women without HIV.

CONCLUSIONS

Among WLH, AC rates were modestly elevated whereas SCC rates were greatly elevated compared to the general population. These findings suggest that there may be differences in the impact of immunosuppression and HIV status in the development of AC compared to SCC, given their common etiology in HPV infection.

Utilization of the Cancer Medications Enquiry Database (CanMED)-National Drug Codes (NDC): Assessment of Systemic Breast Cancer Treatment Patterns

Cancer Medications Enquiry Database (CanMED) is comprised of two interactive, nomenclature-specific databases within the Observational Research in Oncology Toolbox: CanMED-Healthcare Common Procedure Coding System (HCPCS) and CanMED-National Drug Code (NDC), described through this study. CanMED includes medications with a) a US Food and Drug Administration-approved cancer treatment or treatment-related symptom management indication, b) inclusion in treatment guidelines, or c) an orphan drug designation. To demonstrate the joint utility of CanMED, medication codes associated with female breast cancer treatment were identified and utilization patterns were assessed within Surveillance Epidemiology and End Results-Medicare (SEER) data. CanMED-NDC (11_2018 v.1.2.4) includes 6860 NDC codes: chemotherapy (1870), immunotherapy (164), hormone therapy (3074), and ancillary therapy (1752). Treatment patterns among stage I-IIIA (20 701) and stage IIIB-IV (2381) breast cancer patients were accordant with guideline-recommended treatment by stage and molecular subtype. CanMED facilitates identification of medications from observational data (eg, claims and electronic health records), promoting more standardized and efficient treatment-related cancer research.

Development and Utility of the Observational Research in Oncology Toolbox: Cancer Medications Enquiry Database-Healthcare Common Procedure Coding System (HCPCS)

PURPOSE

Health-care claims are of increasing utility as a rich, real-world data resource for conducting treatment-related cancer research. However, multiple dynamic coding nomenclatures exist, leading to study variability. To promote increased standardization and reproducibility, the National Cancer Institute (NCI) developed the Cancer Medications Enquiry Database (CanMED)-Healthcare Common Procedure Coding System (HCPCS) within the Observational Research in Oncology Toolbox.

METHODS

The CanMED-HCPCS includes codes for oncology medications that a) have a US Food and Drug Administration-approved indication for cancer treatment or treatment-related symptom management; b) are present in National Comprehensive Cancer Network guidelines; or c) carry an orphan drug designation for treatment or management of cancer. Included medications and their HCPCS codes were primarily identified based on Center for Medicare and Medicaid Services annual HCPCS Indices (2012-2018). To demonstrate the utility of the CanMED-HCPCS, use of systemic treatment for stage II-IV colorectal cancer patients included in the Surveillance, Epidemiology, and End Results-Medicare data (2007-2013) was assessed.

RESULTS

The CanMED-HCPCS (v2018) includes 332 HCPCS codes for cancer-related medications: chemotherapy (156), immunotherapy (74), hormonal therapy (54), and ancillary therapy (48). Observed treatment trends within the NCI Surveillance, Epidemiology, and End Results-Medicare data were as expected; utilization of each treatment type increased with stage, and immunotherapy was largely confined to use among stage IV patients.

CONCLUSION

The CanMED-HCPCS provides a comprehensive resource that can be used by the research community to facilitate systematic identification of medications within claims or electronic health data using the HCPCS nomenclature and greater reproducibility of cancer surveillance and health services research.

Perceptions of care coordination among older adult cancer survivors: A SEER-CAHPS study

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Background: Care coordination represents deliberate efforts to harmonize and organize patient care activities. This study examined sociodemographic and clinical predictors of patient-reported care coordination among Medicare beneficiaries older than 65 with a history of cancer. Methods: This study utilized the Surveillance, Epidemiology, and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) linked data, including SEER cancer registry data, Medicare CAHPS patient experience surveys, and Medicare claims. We identified Medicare beneficiaries who completed a CAHPS survey within ten years after their most recent cancer diagnosis and reported visiting a personal doctor within six months before their survey (n = 14,646). Multivariable regression models examined associations between cancer survivor characteristics and care coordination, with higher scores indicating better coordination (scale of 0-100). Results: Residing in a rural area at time of diagnosis (1.2-points greater score than urban; p= 0.04) and reporting > 4 visits with a personal doctor within 6 months (3.0-points greater than 1-2 visits; p< 0.001) were significantly associated with higher care coordination scores. Older age ( p< 0.001) and seeing more specialists ( p= 0.006) were associated with significantly lower care coordination scores. Patients with melanoma (women: 5.2-point difference, p< 0.001; men: 2.8 points, p= 0.01) and breast cancer (women: 2.4 points; p< 0.001) also reported significantly lower care coordination scores than did men with prostate cancer (reference group). Conclusions: Adult cancer survivors who are older, have a history of breast, lung, or melanoma cancers, or see more specialists report worse care coordination. Future research should explore and address the multilevel influences that lead to worse care coordination for older adult cancer survivors.

Perceptions of care coordination among older adult cancer survivors: A SEER-CAHPS study

OBJECTIVE

Care coordination reflects deliberate efforts to harmonize patient care. This study examined variables associated with patient-reported care coordination scores among Medicare beneficiaries with a history of cancer.

METHODS

We utilized Surveillance, Epidemiology, and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) linked data, which includes cancer registry data, patient experience surveys, and Medicare claims. We identified Medicare beneficiaries with a CAHPS survey ≤10 years after cancer diagnosis who reported seeing a personal doctor within six months. Multivariable regression models examined associations between cancer survivor characteristics and patient-reported care coordination, with higher scores indicating better coordination.

RESULTS

Cancer site distribution of the 14,646 survey respondents was 33.7% prostate, 22.1% breast, 11.1% colorectal, 7.2% lung, and 25.9% other. Rural residence at diagnosis (versus urban, 1.1-point difference; p = 0.04) and reporting >4 visits with a personal doctor (versus 1-2 visits, 3.0-point difference; p < 0.001) were significantly associated with higher care coordination. Older age (p < 0.001) and seeing more specialists (p = 0.006) were associated with significantly lower care coordination. Patients with melanoma (women: 5.2-point difference, p < 0.001; men: 2.7 points, p = 0.01) or breast cancer (women: 2.4 points; p < 0.001) reported significantly lower care coordination scores than did men with prostate cancer (reference group). Time from diagnosis to survey, cancer stage, number of cancers, and comorbidities were not significantly associated with care coordination scores.

