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Collin LJ, Jones J, Nash R, Switchenko JM, Ward KC, McCullough LE. Racial disparities in initiation of chemotherapy among breast cancer patients with discretionary treatment indication in the state of Georgia. Breast Cancer Res Treat 2024; 205:609-618. [PMID: 38517602 PMCID: PMC11101533 DOI: 10.1007/s10549-024-07279-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 02/07/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE The majority of breast cancer patients are diagnosed with early-stage estrogen receptor (ER) positive disease. Despite effective treatments for these cancers, Black women have higher mortality than White women. We investigated demographic and clinical factors associated with receipt of chemotherapy among those with a discretionary indication who are at risk for overtreatment. METHODS Using Georgia Cancer Registry data, we identified females diagnosed with ER positive breast cancer who had a discretionary indication for chemotherapy (2010-2017). We used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) associating patient demographic and clinical characteristics with chemotherapy initiation overall, and comparing non-Hispanic Black (NHB) with non-Hispanic White (NHW) women within strata of patient factors. RESULTS We identified 11,993 ER positive breast cancer patients with a discretionary indication for chemotherapy. NHB patients were more likely to initiate chemotherapy compared with NHW women (OR = 1.41, 95% CI: 1.28, 1.56). Race differences in chemotherapy initiation were pronounced among those who did not receive Oncotype DX testing (OR = 1.47, 95% CI: 1.31, 1.65) and among those residing in high socioeconomic status neighborhoods (OR = 2.48, 95% CI: 1.70, 3.61). However, we observed equitable chemotherapy receipt among patients who received Oncotype DX testing (OR = 0.90, 95% CI: 0.71, 1.14), were diagnosed with grade 1 disease (OR = 1.00, 95% CI: 0.74, 1.37), and those resided in rural areas (OR = 1.01, 95% CI: 0.76, 1.36). CONCLUSION We observed racial disparities in the initiation of chemotherapy overall and by sociodemographic and clinical factors, and more equitable outcomes when clinical guidelines were followed.
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Affiliation(s)
- Lindsay J Collin
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope Dr, Salt Lake City, UT, 84112, USA.
| | - Jade Jones
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, USA
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lauren E McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Warren JL, Mariotto AB, Stevens J, Davidoff AJ, Shankaran V, Ward KC, Wu XC, Schwartz SM, Penberthy L, Yabroff KR. Association of Major Adverse Financial Events and Later-Stage Cancer Diagnosis in the United States. J Clin Oncol 2024; 42:1001-1010. [PMID: 38320222 PMCID: PMC10950180 DOI: 10.1200/jco.23.01067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 10/25/2023] [Accepted: 11/14/2023] [Indexed: 02/08/2024] Open
Abstract
PURPOSE This study assessed the prevalence of specific major adverse financial events (AFEs)-bankruptcies, liens, and evictions-before a cancer diagnosis and their association with later-stage cancer at diagnosis. METHODS Patients age 20-69 years diagnosed with cancer during 2014-2015 were identified from the Seattle, Louisiana, and Georgia SEER population-based cancer registries. Registry data were linked with LexisNexis consumer data to identify patients with a history of court-documented AFEs before cancer diagnosis. The association of AFEs and later-stage cancer diagnoses (stages III/IV) was assessed using separate sex-specific multivariable logistic regression. RESULTS Among 101,649 patients with cancer linked to LexisNexis data, 36,791 (36.2%) had a major AFE reported before diagnosis. The mean and median timing of the AFE closest to diagnosis were 93 and 77 months, respectively. AFEs were most common among non-Hispanic Black, unmarried, and low-income patients. Individuals with previous AFEs were more likely to be diagnosed with later-stage cancer than individuals with no AFE (males-odds ratio [OR], 1.09 [95% CI, 1.03 to 1.14]; P < .001; females-OR, 1.18 [95% CI, 1.13 to 1.24]; P < .0001) after adjusting for age, race, marital status, income, registry, and cancer type. Associations between AFEs prediagnosis and later-stage disease did not vary by AFE timing. CONCLUSION One third of newly diagnosed patients with cancer had a major AFE before their diagnosis. Patients with AFEs were more likely to have later-stage diagnosis, even accounting for traditional measures of socioeconomic status that influence the stage at diagnosis. The prevalence of prediagnosis AFEs underscores financial vulnerability of patients with cancer before their diagnosis, before any subsequent financial burden associated with cancer treatment.
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Affiliation(s)
- Joan L. Warren
- Division of Cancer Control and Population Science, National Cancer Institute, Bethesda, MD
| | - Angela B. Mariotto
- Division of Cancer Control and Population Science, National Cancer Institute, Bethesda, MD
| | | | - Amy J. Davidoff
- Division of Cancer Control and Population Science, National Cancer Institute, Bethesda, MD
| | - Veena Shankaran
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA
| | - Kevin C. Ward
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Xiao-Cheng Wu
- School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Stephen M. Schwartz
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA
| | - Lynne Penberthy
- Division of Cancer Control and Population Science, National Cancer Institute, Bethesda, MD
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Karanth S, Osazuwa-Peters OL, Wilson LE, Previs RA, Rahman F, Huang B, Pisu M, Liang M, Ward KC, Schymura MJ, Berchuck A, Akinyemiju TF. Health Care Access Dimensions and Racial Disparities in End-of-Life Care Quality among Patients with Ovarian Cancer. Cancer Res Commun 2024; 4:811-821. [PMID: 38441644 PMCID: PMC10946308 DOI: 10.1158/2767-9764.crc-23-0283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/22/2023] [Accepted: 02/15/2024] [Indexed: 03/20/2024]
Abstract
This study investigated the association between health care access (HCA) dimensions and racial disparities in end-of-life (EOL) care quality among non-Hispanic Black (NHB), non-Hispanic White (NHW), and Hispanic patients with ovarian cancer. This retrospective cohort study used the Surveillance, Epidemiology, and End Results-linked Medicare data for women diagnosed with ovarian cancer from 2008 to 2015, ages 65 years and older. Health care affordability, accessibility, and availability measures were assessed at the census tract or regional levels, and associations between these measures and quality of EOL care were examined using multivariable-adjusted regression models, as appropriate. The final sample included 4,646 women [mean age (SD), 77.5 (7.0) years]; 87.4% NHW, 6.9% NHB, and 5.7% Hispanic. In the multivariable-adjusted models, affordability was associated with a decreased risk of intensive care unit stay [adjusted relative risk (aRR) 0.90, 95% confidence interval (CI): 0.83-0.98] and in-hospital death (aRR 0.91, 95% CI: 0.84-0.98). After adjustment for HCA dimensions, NHB patients had lower-quality EOL care compared with NHW patients, defined as: increased risk of hospitalization in the last 30 days of life (aRR 1.16, 95% CI: 1.03-1.30), no hospice care (aRR 1.23, 95% CI: 1.04-1.44), in-hospital death (aRR 1.27, 95% CI: 1.03-1.57), and higher counts of poor-quality EOL care outcomes (count ratio:1.19, 95% CI: 1.04-1.36). HCA dimensions were strong predictors of EOL care quality; however, racial disparities persisted, suggesting that additional drivers of these disparities remain to be identified. SIGNIFICANCE Among patients with ovarian cancer, Black patients had lower-quality EOL care, even after adjusting for three structural barriers to HCA, namely affordability, availability, and accessibility. This suggests an important need to investigate the roles of yet unexplored barriers to HCA such as accommodation and acceptability, as drivers of poor-quality EOL care among Black patients with ovarian cancer.
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Affiliation(s)
- Shama Karanth
- UF Health Cancer Center, University of Florida, Gainesville, Florida
| | | | - Lauren E. Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Rebecca A. Previs
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
| | - Fariha Rahman
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
| | - Bin Huang
- Department of Biostatistics and Kentucky Cancer Registry, Univ of Kentucky, Lexington, Kentucky
| | - Maria Pisu
- Division of Preventive Medicine and O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Margaret Liang
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, and O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kevin C. Ward
- Georgia Cancer Registry, Emory University, Atlanta, Georgia
| | - Maria J. Schymura
- New York State Cancer Registry, New York State Department of Health, Albany, New York
| | - Andrew Berchuck
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
| | - Tomi F. Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
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4
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Miller-Kleinhenz JM, Barber LE, Maliniak ML, Moubadder L, Bliss M, Streiff MJ, Switchenko JM, Ward KC, McCullough LE. Historical Redlining, Persistent Mortgage Discrimination, and Race in Breast Cancer Outcomes. JAMA Netw Open 2024; 7:e2356879. [PMID: 38376843 PMCID: PMC10879950 DOI: 10.1001/jamanetworkopen.2023.56879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/28/2023] [Indexed: 02/21/2024] Open
Abstract
Importance Inequities created by historical and contemporary mortgage discriminatory policies have implications for health disparities. The role of persistent mortgage discrimination (PMD) in breast cancer (BC) outcomes has not been studied. Objective To estimate the race-specific association of historical redlining (HRL) with the development of BC subtypes and late-stage disease and a novel measure of PMD in BC mortality. Design, Setting, and Participants This population-based cohort study used Georgia Cancer Registry data. A total of 1764 non-Hispanic Black and White women with a BC diagnosis and residing in an area graded by the Home Owners' Loan Corporation (HOLC) in Georgia were included. Patients were excluded if they did not have a known subtype or a derived American Joint Committee on Cancer stage or if diagnosed solely by death certificate or autopsy. Participants were diagnosed with a first primary BC between January 1, 2010, to December 31, 2017, and were followed through December 31, 2019. Data were analyzed between May 1, 2022, and August 31, 2023. Exposures Scores for HRL were examined dichotomously as less than 2.5 (ie, nonredlined) vs 2.5 or greater (ie, redlined). Contemporary mortgage discrimination (CMD) scores were calculated, and PMD index was created using the combination of HRL and CMD scores. Main Outcomes and Measures Estrogen receptor (ER) status, late stage at diagnosis, and BC-specific death. Results This study included 1764 women diagnosed with BC within census tracts that were HOLC graded in Georgia. Of these, 856 women (48.5%) were non-Hispanic Black and 908 (51.5%) were non-Hispanic White; 1148 (65.1%) were diagnosed at 55 years or older; 538 (30.5%) resided in tracts with HRL scores less than 2.5; and 1226 (69.5%) resided in tracts with HRL scores 2.5 or greater. Living in HRL areas with HRL scores 2.5 or greater was associated with a 62% increased odds of ER-negative BC among non-Hispanic Black women (odds ratio [OR], 1.62 [95% CI, 1.01-2.60]), a 97% increased odds of late-stage diagnosis among non-Hispanic White women (OR, 1.97 [95% CI, 1.15-3.36]), and a 60% increase in BC mortality overall (hazard ratio, 1.60 [95% CI, 1.17-2.18]). Similarly, PMD was associated with BC mortality among non-Hispanic White women but not among non-Hispanic Black women. Conclusions and Relevance The findings of this cohort study suggest that historical racist policies and persistent discrimination have modern-day implications for BC outcomes that differ by race. These findings emphasize the need for a more nuanced investigation of the social and structural drivers of disparate BC outcomes.
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Affiliation(s)
| | - Lauren E. Barber
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Maret L. Maliniak
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Leah Moubadder
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Maya Bliss
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Micah J. Streiff
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jeffrey M. Switchenko
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lauren E. McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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5
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Barber LE, Maliniak ML, Nash R, Moubadder L, Haynes D, Ward KC, McCullough LE. A Comparison of Three Area-Level Indices of Neighborhood Deprivation and Socioeconomic Status and their Applicability to Breast Cancer Mortality. J Urban Health 2024; 101:75-79. [PMID: 38158547 PMCID: PMC10897108 DOI: 10.1007/s11524-023-00811-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 01/03/2024]
Abstract
Neighborhood deprivation indices are widely used in research, but the performance of these indices has rarely been directly compared in the same analysis. We examined the Area Deprivation Index, Neighborhood Deprivation Index, and Yost index, and compared their associations with breast cancer mortality. Indices were constructed for Georgia census block groups using 2011-2015 American Community Survey data. Pearson correlation coefficients and percent agreement were calculated. Associations between each index and breast cancer mortality were estimated among 36,795 women diagnosed with breast cancer using Cox proportional hazards regression. The indices were strongly correlated (absolute value of correlation coefficients > 0.77), exhibited moderate (41.4%) agreement, and were similarly associated with a 36% increase in breast cancer mortality. The similar associations with breast cancer mortality suggest the indices measure the same underlying construct, despite only moderate agreement. By understanding their correlations, agreement, and associations with health outcomes, researchers can choose the most appropriate index for analysis.
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Affiliation(s)
- Lauren E Barber
- Department of Epidemiology, Emory University Rollins School of Public Health, 1518 Clifton Road, Atlanta, Georgia, 30322, USA.
| | - Maret L Maliniak
- Department of Epidemiology, Emory University Rollins School of Public Health, 1518 Clifton Road, Atlanta, Georgia, 30322, USA
| | - Rebecca Nash
- Department of Epidemiology, Emory University Rollins School of Public Health, 1518 Clifton Road, Atlanta, Georgia, 30322, USA
| | - Leah Moubadder
- Department of Epidemiology, Emory University Rollins School of Public Health, 1518 Clifton Road, Atlanta, Georgia, 30322, USA
| | - David Haynes
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
| | - Kevin C Ward
- Department of Epidemiology, Emory University Rollins School of Public Health, 1518 Clifton Road, Atlanta, Georgia, 30322, USA
| | - Lauren E McCullough
- Department of Epidemiology, Emory University Rollins School of Public Health, 1518 Clifton Road, Atlanta, Georgia, 30322, USA
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Zaorsky NG, Proudfoot JA, Jia AY, Zuhour R, Vince Jr R, Liu Y, Zhao X, Hu J, Schussler NC, Stevens JL, Bentler S, Cress RD, Doherty JA, Durbin EB, Gershman S, Cheng I, Gonsalves L, Hernandez BY, Liu L, Morawski BM, Schymura M, Schwartz SM, Ward KC, Wiggins C, Wu XC, Shoag JE, Ponsky L, Dal Pra A, Schaeffer EM, Ross AE, Sun Y, Davicioni E, Petkov V, Spratt DE. Use of the Decipher genomic classifier among men with prostate cancer in the United States. JNCI Cancer Spectr 2023; 7:pkad052. [PMID: 37525535 PMCID: PMC10505256 DOI: 10.1093/jncics/pkad052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Management of localized or recurrent prostate cancer since the 1990s has been based on risk stratification using clinicopathological variables, including Gleason score, T stage (based on digital rectal exam), and prostate-specific antigen (PSA). In this study a novel prognostic test, the Decipher Prostate Genomic Classifier (GC), was used to stratify risk of prostate cancer progression in a US national database of men with prostate cancer. METHODS Records of prostate cancer cases from participating SEER (Surveillance, Epidemiology, and End Results) program registries, diagnosed during the period from 2010 through 2018, were linked to records of testing with the GC prognostic test. Multivariable analysis was used to quantify the association between GC scores or risk groups and use of definitive local therapy after diagnosis in the GC biopsy-tested cohort and postoperative radiotherapy in the GC-tested cohort as well as adverse pathological findings after prostatectomy. RESULTS A total of 572 545 patients were included in the analysis, of whom 8927 patients underwent GC testing. GC biopsy-tested patients were more likely to undergo active active surveillance or watchful waiting than untested patients (odds ratio [OR] =2.21, 95% confidence interval [CI] = 2.04 to 2.38, P < .001). The highest use of active surveillance or watchful waiting was for patients with a low-risk GC classification (41%) compared with those with an intermediate- (27%) or high-risk (11%) GC classification (P < .001). Among National Comprehensive Cancer Network patients with low and favorable-intermediate risk, higher GC risk class was associated with greater use of local therapy (OR = 4.79, 95% CI = 3.51 to 6.55, P < .001). Within this subset of patients who were subsequently treated with prostatectomy, high GC risk was associated with harboring adverse pathological findings (OR = 2.94, 95% CI = 1.38 to 6.27, P = .005). Use of radiation after prostatectomy was statistically significantly associated with higher GC risk groups (OR = 2.69, 95% CI = 1.89 to 3.84). CONCLUSIONS There is a strong association between use of the biopsy GC test and likelihood of conservative management. Higher genomic classifier scores are associated with higher rates of adverse pathology at time of surgery and greater use of postoperative radiotherapy.In this study the Decipher Prostate Genomic Classifier (GC) was used to analyze a US national database of men with prostate cancer. Use of the GC was associated with conservative management (ie, active surveillance). Among men who had high-risk GC scores and then had surgery, there was a 3-fold higher chance of having worrisome findings in surgical specimens.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | - Angela Y Jia