DISCUSSION

Cancer site, rural residence, and number of physician interactions are associated with patient-reported care coordination scores. Future research should address multilevel influences that lead to worse care coordination for older adult cancer survivors.

Hepatocellular Carcinoma Survival by Etiology: A SEER-Medicare Database Analysis

In the United States, hepatocellular carcinoma (HCC) survival varies with tumor characteristics, patient comorbidities, and treatment. The effect of HCC etiology on survival is less clearly defined. The relationship between HCC etiology and mortality was examined using Surveillance, Epidemiology, and End Results-Medicare data. In a cohort of 11,522 HCC cases diagnosed from 2000 through 2014, etiologies were identified from Medicare data, including metabolic disorders (32.9%), hepatitis C virus (8.2%), alcohol (4.7%), hepatitis B virus (HBV, 2.1%), rare etiologies (0.9%), multiple etiologies (26.7%), and unknown etiology (24.4%). After adjusting for demographics, tumor characteristics, comorbidities and treatment, hazard ratios (HRs) and survival curves by HCC etiology were estimated using Cox proportional hazard models. Compared with HBV-related HCC cases, higher mortality was observed for those with alcohol-related HCC (HR 1.49; 95% confidence interval [95% CI] 1.25-1.77), metabolic disorder-related HCC (HR 1.25; 95% CI 1.07-1.47), and multiple etiology-related HCC (HR 1.25; 95% CI 1.07-1.46), but was not statistically significant for hepatitis C virus-related, rare disorder-related, and HCC of unknown etiology. For all HCC etiologies, there was short median survival ranging from 6.1 months for alcohol to 10.3 months for HBV. Conclusion: More favorable survival was seen with HBV-related HCC. To the extent that HCC screening is more common among persons with HBV infection compared to those with other etiologic risk factors, population-based HCC screening, applied evenly to persons across all HCC etiology categories, could shift HCC diagnosis to earlier stages, when cases with good clinical status are more amenable to curative therapy.

Employment Outcomes Among Cancer Survivors in the United States: Implications for Cancer Care Delivery

The national prevalence of employment changes after a cancer diagnosis has not been fully documented. Cancer survivors who worked for pay at or since diagnosis (n = 1490) were identified from the 2011, 2016, and 2017 Medical Expenditure Panel Survey and Experiences with Cancer supplement. Analyses characterized employment changes due to cancer and identified correlates of those employment changes. Employment changes were made by 41.3% (95% confidence interval [CI] = 38.0% to 44.6%) of cancer survivors, representing more than 3.5 million adults in the United States. Of these, 75.4% (95% CI = 71.3% to 79.2%) took extended paid time off and 46.1% (95% CI = 41.6% to 50.7%) made other changes, including switching to part-time or to a less demanding job. Cancer survivors who were younger, female, non-White, or multiple races and ethnicities, and younger than age 20 years since last cancer treatment were more likely to make employment changes. Findings highlight the need for patient-provider communication about the effects of cancer and its treatment on employment.

Abstract B023: Racial-ethnic disparities in the receipt of initial, cure-intended treatment for localized prostate cancer, SEER Medicare, 2004-2013

Purpose: We sought to determine if there were racial/ethnic disparities in the receipt of initial, cure-intended treatment for localized prostate cancer.

Methods: We analyzed prostate cancer cases reported in 2004-2013 to Surveillance, Epidemiology and End Results (SEER) cancer registries, linked with Medicare claims from 2003-2014. We focused on cases that were fee-for-service with continuous Part A and B Medicare from 12 months before first diagnosis to 6 months after diagnosis, and that had American Joint Committee on Cancer 6th Edition tumor extent T1 or T2 without metastatic disease. We used SEER race/ethnicity to categorize cases as non-Hispanic whites; non-Hispanic blacks; non-Hispanic Asian or Pacific Islanders; Hispanics of any race; and Other/Unknown. We defined initial treatment to include 1 month before to 6 months after first diagnosis; cure-intended radical prostatectomy to include radical prostatectomy with or without radiation therapy; cure-intended radiation therapy to include radiation therapy without a radical prostatectomy; and noncurative treatment to include other initial treatment or no treatment. We used multivariable logistic regression to calculate adjusted odds ratios (OR) and 95% confidence intervals (CI) for receipt of each category of initial treatment, compared with the remaining cases, and adjusting for race/ethnicity; life expectancy from the man's age at diagnosis; pretreatment prostate cancer disease recurrence risk category; Charlson comorbidity score; year of diagnosis; SEER registry region, census tract poverty; and metropolitan or nonmetropolitan county location.

Results: Our final study cohort included a total of 125,072 men, with 95,763 non-Hispanic white, 13,616 non-Hispanic black, 4,658 non-Hispanic Asian or Pacific Islanders, 7,933 Hispanic any race, and 3,102 in the Other/Unknown category. After adjustment for multiple variables, non-Hispanic blacks were less likely than non-Hispanic whites to receive initial radical prostatectomy (with or without radiation therapy) (OR, 0.57; 95% CI, 0.53-0.61) or initial radiation therapy without radical prostatectomy (OR, 0.85; 95% CI, 0.82-0.88), and more likely to receive noncurative treatment (OR, 1.51; 95% CI, 1.45-1.57). Non-Hispanic Asian or Pacific Islanders were more likely than non-Hispanic whites to receive initial radiation therapy without radical prostatectomy (OR, 1.23; 95% CI, 1.16-1.31), and less likely to receive noncurative treatment (OR, 0.84; 95% CI, 0.78-0.89). The adjusted odds ratios for curative and noncurative initial treatment received by Hispanics of any race were similar to those for non-Hispanic whites.