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Raed Zuhour
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Randy Vince Jr
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Yang Liu
- Veracyte, Inc, South San Francisco, CA, USA
| | - Xin Zhao
- Veracyte, Inc, South San Francisco, CA, USA
| | - Jim Hu
- Department of Urology, Weil Cornell Medicine, New York, NY, USA
| | | | | | | | - Rosemary D Cress
- Public Health Institute, Cancer Registry of Greater California, Sacramento, CA, USA
| | - Jennifer A Doherty
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Eric B Durbin
- Cancer Research Informatics Shared Resource Facility, Markey Cancer Center, Kentucky Cancer Registry, University of Kentucky, Lexington, KY, USA
| | | | - Iona Cheng
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Lou Gonsalves
- Connecticut Tumor Registry, Connecticut Department of Public Health, Hartford, CT, USA
| | | | - Lihua Liu
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Maria Schymura
- School of Public Health Epidemiology & Biostatistics, University at Albany, State University of New York, NY, USA
| | - Stephen M Schwartz
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Kevin C Ward
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Charles Wiggins
- Department of Internal Medicine, University of NM, Albuquerque, NM, USA
| | - Xiao-Cheng Wu
- Department of Epidemiology, School of Medicine, Louisiana State University, New Orleans, LA, USA
| | - Jonathan E Shoag
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Lee Ponsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Alan Dal Pra
- Department of Radiation Oncology, University of Miami, Miami, FL, USA
| | | | - Ashley E Ross
- Department of Urology, Northwestern University, Chicago, IL, USA
| | - Yilun Sun
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | - Valentina Petkov
- Surveillance Research Program, National Cancer Institute, Bethesda, MD, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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7
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Mullins MA, Atluri N, Abrahamse P, Radhakrishnan A, Hamilton AS, Ward KC, Hawley ST, Katz SJ, Wallner LP. Primary care provider attitudes about and tendency to use non-recommended surveillance tests after curative breast cancer treatment. Breast Cancer Res Treat 2023; 200:391-398. [PMID: 37296280 PMCID: PMC10706825 DOI: 10.1007/s10549-023-06994-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Little is known about the factors contributing to the receipt of non-recommended surveillance testing among early-stage breast cancer survivors. We assessed primary care providers (PCP) attitudes about and tendency to order non-recommended surveillance testing for asymptomatic early-stage breast cancer survivors post-adjuvant chemotherapy. METHODS A stratified random sample of PCPs identified by early-stage breast cancer survivors were surveyed (N = 518, 61% response rate). PCPs were asked how likely they would be to order bone scans, imaging and/or tumor marker testing using a clinical vignette of an early-stage asymptomatic patient where these tests are non-recommended. A composite tendency to order score was created and categorized by tertiles (low, moderate, high). PCP-reported factors associated with high and moderate tendency to order non-recommended testing (vs. low) were estimated using multivariable, multinomial logistic regression. RESULTS In this sample, 26% reported a high tendency to order non-recommended surveillance tests during survivorship for early-stage breast cancer survivors. PCPs who identified as family practice physicians and PCPs reporting more confidence in ordering surveillance testing were more likely to report a high tendency to order non-recommended testing (vs. low) ((aOR family practice 2.09, CI 1.2, 3.8; aOR more confidence 1.9, CI 1.1, 3.3). CONCLUSIONS In this population-based sample of PCPs caring for breast cancer survivors, over a quarter of PCPs reported they would order non-recommended surveillance testing for asymptomatic early-stage breast cancer survivors. Efforts to better support PCPs and disseminate information about appropriate surveillance for cancer survivors are warranted.
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Affiliation(s)
- Megan A Mullins
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Paul Abrahamse
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Archana Radhakrishnan
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ann S Hamilton
- Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Kevin C Ward
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Sarah T Hawley
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Department of Health Behavior and Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Steven J Katz
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Lauren P Wallner
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48109, USA.
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
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8
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Ge L, Zhang Y, Ward KC, Lash TL, Waller LA, Lyles RH. Tailoring capture-recapture methods to estimate registry-based case counts based on error-prone diagnostic signals. Stat Med 2023; 42:2928-2943. [PMID: 37158167 PMCID: PMC10766101 DOI: 10.1002/sim.9759] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/13/2023] [Accepted: 04/19/2023] [Indexed: 05/10/2023]
Abstract
Surveillance research is of great importance for effective and efficient epidemiological monitoring of case counts and disease prevalence. Taking specific motivation from ongoing efforts to identify recurrent cases based on the Georgia Cancer Registry, we extend recently proposed "anchor stream" sampling design and estimation methodology. Our approach offers a more efficient and defensible alternative to traditional capture-recapture (CRC) methods by leveraging a relatively small random sample of participants whose recurrence status is obtained through a principled application of medical records abstraction. This sample is combined with one or more existing signaling data streams, which may yield data based on arbitrarily non-representative subsets of the full registry population. The key extension developed here accounts for the common problem of false positive or negative diagnostic signals from the existing data stream(s). In particular, we show that the design only requires documentation of positive signals in these non-anchor surveillance streams, and permits valid estimation of the true case count based on an estimable positive predictive value (PPV) parameter. We borrow ideas from the multiple imputation paradigm to provide accompanying standard errors, and develop an adapted Bayesian credible interval approach that yields favorable frequentist coverage properties. We demonstrate the benefits of the proposed methods through simulation studies, and provide a data example targeting estimation of the breast cancer recurrence case count among Metro Atlanta area patients from the Georgia Cancer Registry-based Cancer Recurrence Information and Surveillance Program (CRISP) database.
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Affiliation(s)
- Lin Ge
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Yuzi Zhang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Timothy L. Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lance A. Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Robert H. Lyles
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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9
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Kurian AW, Abrahamse P, Furgal A, Ward KC, Hamilton AS, Hodan R, Tocco R, Liu L, Berek JS, Hoang L, Yussuf A, Susswein L, Esplin ED, Slavin TP, Gomez SL, Hofer TP, Katz SJ. Germline Genetic Testing After Cancer Diagnosis. JAMA 2023; 330:43-51. [PMID: 37276540 PMCID: PMC10242510 DOI: 10.1001/jama.2023.9526] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/18/2023] [Indexed: 06/07/2023]
Abstract
Importance Germline genetic testing is recommended by practice guidelines for patients diagnosed with cancer to enable genetically targeted treatment and identify relatives who may benefit from personalized cancer screening and prevention. Objective To describe the prevalence of germline genetic testing among patients diagnosed with cancer in California and Georgia between 2013 and 2019. Design, Setting, and Participants Observational study including patients aged 20 years or older who had been diagnosed with any type of cancer between January 1, 2013, and March 31, 2019, that was reported to statewide Surveillance, Epidemiology, and End Results registries in California and Georgia. These patients were linked to genetic testing results from 4 laboratories that performed most germline testing for California and Georgia. Main Outcomes and Measures The primary outcome was germline genetic testing within 2 years of a cancer diagnosis. Testing trends were analyzed with logistic regression modeling. The results of sequencing each gene, including variants associated with increased cancer risk (pathogenic results) and variants whose cancer risk association was unknown (uncertain results), were evaluated. The genes were categorized according to their primary cancer association, including breast or ovarian, gastrointestinal, and other, and whether practice guidelines recommended germline testing. Results Among 1 369 602 patients diagnosed with cancer between 2013 and 2019 in California and Georgia, 93 052 (6.8%) underwent germline testing through March 31, 2021. The proportion of patients tested varied by cancer type: male breast (50%), ovarian (38.6%), female breast (26%), multiple (7.5%), endometrial (6.4%), pancreatic (5.6%), colorectal (5.6%), prostate (1.1%), and lung (0.3%). In a logistic regression model, compared with the 31% (95% CI, 30%-31%) of non-Hispanic White patients with male breast cancer, female breast cancer, or ovarian cancer who underwent testing, patients of other races and ethnicities underwent testing less often: 22% (95% CI, 21%-22%) of Asian patients, 25% (95% CI, 24%-25%) of Black patients, and 23% (95% CI, 23%-23%) of Hispanic patients (P < .001 using the χ2 test). Of all pathogenic results, 67.5% to 94.9% of variants were identified in genes for which practice guidelines recommend testing and 68.3% to 83.8% of variants were identified in genes associated with the diagnosed cancer type. Conclusions and Relevance Among patients diagnosed with cancer in California and Georgia between 2013 and 2019, only 6.8% underwent germline genetic testing. Compared with non-Hispanic White patients, rates of testing were lower among Asian, Black, and Hispanic patients.
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Affiliation(s)
- Allison W. Kurian
- Department of Medicine, School of Medicine, Stanford University, Stanford, California
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California
| | - Paul Abrahamse
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | - Allison Furgal
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ann S. Hamilton
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles
| | - Rachel Hodan
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California
| | - Rachel Tocco
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Lihua Liu
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles
| | - Jonathan S. Berek
- Department of Obstetrics and Gynecology, School of Medicine, Stanford University, Stanford, California
| | | | | | | | | | | | - Scarlett L. Gomez
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco
| | - Timothy P. Hofer
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Steven J. Katz
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
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10
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Modi PK, Ward KC, Filson CP. Characteristics of prostate cancer patients captured by facility-based versus geography-based cancer registries. Urol Oncol 2023; 41:324.e1-324.e7. [PMID: 37150737 DOI: 10.1016/j.urolonc.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/15/2023] [Accepted: 04/09/2023] [Indexed: 05/09/2023]
Abstract
PURPOSE We determined differences in demographics, tumor factors, and treatment patterns of prostate cancer patients in a geographic-based cancer registry based on eligibility for a facility-based cancer registry system. METHODS We identified prostate cancer patients captured by the Surveillance, Epidemiology, and End Results (SEER) database from 2018 to 2019. Our exposure was receipt of cancer care at a facility accredited by the American College of Surgeons' Commission on Cancer (CoC) providing eligibility for inclusion in the National Cancer Database (NCDB). Outcomes included patient demographics, tumor factors (e.g., biopsy grade), and treatment with radical prostatectomy. RESULTS We identified 113,733 prostate cancer patients of whom 65,708 (57%) were NCDB-eligible with an analytic abstract, and 11,010 (10%) were NCDB-eligible without an analytic abstract. NCDB-eligible men were younger (67.0 vs. 68.1 years, P < 0.001), less likely to be Hispanic/Latino (8.7% vs. 13.2%, P < 0.001), and more likely in a county with median income over $75,000 (40.9% vs. 30.0%, P < 0.001). NCDB eligibility varied widely by registry, from 95.9% in Connecticut to 42.6% in Utah. NCDB-ineligible patients were more likely to have unknown stage (17.2% vs. 2.9% NCDB-eligible) and missing PSA (22.9% vs 9.3% NCDB-eligible). NCDB-eligible men were less likely to have Grade Group 1 cancer on biopsy (28.2% vs. 39.2%, P < 0.001). Treatment with prostatectomy was more common among NCDB-eligible patients for low-risk (19.6% vs. 8.8%, adjusted OR 2.30, 95% CI 1.72-6.66) and high-risk tumors (43.5% vs. 26.0%, adjusted OR 1.95, 95% CI 1.33-2.86). CONCLUSION Compared NCDB-ineligible patients, those eligible for inclusion in the NCDB have important differences in demographics, eligibility for active surveillance, and treatment patterns. Generalizations related to epidemiologic trends, practice patterns, and outcomes for this select population should be interpreted with caution.
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Affiliation(s)
- Parth K Modi
- Department of Surgery, Section of Urology, University of Chicago, Chicago, IL
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA; Winship Cancer Institute, Emory Healthcare, Atlanta, GA
| | - Christopher P Filson
- Winship Cancer Institute, Emory Healthcare, Atlanta, GA; Department of Urology, Emory University School of Medicine, Atlanta, GA.
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11
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Bailey CN, Martin BJ, Petkov VI, Schussler NC, Stevens JL, Bentler S, Cress RD, Doherty JA, Durbin EB, Gomez SL, Gonsalves L, Hernandez BY, Liu L, Morawski BM, Schymura MJ, Schwartz SM, Ward KC, Wiggins C, Wu XC, Goldberg MS, Siegel JJ, Cook RW, Covington KR, Kurley SJ. 31-Gene Expression Profile Testing in Cutaneous Melanoma and Survival Outcomes in a Population-Based Analysis: A SEER Collaboration. JCO Precis Oncol 2023; 7:e2300044. [PMID: 37384864 PMCID: PMC10530886 DOI: 10.1200/po.23.00044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/12/2023] [Accepted: 05/15/2023] [Indexed: 07/01/2023] Open
Abstract
PURPOSE The DecisionDx-Melanoma 31-gene expression profile (31-GEP) test is validated to classify cutaneous malignant melanoma (CM) patient risk of recurrence, metastasis, or death as low (class 1A), intermediate (class 1B/2A), or high (class 2B). This study aimed to examine the effect of 31-GEP testing on survival outcomes and confirm the prognostic ability of the 31-GEP at the population level. METHODS Patients with stage I-III CM with a clinical 31-GEP result between 2016 and 2018 were linked to data from 17 SEER registries (n = 4,687) following registries' operation procedures for linkages. Melanoma-specific survival (MSS) and overall survival (OS) differences by 31-GEP risk category were examined using Kaplan-Meier analysis and the log-rank test. Crude and adjusted hazard ratios (HRs) were calculated using Cox regression model to evaluate variables associated with survival. 31-GEP tested patients were propensity score-matched to a cohort of non-31-GEP tested patients from the SEER database. Robustness of the effect of 31-GEP testing was assessed using resampling. RESULTS Patients with a 31-GEP class 1A result had higher 3-year MSS and OS than patients with a class 1B/2A or class 2B result (MSS: 99.7% v 97.1% v 89.6%, P < .001; OS: 96.6% v 90.2% v 79.4%, P < .001). A class 2B result was an independent predictor of MSS (HR, 7.00; 95% CI, 2.70 to 18.00) and OS (HR, 2.39; 95% CI, 1.54 to 3.70). 31-GEP testing was associated with a 29% lower MSS mortality (HR, 0.71; 95% CI, 0.53 to 0.94) and 17% lower overall mortality (HR, 0.83; 95% CI, 0.70 to 0.99) relative to untested patients. CONCLUSION In a population-based, clinically tested melanoma cohort, the 31-GEP stratified patients by their risk of dying from melanoma.