Conclusion: Compared with non-Hispanic whites, non-Hispanic black men were less likely to receive curative and more likely to receive noncurative initial treatment for localized prostate cancer during 2004-2013.

Citation Format: Thomas B. Richards, David G. Stinchcomb, Timothy S. McNeel, Wilhelmina Ross, Diane Ng. Racial-ethnic disparities in the receipt of initial, cure-intended treatment for localized prostate cancer, SEER Medicare, 2004-2013 [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B023.

Estimating Chemotherapy Use Among Patients With a Prior Primary Cancer Diagnosis Using SEER-Medicare Data

Cancer treatment studies commonly exclude patients with prior primary cancers due to difficulties in ascertaining for which site treatment is intended. Surveillance, Epidemiology, and End Results-Medicare patients 65 years and older diagnosed with an index colon or rectal cancer (CRC) or female breast cancer (BC) between 2004 and 2013 were included. Chemotherapy, defined as "any chemotherapy" and more restrictively as "chemotherapy with confirmatory diagnoses," was ascertained based on claims data within 6 months of index cancer diagnosis by prior cancer history. Any chemotherapy use was slightly lower among patients with a prior cancer (CRC: no prior = 17.4%, prior = 16.1%; BC: no prior = 12.9%, prior = 12.0%). With confirmatory diagnoses required, estimates were lower, especially among patients with a prior cancer (CRC: no prior = 16.8%, prior = 13.6%; BC: no prior = 12.6%, prior = 11.0%). These findings suggest that patients with prior cancers can be included in studies of chemotherapy use; requiring confirmatory diagnoses can increase treatment assignment confidence.

Metabolic syndrome and risk of ovarian and fallopian tube cancer in the United States: An analysis of linked SEER-Medicare data

OBJECTIVE

To clarify associations between metabolic syndrome, its components, and ovarian cancer risk.

METHODS

Using a case-control study within the U.S.-based Surveillance, Epidemiology and End Results (SEER)-Medicare linked database, we examined metabolic syndrome, its components (obesity, impaired fasting glucose, hypertension, HDL cholesterol, triglycerides), and ovarian/fallopian tube cancer risk. Cases (n = 16,850) were diagnosed with cancer between age 68-89 from 1994 through 2013. Controls (n = 281,878) were Medicare enrollees without these cancers living in registry areas. We estimated adjusted odds ratios (OR) and 95% confidence intervals (CI) with logistic regression.

RESULTS

Women with metabolic syndrome had reduced ovarian cancer risk compared to women not meeting the diagnostic criteria (OR 0.86, CI 0.82-0.89). Having one or two syndrome components was associated with increased risk, but having ≥3 was not, when compared to women without any components. Impaired fasting glucose, which was highly prevalent among those with metabolic syndrome, was associated with reduced risk (OR 0.90, CI 0.87-0.93). Hypertension and high triglycerides, the most prevalent components among women without metabolic syndrome, were associated with increased risks (OR 1.08, CI 1.04-1.12; OR 1.05, CI 1.01-1.08, respectively).

CONCLUSIONS

Specific metabolic syndrome components may have modest associations with ovarian cancer. These associations varied in direction and the prevalence of the components influenced the overall association between metabolic syndrome and ovarian cancer. Evaluating metabolic syndrome as a composite exposure could be misleading in ovarian cancer research, but further study of the syndrome components is warranted.

Patient experiences of care in localized prostate cancer

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Background: Over 161,000 new prostate cancer patients diagnosed annually, with 75% diagnosed at early stages. Limited evidence exists supporting choice of treatment (including radical prostatectomy, radiation therapy, hormonal therapy, active surveillance or watchful waiting) for localized prostate cancer. Treatments have varying side effects associated with impaired functional status and health-related quality of life. Patient care experiences are important quality indicators, but research examining patient experiences by prostate cancer treatment is limited. The purpose of this study was to examine the association between treatment received (surgery, radiation, or no treatment) and CAHPS ratings of overall care over the prior six months. Methods: This study used data from SEER-CAHPS, which links Surveillance, Epidemiology, and End Results (SEER) data with Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience survey and Medicare claims data. Medicare Fee-for-Service beneficiaries ≥65 years with a National Comprehensive Cancer Network (NCCN) low- or intermediate-risk prostate cancer diagnosis were assigned to surgery only, radiation only, and no treatment received groups for analysis. The outcome variable was a CAHPS rating of overall care (0 = worst; 10 = best). The analysis adjusted for case mix and other cancer-specific variables. Results: The final cohort included 507 prostate cancer survivors (surgery n = 109 [21%]; radiation n = 197 [39%]; no treatment n = 201 [40%]). Respondents who received radiation rated their overall care higher than those not receiving treatment (adjusted mean 8.9 vs 8.3; p= 0.02). Ratings did not differ significantly between the surgery and no treatment groups. Conclusions: This study represents a first look at patient experiences among localized prostate cancer survivors receiving surgery, radiation, or no treatment. It is not clear whether those who did not receive treatment chose active surveillance or watchful waiting, or whether they did not have access to care, which could have affected results. Future research should explore associations between receipt of treatment and patient care experiences in an adequately powered sample to inform future interventions.

Genetic counseling, genetic testing, and risk perceptions for breast and colorectal cancer: Results from the 2015 National Health Interview Survey

We examined what proportion of the U.S. population with no personal cancer history reported receiving either genetic counseling or genetic testing for cancer risk, and also the association of these behaviors with cancer risk perceptions. We used data from the 2015 National Health Interview Survey. Objective relative risk scores for breast (women) and colorectal (men and women) cancer risk were generated for individuals without a personal history of cancer. Participants' risk perceptions were compared with their objective relative risk. Of 12,631 women, 1.2% reported receiving genetic counseling and 0.8% genetic testing for hereditary breast cancer risk. Of 15,085 men and women, 0.8% reported receiving genetic counseling and 0.3% genetic testing for hereditary colorectal cancer risk. Higher breast cancer risk perception was associated with genetic counseling (OR: 4.31, 95%CI: 2.56, 7.26) and testing (OR: 3.56, 95%CI: 1.80, 7.03). Similarly, higher perception of colorectal cancer risk was associated with genetic counseling (OR: 5.04, 95%CI: 2.57, 9.89) and testing (OR: 5.92, 95%CI: 2.40, 14.63). A higher proportion of individuals with colorectal cancer risk perceptions concordant with their objective risk (vs. discordant) had undergone genetic counseling or testing for colorectal cancer risk. Concordant risk perceptions for breast cancer were not associated with breast cancer genetic counseling or testing. Given frequent dialogue about implementing population level programs involving genetic services for cancer risk, policy makers and investigators should consider the role of risk perceptions in the effectiveness and design of such programs and potential strategies for addressing inaccuracies in risk perceptions.