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Affiliation(s)
| | | | - Valentina I. Petkov
- Surveillance Research Program, Division of Cancer Control & Population Sciences, National Cancer Institute, Bethesda, MD
| | | | | | | | - Rosemary D. Cress
- Public Health Institute, Cancer Registry of Greater California, Sacramento, CA
| | - Jennifer A. Doherty
- Hunstman Cancer Institute, University of Utah, Salt Lake City, UT
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT
| | - Eric B. Durbin
- Cancer Research Informatics Shared Resource Facility, Markey Cancer Center, Kentucky Cancer Registry, University of Kentucky, KY
| | - Scarlett L. Gomez
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Lou Gonsalves
- Connecticut Tumor Registry, Connecticut Department of Public Health, Hartford, CT
| | | | - Lihua Liu
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Maria J. Schymura
- Bureau of Cancer Epidemiology, New York State Department of Health, Albany, NY
- School of Public Health Epidemiology & Biostatistics, University at Albany, State University of New York, New York, NY
| | - Stephen M. Schwartz
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA
| | | | - Charles Wiggins
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM
| | - Xiao-Cheng Wu
- Louisiana State University, School of Medicine, New Orleans, LA
| | - Matthew S. Goldberg
- Castle Biosciences, Inc, Friendswood, TX
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, Mount Sinai, NY
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12
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Katz SJ, Abrahamse P, Hodan R, Kurian AW, Rankin A, Tocco RS, Rios-Ventura S, Ward KC, An LC. Cascade Genetic Risk Education and Testing in Families With Hereditary Cancer Syndromes: A Pilot Study. JCO Oncol Pract 2023; 19:e848-e858. [PMID: 36921235 PMCID: PMC10332838 DOI: 10.1200/op.22.00677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/07/2023] [Indexed: 03/17/2023] Open
Abstract
PURPOSE Cascade genetic risk evaluation in families with hereditary cancer can reduce the burden of disease but the rate of germline genetic testing in relatives of patients at risk is low. METHODS We identified all 277 women diagnosed with breast cancer in Georgia in 2017 who linked to a clinically actionable germline pathogenic variant through a Surveillance, Epidemiology, and End Results registry-variant linkage initiative. We surveyed them, and then invited eligible respondents to an online platform hosted by a navigator that offered cancer genetic risk education and germline genetic testing to untested relatives. We randomly assigned patient-family clusters at the time of the patient enrollment offer to free versus $50 (USD) test cost. Patients invited relatives to join the study through personalized e-mail. Enrolled relatives received online cancer genetic education and the opportunity to order clinical germline genetic testing through the platform. The primary outcome was the number of relatives who ordered genetic testing. RESULTS One hundred twenty-five of 277 patients completed surveys (45.2%). Most respondents were eligible for the trial offer (113 of 125; 90.4%). In the free testing arm, 20 of 56 eligible patients participated (35.7% of eligible respondents) and they invited 28 relatives: 12 relatives enrolled and 10 ordered testing. In the $50 (USD) arm, 16 of 57 eligible patients participated (28.1%) and they invited 38 relatives: 18 relatives enrolled and 17 ordered testing. CONCLUSION Cascade genetic testing in families with hereditary cancer syndromes accrued through a population-based cancer registry can be achieved through an online platform that offers genetic risk education and low-cost testing to relatives. A modest charge did not appear to influence the percentage of participating patients, numbers of participating relatives, and numbers of relatives who received genetic testing.
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Affiliation(s)
- Steven J. Katz
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Department of Health Management and Policy, School of Public Health, University of Michigan Ann Arbor, MI
| | - Paul Abrahamse
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Rachel Hodan
- Cancer Genetics, Stanford Health Care, Stanford, CA
| | - Allison W. Kurian
- Department of Medicine, Stanford University, Stanford, CA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA
| | - Aaron Rankin
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Rachel S. Tocco
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Sonia Rios-Ventura
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Lawrence C. An
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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13
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Ghazal LV, Abrahamse P, Ward KC, Morris AM, Hawley ST, Veenstra CM. Financial Toxicity and Its Association With Health-Related Quality of Life Among Partners of Colorectal Cancer Survivors. JAMA Netw Open 2023; 6:e235897. [PMID: 37022684 PMCID: PMC10080378 DOI: 10.1001/jamanetworkopen.2023.5897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/31/2023] [Indexed: 04/07/2023] Open
Abstract
Importance Partners of colorectal cancer (CRC) survivors play a critical role in diagnosis, treatment, and survivorship. While financial toxicity (FT) is well documented among patients with CRC, little is known about long-term FT and its association with health-related quality of life (HRQoL) among their partners. Objective To understand long-term FT and its association with HRQoL among partners of CRC survivors. Design, Setting, and Participants This survey study incorporating a mixed-methods design consisted of a mailed dyadic survey with closed- and open-ended responses. In 2019 and 2020, we surveyed survivors who were 1 to 5 years from a stage III CRC diagnosis and included a separate survey for their partners. Patients were recruited from a rural community oncology practice in Montana, an academic cancer center in Michigan, and the Georgia Cancer Registry. Data analysis was performed from February 2022 to January 2023. Exposures Three components of FT, including financial burden, debt, and financial worry. Main Outcomes and Measures Financial burden was assessed with the Personal Financial Burden scale, whereas debt and financial worry were each assessed with a single survey item. We measured HRQoL using the PROMIS-29+2 Profile, version 2.1. We used multivariable regression analysis to assess associations of FT with individual domains of HRQoL. We used thematic analysis to explore partner perspectives on FT, and we merged quantitative and qualitative findings to explain the association between FT and HRQoL. Results Of the 986 patients eligible for this study, 501 (50.8%) returned surveys. A total of 428 patients (85.4%) reported having a partner, and 311 partners (72.6%) returned surveys. Four partner surveys were returned without a corresponding patient survey, resulting in a total of 307 patient-partner dyads for this analysis. Among the 307 partners, 166 (56.1%) were aged younger than 65 years (mean [SD] age, 63.7 [11.1] years), 189 (62.6%) were women, and 263 (85.7%) were White. Most partners (209 [68.1%]) reported adverse financial outcomes. High financial burden was associated with worse HRQoL in the pain interference domain (mean [SE] score, -0.08 [0.04]; P = .03). Debt was associated with worse HRQoL in the sleep disturbance domain (-0.32 [0.15]; P = .03). High financial worry was associated with worse HRQoL in the social functioning (mean [SE] score, -0.37 [0.13]; P = .005), fatigue (-0.33 [0.15]; P = .03), and pain interference (-0.33 [0.14]; P = .02) domains. Qualitative findings revealed that in addition to systems-level factors, individual-level behavioral factors were associated with partner financial outcomes and HRQoL. Conclusions and Relevance This survey study found that partners of CRC survivors experienced long-term FT that was associated with worse HRQoL. Multilevel interventions for both patients and partners are needed to address factors at individual and systemic levels and incorporate behavioral approaches.