Contemporary Associations of Exclusive Cigarette, Cigar, Pipe, and Smokeless Tobacco Use With Overall and Cause-Specific Mortality in the United States

Background

A growing proportion of tobacco users in the United States use non-cigarette products including cigars, pipes, and smokeless tobacco. Studies examining the disease and mortality risks of these products are urgently needed.

Methods

We harmonized tobacco use data from 165 335 adults in the 1991, 1992, 1998, 2000, 2005, and 2010 National Health Interview Surveys. Hazard ratios (HRs) and 95% confidence intervals (CIs) for overall and cause-specific mortality occurring through December 31, 2015, were estimated by exclusive use of cigarettes, cigars, pipes, or smokeless tobacco using Cox proportional hazards regression with age as the underlying time metric and never tobacco users as the referent group.

Results

Current use of cigarettes (HR = 2.23, 95% CI = 2.13 to 2.33) and smokeless tobacco (HR = 1.36, 95% CI = 1.17 to 1.59) were each associated with overall mortality. Relative to never tobacco users, higher risks were observed both in daily (HR = 2.34, 95% CI = 2.24 to 2.44) and nondaily (HR = 1.69, 95% CI = 1.54 to 1.86) cigarette smokers, with associations also observed across major smoking-related causes of death. Daily use of smokeless tobacco was also associated with overall mortality (HR = 1.41, 95% CI = 1.20 to 1.66) as was daily use of cigars (HR = 1.52, 95% CI = 1.12 to 2.08). Current smokeless tobacco use was associated with a higher risk of mortality from heart disease and smoking-related cancer, with strong associations observed for cancers of the oral cavity and bladder.

Conclusions

Exclusive daily use of cigarettes, cigars, and smokeless tobacco was associated with higher mortality risk. Tobacco control efforts should include cigars and smokeless tobacco.

Postbiliary drainage rates of cholangitis are impacted by procedural technique for patients with supra-ampullary cholangiocarcinoma: A SEER-Medicare analysis

BACKGROUND

The optimal approach to biliary drainage for patients with supra-ampullary cholangiocarcinoma remains undetermined. Violation of sphincter of Oddi results in bacterial colonization of bile ducts and may increase postdrainage infectious complications. We sought to determine if rates of cholangitis are affected by the type of drainage procedure.

METHODS

We examined the Surveillance, Epidemiology, and End Results-Medicare linked database from 1991 to 2013 for cholangiocarcinoma. Biliary drainage procedures were categorized as sphincter of Oddi violating (SOV) or sphincter of Oddi preserving (SOP). Patients were stratified by resection.

RESULTS

A total of 1914 patients were included in the final analysis. A total of 1264 patients did not undergo a postdrainage resection (SOP 83, SOV 1181) while 650 did undergo a postdrainage resection (SOP 26, SOV 624). For those patients not undergoing a postdrainage resection, the rate of cholangitis 90 days after an SOP procedure was 19% compared with 34% in the SOV cohort (P = 0.007). For those patients undergoing a postdrainage resection, the rate of cholangitis 90 days after an SOP procedure was less than 42.3% compared with 30% in the SOV cohort (P = 0.66).

CONCLUSION

For patients with supra-ampullary cholangiocarcinoma that did not undergo resection, biliary drainage procedures that violated the sphincter of Oddi were associated with increased rates of cholangitis.

Non-Daily Cigarette Smokers: Mortality Risks in the U.S

INTRODUCTION

Worldwide, an estimated 189 million adults smoke tobacco "occasionally" but not every day. Yet few studies have examined the health risks of non-daily smoking.

METHODS

Data from the 1991, 1992, and 1995 U.S. National Health Interview Surveys, a nationally representative sample of 70,913 U.S. adults (aged 18-95 years) were pooled. Hazard ratios and 95% CIs for death through 2011 were estimated from Cox proportional hazards regression using age as the underlying time metric and stratified by 5-year birth cohorts in 2017.

RESULTS

Non-daily smokers reported smoking a median of 15 days and 50 cigarettes per month in contrast to daily smokers who smoked a median of 600 cigarettes per month. Compared with never smokers, lifelong nondaily smokers who had never smoked daily had a 72% higher mortality risk (95% CI=1.36, 2.18): higher risks were observed for cancer, heart disease, and respiratory disease mortalities. Higher mortality risks were observed among lifelong non-daily smokers who reported 11-30 (hazard ratio=1.34, 95% CI=0.81, 2.20); 31-60 (hazard ratio=2.02, 95% CI=1.17, 3.29); and >60 cigarettes per month (hazard ratio=1.74, 95% CI=1.12, 2.72) than never smokers. Median life-expectancy was about 5 years shorter for lifelong non-daily smokers than never smokers. As expected, daily smokers had even higher mortality risks (hazard ratio=2.50, 95% CI=2.35, 2.66) and shorter survival (10 years less).

CONCLUSIONS

Although the mortality risks of non-daily smokers are lower than daily smokers, they are still substantial. Policies should be specifically directed at this growing group of smokers.

Use of Next-Generation Sequencing Tests to Guide Cancer Treatment: Results From a Nationally Representative Survey of Oncologists in the United States

Purpose

There are no nationally representative data on oncologists' use of next-generation sequencing (NGS) testing in practice. The purpose of this study was to investigate how oncologists in the United States use NGS tests to evaluate patients with cancer and to inform treatment recommendations.

Methods

The study used data from the National Survey of Precision Medicine in Cancer Treatment, which was mailed to a nationally representative sample of oncologists in 2017 (N = 1,281; cooperation rate = 38%). Weighted percentages were calculated to describe NGS test use. Multivariable modeling was conducted to assess the association of test use with oncologist practice characteristics.

Results

Overall, 75.6% of oncologists reported using NGS tests to guide treatment decisions. Of these oncologists, 34.0% used them often to guide treatment decisions for patients with advanced refractory disease, 29.1% to determine eligibility for clinical trials, and 17.5% to decide on off-label use of Food and Drug Administration-approved drugs. NGS test results informed treatment recommendations often for 26.8%, sometimes for 52.4%, and never or rarely for 20.8% of oncologists. Oncologists younger than 50 years of age, holding a faculty appointment, having genomics training, seeing more than 50 unique patients per month, and having access to a molecular tumor board were more likely to use NGS tests.

Conclusion

In 2017, most oncologists in the United States were using NGS tests to guide treatment decisions for their patients. More research is needed to establish the clinical usefulness of these tests, to develop evidence-based clinical guidelines for their use in practice, and to ensure that patients who can benefit from these new technologies receive appropriate testing and treatment.

Examining the relative influence of multimorbidity on variations in older cancer patients’ experiences with care

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Background: Cancer patients often have multiple chronic conditions and require complex care coordination. We compared older (ages 66+) cancer patients’ reports of their healthcare experiences based on level of multimorbidity. Methods: Data from the SEER-CAHPS combines cancer registry (Surveillance, Epidemiology, and End Results; SEER), patient experiences (Consumer Assessment of Healthcare Providers and Systems; CAHPS) and Medicare claims data. Multimorbidity was captured as: (1) the National Cancer Institute-Combined Comorbidity Index (NCCI, 16 Charlson conditions diagnosed ≤12 months prior to cancer); and (2) a Multimorbidity Burden Index (MBI), which categorizes conditions based on the impact to cancer treatment (no comorbidity, low/medium, and high). Outcomes were CAHPS patient experience measures: Doctor Communication, Getting Care Quickly, Getting Needed Care, Obtaining Prescription Drugs, Customer Service, and ratings of Overall Care, Personal Doctor, and Specialist. Multivariable linear regression provided associations of each multimorbidity measure with CAHPS measures controlling for standard case mix adjustors, years from diagnosis to survey and diagnostic stage. Results: The study cohort included 9305 cancer patients (53% male, 84% Non-Hispanic White, average age 77, average time from diagnosis 29 months), with a distribution of NCCI conditions as: 0 (cancer only), 73%; 1, 17%; ≥2, 10%. Cancer patients with NCCI = 0 and those with MBI = no comorbidity rated their Personal Doctor more negatively than those with any comorbidities ( p < 0.02). Those with NCCI ≥ 2 or MBI = low/medium reported better Doctor Communication ( p < 0.04). Those with high MBI rated their specialist physician better than those with no multimorbidity ( p = 0.04), and those with low/medium MBI reported better experiences Getting Care Quickly ( p = 0.02). No other associations were significant. Conclusions: Cancer patients with multimorbidity report better communication with their doctor and care = by = personal doctors and specialists. Increased attention to the care experiences of cancer patients with multimorbidity may lead to insights and interventions that benefit all cancer patients.

Understanding personal risk of oropharyngeal cancer: risk-groups for oncogenic oral HPV infection and oropharyngeal cancer

Background

Incidence of human papillomavirus (HPV)-related oropharyngeal cancer is increasing. There is interest in identifying healthy individuals most at risk for development of oropharyngeal cancer to inform screening strategies.

Patients and methods

All data are from 2009 to 2014, including 13 089 people ages 20-69 in the National Health and Nutrition Examination Survey (NHANES), oropharyngeal cancer cases from the Surveillance, Epidemiology, and End Results (SEER 18) registries (representing ∼28% of the US population), and oropharyngeal cancer mortality from National Center for Health Statistics (NCHS). Primary study outcomes are (i) prevalence of oncogenic HPV DNA in an oral rinse and gargle sample, and (ii) incident oropharyngeal squamous cell cancer.

Results

Oncogenic oral HPV DNA is detected in 3.5% of all adults age 20-69 years; however, the lifetime risk of oropharyngeal cancer is low (37 per 10 000). Among men 50-59 years old, 8.1% have an oncogenic oral HPV infection, 2.1% have an oral HPV16 infection, yet only 0.7% will 'ever' develop oropharyngeal cancer in their lifetime. Oncogenic oral HPV prevalence was higher in men than women, and increased with number of lifetime oral sexual partners and tobacco use. Men who currently smoked and had ≥5 lifetime oral sexual partners had 'elevated risk' (prevalence = 14.9%). Men with only one of these risk factors (i.e. either smoked and had 2-4 partners or did not smoke and had ≥5 partners) had 'medium risk' (7.3%). Regardless of what other risk factors participants had, oncogenic oral HPV prevalence was 'low' among those with only ≤1 lifetime oral sexual partner (women = 0.7% and men = 1.7%).

Conclusions

Screening based upon oncogenic oral HPV detection would be challenging. Most groups have low oncogenic oral HPV prevalence. In addition to the large numbers of individuals who would need to be screened to identify prevalent oncogenic oral HPV, the lifetime risk of developing oropharyngeal caner among those with infection remains low.

Impact of sociodemographic characteristics on underemployment in a longitudinal, nationally representative study of cancer survivors: Evidence for the importance of gender and marital status

BACKGROUND

We examined the longitudinal association between sociodemographic factors and an expanded definition of underemployment among those with and without cancer history in the United States.

METHODS

Medical Expenditure Panel Survey data (2007-2013) were used in multivariable regression analyses to compare employment status between baseline and two-year follow-up among adults aged 25-62 years at baseline (n = 1,614 with and n = 39,324 without cancer). Underemployment was defined as becoming/staying unemployed, changing from full to part-time, or reducing part-time work significantly. Interaction effects between cancer history/time since diagnosis and predictors known to be associated with employment patterns, including age, gender/marital status, education, and health insurance status at baseline were modeled.