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Affiliation(s)
- Lauren V. Ghazal
- Department of Systems, Populations, and Leadership, School of Nursing, University of Michigan, Ann Arbor
| | - Paul Abrahamse
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Arden M. Morris
- Department of Surgery, Stanford University, Stanford, California
| | - Sarah T. Hawley
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Christine M. Veenstra
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
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14
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Girardi F, Matz M, Stiller C, You H, Marcos Gragera R, Valkov MY, Bulliard JL, De P, Morrison D, Wanner M, O'Brian DK, Saint-Jacques N, Coleman MP, Allemani C, Hamdi-Chérif M, Kara L, Meguenni K, Regagba D, Bayo S, Cheick Bougadari T, Manraj SS, Bendahhou K, Ladipo A, Ogunbiyi OJ, Somdyala NIM, Chaplin MA, Moreno F, Calabrano GH, Espinola SB, Carballo Quintero B, Fita R, Laspada WD, Ibañez SG, Lima CA, Da Costa AM, De Souza PCF, Chaves J, Laporte CA, Curado MP, de Oliveira JC, Veneziano CLA, Veneziano DB, Almeida ABM, Latorre MRDO, Rebelo MS, Santos MO, Azevedo e Silva G, Galaz JC, Aparicio Aravena M, Sanhueza Monsalve J, Herrmann DA, Vargas S, Herrera VM, Uribe CJ, Bravo LE, Garcia LS, Arias-Ortiz NE, Morantes D, Jurado DM, Yépez Chamorro MC, Delgado S, Ramirez M, Galán Alvarez YH, Torres P, Martínez-Reyes F, Jaramillo L, Quinto R, Castillo J, Mendoza M, Cueva P, Yépez JG, Bhakkan B, Deloumeaux J, Joachim C, Macni J, Carrillo R, Shalkow Klincovstein J, Rivera Gomez R, Perez P, Poquioma E, Tortolero-Luna G, Zavala D, Alonso R, Barrios E, Eckstrand A, Nikiforuk C, Woods RR, Noonan G, Turner D, Kumar E, Zhang B, Dowden JJ, Doyle GP, Saint-Jacques N, Walsh G, Anam A, De P, McClure CA, Vriends KA, Bertrand C, Ramanakumar AV, Davis L, Kozie S, Freeman T, George JT, Avila RM, O’Brien DK, Holt A, Almon L, Kwong S, Morris C, Rycroft R, Mueller L, Phillips CE, Brown H, Cromartie B, Ruterbusch J, Schwartz AG, Levin GM, Wohler B, Bayakly R, Ward KC, Gomez SL, McKinley M, Cress R, Davis J, Hernandez B, Johnson CJ, Morawski BM, Ruppert LP, Bentler S, Charlton ME, Huang B, Tucker TC, Deapen D, Liu L, Hsieh MC, Wu XC, Schwenn M, Stern K, Gershman ST, Knowlton RC, Alverson G, Weaver T, Desai J, Rogers DB, Jackson-Thompson J, Lemons D, Zimmerman HJ, Hood M, Roberts-Johnson J, Hammond W, Rees JR, Pawlish KS, Stroup A, Key C, Wiggins C, Kahn AR, Schymura MJ, Radhakrishnan S, Rao C, Giljahn LK, Slocumb RM, Dabbs C, Espinoza RE, Aird KG, Beran T, Rubertone JJ, Slack SJ, Oh J, Janes TA, Schwartz SM, Chiodini SC, Hurley DM, Whiteside MA, Rai S, Williams MA, Herget K, Sweeney C, Kachajian J, Keitheri Cheteri MB, Migliore Santiago P, Blankenship SE, Conaway JL, Borchers R, Malicki R, Espinoza J, Grandpre J, Weir HK, Wilson R, Edwards BK, Mariotto A, Rodriguez-Galindo C, Wang N, Yang L, Chen JS, Zhou Y, He YT, Song GH, Gu XP, Mei D, Mu HJ, Ge HM, Wu TH, Li YY, Zhao DL, Jin F, Zhang JH, Zhu FD, Junhua Q, Yang YL, Jiang CX, Biao W, Wang J, Li QL, Yi H, Zhou X, Dong J, Li W, Fu FX, Liu SZ, Chen JG, Zhu J, Li YH, Lu YQ, Fan M, Huang SQ, Guo GP, Zhaolai H, Wei K, Chen WQ, Wei W, Zeng H, Demetriou AV, Mang WK, Ngan KC, Kataki AC, Krishnatreya M, Jayalekshmi PA, Sebastian P, George PS, Mathew A, Nandakumar A, Malekzadeh R, Roshandel G, Keinan-Boker L, Silverman BG, Ito H, Koyanagi Y, Sato M, Tobori F, Nakata I, Teramoto N, Hattori M, Kaizaki Y, Moki F, Sugiyama H, Utada M, Nishimura M, Yoshida K, Kurosawa K, Nemoto Y, Narimatsu H, Sakaguchi M, Kanemura S, Naito M, Narisawa R, Miyashiro I, Nakata K, Mori D, Yoshitake M, Oki I, Fukushima N, Shibata A, Iwasa K, Ono C, Matsuda T, Nimri O, Jung KW, Won YJ, Alawadhi E, Elbasmi A, Ab Manan A, Adam F, Nansalmaa E, Tudev U, Ochir C, Al Khater AM, El Mistiri MM, Lim GH, Teo YY, Chiang CJ, Lee WC, Buasom R, Sangrajrang S, Suwanrungruang K, Vatanasapt P, Daoprasert K, Pongnikorn D, Leklob A, Sangkitipaiboon S, Geater SL, Sriplung H, Ceylan O, Kög I, Dirican O, Köse T, Gurbuz T, Karaşahin FE, Turhan D, Aktaş U, Halat Y, Eser S, Yakut CI, Altinisik M, Cavusoglu Y, Türkköylü A, Üçüncü N, Hackl M, Zborovskaya AA, Aleinikova OV, Henau K, Van Eycken L, Atanasov TY, Valerianova Z, Šekerija M, Dušek L, Zvolský M, Steinrud Mørch L, Storm H, Wessel Skovlund C, Innos K, Mägi M, Malila N, Seppä K, Jégu J, Velten M, Cornet E, Troussard X, Bouvier AM, Guizard AV, Bouvier V, Launoy G, Dabakuyo Yonli S, Poillot ML, Maynadié M, Mounier M, Vaconnet L, Woronoff AS, Daoulas M, Robaszkiewicz M, Clavel J, Poulalhon C, Desandes E, Lacour B, Baldi I, Amadeo B, Coureau G, Monnereau A, Orazio S, Audoin M, D’Almeida TC, Boyer S, Hammas K, Trétarre B, Colonna M, Delafosse P, Plouvier S, Cowppli-Bony A, Molinié F, Bara S, Ganry O, Lapôtre-Ledoux B, Daubisse-Marliac L, Bossard N, Uhry Z, Estève J, Stabenow R, Wilsdorf-Köhler H, Eberle A, Luttmann S, Löhden I, Nennecke AL, Kieschke J, Sirri E, Justenhoven C, Reinwald F, Holleczek B, Eisemann N, Katalinic A, Asquez RA, Kumar V, Petridou E, Ólafsdóttir EJ, Tryggvadóttir L, Murray DE, Walsh PM, Sundseth H, Harney M, Mazzoleni G, Vittadello F, Coviello E, Cuccaro F, Galasso R, Sampietro G, Giacomin A, Magoni M, Ardizzone A, D’Argenzio A, Di Prima AA, Ippolito A, Lavecchia AM, Sutera Sardo A, Gola G, Ballotari P, Giacomazzi E, Ferretti S, Dal Maso L, Serraino D, Celesia MV, Filiberti RA, Pannozzo F, Melcarne A, Quarta F, Andreano A, Russo AG, Carrozzi G, Cirilli C, Cavalieri d’Oro L, Rognoni M, Fusco M, Vitale MF, Usala M, Cusimano R, Mazzucco W, Michiara M, Sgargi P, Boschetti L, Marguati S, Chiaranda G, Seghini P, Maule MM, Merletti F, Spata E, Tumino R, Mancuso P, Cassetti T, Sassatelli R, Falcini F, Giorgetti S, Caiazzo AL, Cavallo R, Piras D, Bella F, Madeddu A, Fanetti AC, Maspero S, Carone S, Mincuzzi A, Candela G, Scuderi T, Gentilini MA, Rizzello R, Rosso S, Caldarella A, Intrieri T, Bianconi F, Contiero P, Tagliabue G, Rugge M, Zorzi M, Beggiato S, Brustolin A, Gatta G, De Angelis R, Vicentini M, Zanetti R, Stracci F, Maurina A, Oniščuka M, Mousavi M, Steponaviciene L, Vincerževskienė I, Azzopardi MJ, Calleja N, Siesling S, Visser O, Johannesen TB, Larønningen S, Trojanowski M, Macek P, Mierzwa T, Rachtan J, Rosińska A, Kępska K, Kościańska B, Barna K, Sulkowska U, Gebauer T, Łapińska JB, Wójcik-Tomaszewska J, Motnyk M, Patro A, Gos A, Sikorska K, Bielska-Lasota M, Didkowska JA, Wojciechowska U, Forjaz de Lacerda G, Rego RA, Carrito B, Pais A, Bento MJ, Rodrigues J, Lourenço A, Mayer-da-Silva A, Coza D, Todescu AI, Valkov MY, Gusenkova L, Lazarevich O, Prudnikova O, Vjushkov DM, Egorova A, Orlov A, Pikalova LV, Zhuikova LD, Adamcik J, Safaei Diba C, Zadnik V, Žagar T, De-La-Cruz M, Lopez-de-Munain A, Aleman A, Rojas D, Chillarón RJ, Navarro AIM, Marcos-Gragera R, Puigdemont M, Rodríguez-Barranco M, Sánchez Perez MJ, Franch Sureda P, Ramos Montserrat M, Chirlaque López MD, Sánchez Gil A, Ardanaz E, Guevara M, Cañete-Nieto A, Peris-Bonet R, Carulla M, Galceran J, Almela F, Sabater C, Khan S, Pettersson D, Dickman P, Staehelin K, Struchen B, Egger Hayoz C, Rapiti E, Schaffar R, Went P, Mousavi SM, Bulliard JL, Maspoli-Conconi M, Kuehni CE, Redmond SM, Bordoni A, Ortelli L, Chiolero A, Konzelmann I, Rohrmann S, Wanner M, Broggio J, Rashbass J, Stiller C, Fitzpatrick D, Gavin A, Morrison DS, Thomson CS, Greene G, Huws DW, Grayson M, Rawcliffe H, Allemani C, Coleman MP, Di Carlo V, Girardi F, Matz M, Minicozzi P, Sanz N, Ssenyonga N, James D, Stephens R, Chalker E, Smith M, Gugusheff J, You H, Qin Li S, Dugdale S, Moore J, Philpot S, Pfeiffer R, Thomas H, Silva Ragaini B, Venn AJ, Evans SM, Te Marvelde L, Savietto V, Trevithick R, Aitken J, Currow D, Fowler C, Lewis C. Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3). Neuro Oncol 2023; 25:580-592. [PMID: 36355361 PMCID: PMC10013649 DOI: 10.1093/neuonc/noac217] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology. METHODS We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator. RESULTS The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults. CONCLUSIONS To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.