RESULTS

Approximately 25% of cancer survivors and 21% of individuals without cancer reported underemployment at follow-up (p = 0.002). Multivariable analyses indicated that those with a cancer history report underemployment more frequently (24.7%) than those without cancer (21.4%, p = 0.002) with underemployment rates increasing with time since cancer diagnosis. A significant interaction between gender/marital status and cancer history and underemployment was found (p = 0.0004). There were no other significant interactions. Married female survivors diagnosed >10 years ago reported underemployment most commonly (38.7%), and married men without cancer reported underemployment most infrequently (14.0%). A wider absolute difference in underemployment reports for married versus unmarried women as compared to married versus unmarried men was evident, with the widest difference apparent for unmarried versus married women diagnosed >10 years ago (18.1% vs. 38.7%).

CONCLUSION

Cancer survivors are more likely to experience underemployment than those without cancer. Longer time since cancer diagnosis and gender/marital status are critical factors in predicting those at greatest risk of underemployment. The impact of cancer on work should be systematically studied across sociodemographic groups and recognized as a component of comprehensive survivorship care.

Abstract PR06: Racial-ethnic disparities in receipt of anatomic pulmonary resection in non-small cell lung cancer, SEER Medicare, 2000-2011

Purpose: Anatomic pulmonary resection includes surgical procedures such as pneumonectomy, lobectomy, and segmentectomy, in contrast to non-anatomic pulmonary surgical procedures such as wedge resection. National Comprehensive Cancer Network guidelines for non-small cell lung cancer (NSCLC) indicate that anatomic pulmonary resection is preferred when surgery is indicated. The purpose of the current study is to describe racial-ethnic disparities in the receipt of anatomic pulmonary resection among NSCLC patients.

Methods: We analyzed Surveillance, Epidemiology, and End Results (SEER) patients linked with Medicare claims, first diagnosed in 2000-2011. We required patients to have NSCLC as their first malignancy and covered by fee-for-service with continuous Part A and B Medicare from 12 months before to 4 months after first diagnosis. We categorized stage using American Joint Committee on Cancer 6th Edition. We excluded patients who were age ≤65 years; diagnosed at occult stage or stage 0; diagnosed at death; had unknown race, census tract poverty, urban-rural status, month of diagnosis, or month of death; or were enrolled in a health maintenance organization at any time from 12 months before to 4 months after diagnosis. We used SEER race to classify cases as: non-Hispanic whites; non-Hispanic blacks; Hispanics of white or black race (hereafter referred to as Hispanics), and Asian or Pacific Islanders. We reserved cases with American Indian or Alaska Native race for a future, separate analysis because numbers were smaller compared to other racial-ethnic groups. We defined anatomic pulmonary resection to include pneumonectomy, lobectomy, and segmentectomy. We identified receipt of anatomic pulmonary resection from the month of diagnosis to 4 months after first NSCLC diagnosis using Healthcare Common Procedure Coding System and International Classification of Disease 9th edition Clinical Modification codes. We used multiple variable logistic regression to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for receipt of anatomic pulmonary resection by males, and separately by females, adjusting for age at diagnosis, racial-ethnic group, mediastinal exploration, stage, histology, census tract poverty, SEER region, year of diagnosis, and comorbidity.

Results: Our study cohort included 99,766 NSCLC cases, with similar proportions of males (51.2%) and females (48.8%). Overall, 23.2% (n=23,105) received anatomic pulmonary resection, but receipt varied by racial-ethnic group. Compared to non-Hispanic black men, anatomic resection procedures were more commonly received by men who were non-Hispanic white (aOR, 1.93; 95% CI, 1.70-2.19), Hispanic (aOR, 1.82; 95% CI, 1.49-2.22), or Asian or Pacific Islander (aOR, 2.06; 95% CI, 1.71-2.49). Compared to non-Hispanic black females, anatomic resection procedures also were more commonly received by females who were non-Hispanic white (aOR, 1.39; 95% CI, 1.23-1.57), Hispanic (aOR, 1.46; 95% CI, 1.20-1.79) or Asian or Pacific Islander (aOR, 1.42; 95% CI, 1.16-1.73).

Conclusions: Non-Hispanic black men diagnosed with NSCLC from 2000-2011 were less likely to receive anatomic pulmonary resection than non-Hispanic white, Hispanic, or Asian or Pacific Islander men. Non-Hispanic black females also were less likely to receive anatomic pulmonary resection, but the differences in aORs by race were smaller among females than among males.

Citation Format: Thomas B. Richards, Serban Negoita, Timothy S. McNeel, Dylan L. Holt, Marie Topor, S Jane Henley, Arica White, Jun Li, Chunyu Li. Racial-ethnic disparities in receipt of anatomic pulmonary resection in non-small cell lung cancer, SEER Medicare, 2000-2011. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr PR06.

Quality of Patient-Provider Communication Among Cancer Survivors: Findings From a Nationally Representative Sample

PURPOSE

Although patient-provider communication is an essential component of health care delivery, little is known about the quality of these discussions among patients with cancer.

METHODS

Data are from the 2011 Medical Expenditure Panel Survey Experiences with Cancer survey among 1,202 adult cancer survivors. We evaluated discussions with any provider after a cancer diagnosis about: (1) follow-up care; (2) late or long-term treatment effects; (3) lifestyle recommendations, such as diet, exercise, and quitting smoking; and (4) emotional or social needs. Using a response scale ranging from "did not discuss" to "discussed in detail," a summary score was constructed to define communication quality as high, medium, or low. Patient factors associated with the quality of provider discussions were examined using multivariable polytomous logistic regression analyses.

RESULTS

At the time of the survey, approximately one half of the patients (46%) were either within 1 year (24.1%) or between 1 and 5 years (22.0%) of treatment. More than one third of cancer survivors reported that they did not receive detailed communication about follow-up care, and more than one half reported that they did not receive detailed communication regarding late or long-term effects, lifestyle recommendations, or emotional and social needs. Only 24% reported high-quality communication for all four elements, indicating that the vast majority experienced suboptimal communication. In multivariable analysis, survivors reporting a high communication quality with providers included those who were within 1 year of treatment, between the ages of 18 and 64 years, non-Hispanic black or other ethnicity, and married.