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Affiliation(s)
- Fabio Girardi
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, London, UK.,Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK.,Division of Medical Oncology 2, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Melissa Matz
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Charles Stiller
- National Cancer Registration and Analysis Service, Public Health England, London, UK
| | - Hui You
- Cancer Information Analysis Unit, Cancer Institute NSW, St Leonards, New South Wales, Australia
| | - Rafael Marcos Gragera
- Epidemiology Unit and Girona Cancer Registry, Catalan Institute of Oncology, Girona, Spain
| | - Mikhail Y Valkov
- Department of Radiology, Radiotherapy and Oncology, Northern State Medical University, Arkhangelsk, Russia
| | - Jean-Luc Bulliard
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.,Neuchâtel and Jura Tumour Registry, Neuchâtel, Switzerland
| | - Prithwish De
- Surveillance and Cancer Registry, and Research Office, Clinical Institutes and Quality Programs, Ontario Health, Toronto, Ontario, Canada
| | - David Morrison
- Scottish Cancer Registry, Public Health Scotland, Edinburgh, UK
| | - Miriam Wanner
- Cancer Registry Zürich, Zug, Schaffhausen and Schwyz, University Hospital Zürich, Zürich, Switzerland
| | - David K O'Brian
- Alaska Cancer Registry, Alaska Department of Health and Social Services, Anchorage, Alaska, USA
| | - Nathalie Saint-Jacques
- Department of Medicine and Community Health and Epidemiology, Centre for Clinical Research, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michel P Coleman
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, London, UK.,Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Claudia Allemani
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, London, UK
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15
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Aggarwal A, Rama R, Dhillon PK, Deepa M, Kondal D, Kaushik N, Bumb D, Mehrotra R, Kohler BA, Mohan V, Gillespie TW, Patel AV, Rajaraman S, Prabhakaran D, Ward KC, Goodman M. Linking population-based cohorts with cancer registries in LMIC: a case study and lessons learnt in India. BMJ Open 2023; 13:e068644. [PMID: 36878651 PMCID: PMC9990691 DOI: 10.1136/bmjopen-2022-068644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
OBJECTIVES In resource-constrained settings, cancer epidemiology research typically relies on self-reported diagnoses. To test a more systematic alternative approach, we assessed the feasibility of linking a cohort with a cancer registry. SETTING Data linkage was performed between a population-based cohort in Chennai, India, with a local population-based cancer registry. PARTICIPANTS Data set of Centre for Cardiometabolic Risk Reduction in South-Asia (CARRS) cohort participants (N=11 772) from Chennai was linked with the cancer registry data set for the period 1982-2015 (N=140 986). METHODS AND OUTCOME MEASURES Match*Pro, a probabilistic record linkage software, was used for computerised linkages followed by manual review of high scoring records. The variables used for linkage included participant name, gender, age, address, Postal Index Number and father's and spouse's name. Registry records between 2010 and 2015 and between 1982 and 2015, respectively, represented incident and all (both incident and prevalent) cases. The extent of agreement between self-reports and registry-based ascertainment was expressed as the proportion of cases found in both data sets among cases identified independently in each source. RESULTS There were 52 self-reported cancer cases among 11 772 cohort participants, but 5 cases were misreported. Of the remaining 47 eligible self-reported cases (incident and prevalent), 37 (79%) were confirmed by registry linkage. Among 29 self-reported incident cancers, 25 (86%) were found in the registry. Registry linkage also identified 24 previously not reported cancers; 12 of those were incident cases. The likelihood of linkage was higher in more recent years (2014-2015). CONCLUSIONS Although linkage variables in this study had limited discriminatory power in the absence of a unique identifier, an appreciable proportion of self-reported cases were confirmed in the registry via linkages. More importantly, the linkages also identified many previously unreported cases. These findings offer new insights that can inform future cancer surveillance and research in low-income and middle-income countries.
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Affiliation(s)
- Aastha Aggarwal
- The Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurugram, Haryana, India
- Centre for Chronic Disease Control, Dwarka, Delhi, India
| | | | - Preet K Dhillon
- The Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurugram, Haryana, India
- Centre for Chronic Disease Control, Dwarka, Delhi, India
- Genentech Inc, South San Francisco, California, USA
| | - Mohan Deepa
- Madras Diabetes Research Foundation (ICMR Center for Advanced Research on Diabetes), Chennai, Tamil Nadu, India
| | - Dimple Kondal
- Centre for Chronic Disease Control, Dwarka, Delhi, India
| | - Naveen Kaushik
- Centre for Chronic Disease Control, Dwarka, Delhi, India
| | - Dipika Bumb
- Ramaiah International Centre for Public Health Innovations, Bengaluru, Karnataka, India
| | - Ravi Mehrotra
- Centre for Health, Innovation and Policy, Noida, Uttar Pradesh, India
- Department of Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Betsy A Kohler
- North American Association of Central Cancer Registries, Springfield, Illinois, USA
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation (ICMR Center for Advanced Research on Diabetes), Chennai, Tamil Nadu, India
- Dr. Mohan's Diabetes Specialities Centre (IDF Centre of Excellence in Diabetes Care), Gopalapuram, Chennai, Tamil Nadu, India
| | - Theresa W Gillespie
- Department of Hematology & Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory University Winship Cancer Institute, Atlanta, Georgia, USA
| | - Alpa V Patel
- Department of Population Science, American Cancer Society, Atlanta, Georgia, USA
| | | | - Dorairaj Prabhakaran
- The Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurugram, Haryana, India
- Centre for Chronic Disease Control, Dwarka, Delhi, India
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
- Emory University Winship Cancer Institute, Atlanta, Georgia, USA
- Centre for Cancer Statistics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
- Emory University Winship Cancer Institute, Atlanta, Georgia, USA
- Centre for Cancer Statistics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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16
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Montes de Oca MK, Chen Q, Howell E, Wilson LE, Meernik C, Previs RA, Huang B, Pisu M, Liang MI, Ward KC, Schymura MJ, Berchuck A, Akinyemiju T. Health-care access dimensions and ovarian cancer survival: SEER-Medicare analysis of the ORCHiD study. JNCI Cancer Spectr 2023; 7:pkad011. [PMID: 36794910 PMCID: PMC10066801 DOI: 10.1093/jncics/pkad011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/07/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities in ovarian cancer (OC) survival are well-documented. However, few studies have investigated how health-care access (HCA) contributes to these disparities. METHODS To evaluate the influence of HCA on OC mortality, we analyzed 2008-2015 Surveillance, Epidemiology, and End Results-Medicare data. Multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between HCA dimensions (affordability, availability, accessibility) and OC-specific and all-cause mortality, adjusting for patient characteristics and treatment receipt. RESULTS The study cohort included 7590 OC patients: 454 (6.0%) Hispanic, 501 (6.6%) Non-Hispanic (NH) Black, and 6635 (87.4%) NH White. Higher affordability (HR = 0.90, 95% CI = 0.87 to 0.94), availability (HR = 0.95, 95% CI = 0.92 to 0.99), and accessibility scores (HR = 0.93, 95% CI = 0.87 to 0.99) were associated with lower risk of OC mortality after adjusting for demographic and clinical factors. Racial disparities were observed after additional adjustment for these HCA dimensions: NH Black patients experienced a 26% higher risk of OC mortality compared with NH White patients (HR = 1.26, 95% CI = 1.11 to 1.43) and a 45% higher risk among patients who survived at least 12 months (HR = 1.45, 95% CI = 1.16 to 1.81). CONCLUSIONS HCA dimensions are statistically significantly associated with mortality after OC and explain some, but not all, of the observed racial disparity in survival of patients with OC. Although equalizing access to quality health care remains critical, research on other HCA dimensions is needed to determine additional factors contributing to disparate OC outcomes by race and ethnicity and advance the field toward health equity.