CONCLUSION

Study findings demonstrate gaps in the communication quality experienced by cancer survivors in the United States and help identify survivors for targeted interventions.

Access to Cancer Care and General Medical Care Services Among Cancer Survivors in the United States: An Analysis of 2011 Medical Expenditure Panel Survey Data

OBJECTIVES

Cancer survivors require appropriate health care to manage their unique health needs. This study describes access to cancer care among cancer survivors in the United States and compares access to general medical care between cancer survivors and people who have no history of cancer.

METHODS

We assessed access to general medical care using the core 2011 Medical Expenditure Panel Survey (MEPS). We assessed access to cancer care using the MEPS Experiences With Cancer Survey. We used multivariable logistic regression to compare access to general medical care among 2 groups of cancer survivors (those who reported having access to all necessary cancer care [n = 1088] and those who did not [n = 70]) with self-reported access to general medical care among people who had no history of cancer (n = 22 434).

RESULTS

Of the 1158 cancer survivors, 70 (6.0%) reported that they did not receive all necessary cancer care. Adjusted analyses found that cancer survivors who reported not receiving all necessary cancer care were also less likely to report receiving general medical care (78.0%) than cancer survivors who reported having access to necessary cancer care (87.1%) and people who had no history of cancer (87.8%).

CONCLUSIONS

This study provides nationally representative data on the proportion of cancer survivors who have access to necessary cancer care and yields insight into factors that impede survivors' access to both cancer care and general medical care. This study is a reference for future work on access to care.

Employment implications of informal cancer caregiving

PURPOSE

Previous research describing how informal cancer caregiving impacts employment has been conducted in small samples or a single disease site. This paper provides population-based estimates of the effect of informal cancer caregiving on employment and characterizes employment changes made by caregivers.

METHODS

The samples included cancer survivors with a friend or family caregiver, participating in either the Medical Expenditure Panel Survey Experiences with Cancer Survivorship Survey (ECSS) (n = 458) or the LIVESTRONG 2012 Survey for People Affected by Cancer (SPAC) (n = 4706). Descriptive statistics characterized the sample of survivors and their caregivers' employment changes. Multivariable logistic regression identified predictors of caregivers' extended employment changes, comprising time off and changes to hours, duties, or employment status.

RESULTS

Among survivors with an informal caregiver, 25 % from the ECSS and 29 % from the SPAC reported that their caregivers made extended employment changes. Approximately 8 % of survivors had caregivers who took time off from work lasting ≥2 months. Caregivers who made extended employment changes were more likely to care for survivors: treated with chemotherapy or transplant; closer to diagnosis or end of treatment; who experienced functional limitations; and made work changes due to cancer themselves compared to caregivers who did not make extended employment changes.

CONCLUSIONS

Many informal cancer caregivers make employment changes to provide care during survivors' treatment and recovery.

IMPLICATIONS FOR CANCER SURVIVORS

This study describes cancer caregiving in a prevalent sample of cancer survivors, thereby reflecting the experiences of individuals with many different cancer types and places in the cancer treatment trajectory.

Abstract B44: Adjusted American Joint Committee on Cancer 6th edition stage for analysis of trends in black-white disparities in non-small cell lung cancer, SEER Medicare, 2000-2011

Purpose: Analyses of racial disparities in survival and treatment trends may be confounded by changes over time in cancer staging systems. For Surveillance, Epidemiology, and End Results (SEER) data linked with Medicare claims, non-small cell lung cancer (NSCLC) is available with American Joint Committee on Cancer (AJCC) 3rd edition stage from 2000–2003, and with AJCC 6th edition (AJCC6) stage from 2004–2011. We wanted to maximize the number of years that AJCC6 stage was available for analysis of trends. In this study, we describe the results of our methods to assign all NSCLC cases from 2000–2011 with stage group equivalent to AJCC6, and our assessment of black-white differences by stage and year following the stage reclassification.

Methods: We focused on SEER-Medicare linked NSCLS cases, diagnosed 2000–2011, enrolled in Medicare during the month of diagnosis, and with SEER race coded as white or black. We used SEER Extent of Disease 1988 (10 digit) codes to assign AJCC6 to cases diagnosed 2000–2003, Collaborative Stage version 1 to assign AJCC6 to cases diagnosed 2004–2009, and Collaborative Stage version 2 to assign AJCC6 to cases diagnosed 2010–2011. To evaluate our adjusted AJCC6, we calculated the percentage point (pp) differences in the proportions of cases by stage and race between 2003 and 2004, and also for the 2000–2003, 2004–2009, and 2010–2011 sub-cohorts. In addition, we used SEER Joinpoint regression analysis to calculate annual percentage change (APC) by stage and race, including coincident and parallel pairwise comparisons by race. We defined statistical significance as p&lt;0.05.

Results: Our final study cohort included 156,125 white and 16,594 black NSCLC cases. Overall from 2000 to 2011, the proportion of cases by stage was: IA (12.4%), IB (11.8%), IIA (1.2%), IIB (4.5%), IIIA (9.9%), IIIB (18.0%), and IV (41.0%); the remaining 1.2% were categorized Occult Carcinoma or Stage 0. The mean difference in proportions for stages I to IV between 2003 and 2004 was 0.3 pp, but the difference by specific stage varied up to 4.1 pp. The proportion Stage IA was higher in whites than in blacks (3.1 pp in 2000–2003; 3.7 pp in 2004–2009; and 3.5 pp in 2010–2011). The proportion Stage IV was higher in blacks than in whites (2.6 pp in 2000–2003; 3.2 pp in 2004–2009; and 3.5 pp in 2010–2011). Differences in proportions between whites and blacks for Stage IIA, IIB, and Stage IIIA were less than 1 pp for each of the three time periods. Proportions by stage for whites were greater than those for blacks for Stage IA to Stage IIB, and proportions by stage for blacks exceeded those for whites for Stage IIIB and Stage IV. The predicted proportions of white and black cases diagnosed at Stage IIIA were statistically identical. Significant changes in APCs were present among whites in Stage IA (at 2004), Stage IB (at 2006 and 2009), and Stage IV (at 2004). No statistically significant changes in APCs were detected among blacks.

Conclusion: Our methods to reclassify NSCLC cases according to AJCC6 appear reasonable to support analyses that require cancer stage and race of all cohort patients diagnosed between 2000 and 2011. Some year-to-year differences are present, but they appear at most 4.1 pp between 2003 and 2004. Following the stage reclassification, our results suggest that whites were more likely to be diagnosed at a favorable stage (IA, IB, IIA, and IIB) compared with blacks, while blacks were more likely to be diagnosed at a less favorable stage (IIIB and IV) compared with whites.

Citation Format: Thomas B. Richards, Serban Negoita, Timothy S. McNeel, Dylan L. Holt, Marie Topor, S Jane Henley, Arica White, Jun Li, Chunyu Li. Adjusted American Joint Committee on Cancer 6th edition stage for analysis of trends in black-white disparities in non-small cell lung cancer, SEER Medicare, 2000-2011. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B44.

Financial Hardship Associated With Cancer in the United States: Findings From a Population-Based Sample of Adult Cancer Survivors

PURPOSE

To estimate the prevalence of financial hardship associated with cancer in the United States and identify characteristics of cancer survivors associated with financial hardship.

METHODS

We identified 1,202 adult cancer survivors diagnosed or treated at ≥ 18 years of age from the 2011 Medical Expenditure Panel Survey Experiences With Cancer questionnaire. Material financial hardship was measured by ever (1) borrowing money or going into debt, (2) filing for bankruptcy, (3) being unable to cover one's share of medical care costs, or (4) making other financial sacrifices because of cancer, its treatment, and lasting effects of treatment. Psychological financial hardship was measured as ever worrying about paying large medical bills. We examined factors associated with any material or psychological financial hardship using separate multivariable logistic regression models stratified by age group (18 to 64 and ≥ 65 years).

RESULTS

Material financial hardship was more common in cancer survivors age 18 to 64 years than in those ≥ 65 years of age (28.4% v 13.8%; P < .001), as was psychological financial hardship (31.9% v 14.7%, P < .001). In adjusted analyses, cancer survivors age 18 to 64 years who were younger, female, nonwhite, and treated more recently and who had changed employment because of cancer were significantly more likely to report any material financial hardship. Cancer survivors who were uninsured, had lower family income, and were treated more recently were more likely to report psychological financial hardship. Among cancer survivors ≥ 65 years of age, those who were younger were more likely to report any financial hardship.

CONCLUSION

Cancer survivors, especially the working-age population, commonly experience material and psychological financial hardship.

Early childhood caries and intake of 100 percent fruit juice: Data from NHANES, 1999-2004

BACKGROUND

The results of several studies conducted in the United States show no association between intake of 100 percent fruit juice and early childhood caries (ECC). The authors examined this association according to poverty and race/ethnicity among U.S. preschool children.

METHODS

The authors analyzed data from the 1999-2004 National Health and Nutrition Examination Survey (NHANES) for 2,290 children aged 2 through 5 years. They used logistic models for caries (yes or no) to assess the association between caries and intake of 100 percent fruit juice, defined as consumption (yes or no), ounces (categories) consumed in the previous 24 hours or usual intake (by means of a statistical method from the National Cancer Institute).

RESULTS

The association between caries and consumption of 100 percent fruit juice (yes or no) was not statistically significant in an unadjusted logistic model (odds ratio [OR], 0.76; 95 percent confidence interval [CI], 0.57-1.01), and it remained nonsignificant after covariate adjustment (OR, 0.89; 95 percent CI, 0.63-1.24). Similarly, models in which we evaluated categorical consumption of 100 percent juice (that is, 0 oz; > 0 and ≤ 6 oz; and > 6 oz), unadjusted and adjusted by covariates, did not indicate an association with ECC.

CONCLUSIONS

Our study findings are consistent with those of other studies that show consumption of 100 percent fruit juice is not associated with ECC.

Earlier presentation and application of curative treatments in hepatocellular carcinoma

The purpose of the study was to assess the use of curative therapies for hepatocellular carcinoma (HCC) in the population. HCC treatment patterns were examined in Surveillance, Epidemiology, and End Results (SEER) 18 registries (28% of U.S.). Joinpoint regression analyses were performed to assess 2000-2010 incidence trends by tumor size, count, and receipt of potentially curative treatments (transplantation, resection, and ablation). SEER-Medicare data enabled evaluation of treatment patterns including receipt of sorafenib or transarterial chemoembolization (TACE) by HCC-associated comorbidities. Diagnoses of tumors≤5.0 cm in diameter significantly increased during 2000-2010, surpassing diagnosis of larger tumors. Overall, 23% of cases received potentially curative treatment. Joinpoint models indicated incidence rates of treatment with curative intent increased 17.6% per year during 2000-2005, then declined by -2.9% per year during 2005-2010 (P<0.001). Among HCC cases with a single tumor≤5.0 cm and no extension beyond the liver, use of ablative therapy significantly increased during 2000-2010. Use of invasive surgery for single tumors, regardless of size, significantly increased during the initial years of the decade, then plateaued. The group most likely to receive curative treatment in the SEER-Medicare cases was patients with one, small tumor confined to the liver (657 of 1,597 cases, 41%), with no difference in treatment by hepatic comorbidity status (P=0.24). A higher proportion of cases with reported liver-associated comorbidities were, however, diagnosed with tumors≤5.0 cm in diameter (1,745 0f 2,464, 71%) compared to patients with no reported comorbidities (996 of 2,596, 38%, P<0.001).

CONCLUSION

Although more HCC patients were diagnosed with early disease over time, the use of curative treatments in this patient group has recently plateaued. Efforts to identify and treat more eligible candidates for curative therapy could be beneficial.