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Affiliation(s)
| | - Quan Chen
- Division of Cancer Biostatistics and Kentucky Cancer Registry, University of Kentucky, Lexington, KY, USA
| | - Elizabeth Howell
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Clare Meernik
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Rebecca A Previs
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Bin Huang
- Division of Cancer Biostatistics and Kentucky Cancer Registry, University of Kentucky, Lexington, KY, USA
| | - Maria Pisu
- Division of Preventive Medicine and O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Margaret I Liang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Maria J Schymura
- New York State Department of Health, New York State Cancer Registry, Albany, NY, USA
| | - Andrew Berchuck
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Tomi Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
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17
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Gupta A, Chen Q, Wilson LE, Huang B, Pisu M, Liang M, Previs RA, Moss HA, Ward KC, Schymura MJ, Berchuck A, Akinyemiju TF. Factor Analysis of Health Care Access With Ovarian Cancer Surgery and Gynecologic Oncologist Consultation. JAMA Netw Open 2023; 6:e2254595. [PMID: 36723938 PMCID: PMC9892953 DOI: 10.1001/jamanetworkopen.2022.54595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Poor health care access (HCA) is associated with racial and ethnic disparities in ovarian cancer (OC) survival. OBJECTIVE To generate composite scores representing health care affordability, availability, and accessibility via factor analysis and to evaluate the association between each score and key indicators of guideline-adherent care. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from patients with OC diagnosed between 2008 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) Medicare database. The SEER Medicare database uses cancer registry data and linked Medicare claims from 12 US states. Included patients were Hispanic, non-Hispanic Black, and non-Hispanic White individuals aged 65 years or older diagnosed from 2008 to 2015 with first or second primary OC of any histologic type (International Classification of Diseases for Oncology, 3rd Edition [ICD-O-3] code C569). Data were analyzed from June 2020 to June 2022. EXPOSURES The SEER-Medicare data set was linked with publicly available data sets to obtain 35 variables representing health care affordability, availability, and accessibility. A composite score was created for each dimension using confirmatory factor analysis followed by a promax (oblique) rotation on multiple component variables. MAIN OUTCOMES AND MEASURES The main outcomes were consultation with a gynecologic oncologist for OC and receipt of OC-related surgery in the 2 months prior to or 6 months after diagnosis. RESULTS The cohort included 8987 patients, with a mean (SD) age of 76.8 (7.3) years and 612 Black patients (6.8%), 553 Hispanic patients (6.2%), and 7822 White patients (87.0%). Black patients (adjusted odds ratio [aOR], 0.75; 95% CI, 0.62-0.91) and Hispanic patients (aOR, 0.81; 95% CI, 0.67-0.99) were less likely to consult a gynecologic oncologist compared with White patients, and Black patients were less likely to receive surgery after adjusting for demographic and clinical characteristics (aOR, 0.76; 95% CI, 0.62-0.94). HCA availability and affordability were each associated with gynecologic oncologist consultation (availability: aOR, 1.16; 95% CI, 1.09-1.24; affordability: aOR, 1.13; 95% CI, 1.07-1.20), while affordability was associated with receipt of OC surgery (aOR, 1.08; 95% CI, 1.01-1.15). In models mutually adjusted for availability, affordability, and accessibility, Black patients remained less likely to consult a gynecologic oncologist (aOR, 0.80; 95% CI, 0.66-0.97) and receive surgery (aOR, 0.80; 95% CI, 0.65-0.99). CONCLUSIONS AND RELEVANCE In this cohort study of Hispanic, non-Hispanic Black, and non-Hispanic White patients with OC, HCA affordability and availability were significantly associated with receiving surgery and consulting a gynecologic oncologist. However, these dimensions did not fully explain racial and ethnic disparities.
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Affiliation(s)
- Anjali Gupta
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Quan Chen
- Department of Biostatistics and Kentucky Cancer Registry, University of Kentucky, Lexington
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Bin Huang
- Department of Biostatistics and Kentucky Cancer Registry, University of Kentucky, Lexington
| | - Maria Pisu
- O'Neal Comprehensive Cancer Center, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham
| | - Margaret Liang
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham
| | - Rebecca A Previs
- Duke Cancer Institute, Division of Gynecologic Oncology, Duke University School of Medicine, Durham, North Carolina
- Labcorp Oncology, Durham, North Carolina
| | - Haley A Moss
- Duke Cancer Institute, Division of Gynecologic Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Kevin C Ward
- Georgia Cancer Registry, Emory University, Atlanta
| | - Maria J Schymura
- New York State Cancer Registry, New York State Department of Health, Albany
| | - Andrew Berchuck
- Duke Cancer Institute, Division of Gynecologic Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Tomi F Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
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18
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Akinyemiju T, Chen Q, Wilson LE, Previs RA, Joshi A, Liang M, Pisu M, Ward KC, Berchuck A, Schymura MJ, Huang B. Healthcare Access Domains Mediate Racial Disparities in Ovarian Cancer Treatment Quality in a US Patient Cohort: A Structural Equation Modelling Analysis. Cancer Epidemiol Biomarkers Prev 2023; 32:74-81. [PMID: 36306380 PMCID: PMC9839516 DOI: 10.1158/1055-9965.epi-22-0650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/07/2022] [Accepted: 10/25/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Ovarian cancer survival disparities have persisted for decades, driven by lack of access to quality treatment. We conducted structural equation modeling (SEM) to define latent variables representing three healthcare access (HCA) domains: affordability, availability, and accessibility, and evaluated the direct and indirect associations between race and ovarian cancer treatment mediated through the HCA domains. METHODS Patients with ovarian cancer ages 65 years or older diagnosed between 2008 and 2015 were identified from the SEER-Medicare dataset. Generalized SEM was used to estimate latent variables representing HCA domains by race in relation to two measures of ovarian cancer-treatment quality: gynecologic oncology consultation and receipt of any ovarian cancer surgery. RESULTS A total of 8,987 patients with ovarian cancer were included in the analysis; 7% were Black. The affordability [Ω: 0.876; average variance extracted (AVE) = 0.689], availability (Ω: 0.848; AVE = 0.636), and accessibility (Ω: 0.798; AVE = 0.634) latent variables showed high composite reliability in SEM analysis. Black patients had lower affordability and availability, but higher accessibility compared with non-Black patients. In fully adjusted models, there was no direct effect observed between Black race to receipt of surgery [β: -0.044; 95% confidence interval (CI), -0.264 to 0.149]; however, there was an inverse total effect (β: -0.243; 95% CI, -0.079 to -0.011) that was driven by HCA affordability (β: -0.025; 95% CI, -0.036 to -0.013), as well as pathways that included availability and consultation with a gynecologist oncologist. CONCLUSIONS Racial differences in ovarian cancer treatment appear to be driven by latent variables representing healthcare affordability, availability, and accessibility. IMPACT Strategies to mitigate disparities in multiple HCA domains will be transformative in advancing equity in cancer treatment.
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Affiliation(s)
- Tomi Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
- Duke Cancer Institute, Duke University School of Medicine, Durham NC
| | - Quan Chen
- Division of Cancer Biostatistics and Kentucky Cancer Registry, Univ of Kentucky, Lexington KY
| | - Lauren E. Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
| | - Rebecca A. Previs
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham NC
| | - Ashwini Joshi
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
| | - Margaret Liang
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Maria Pisu
- Division of Preventive Medicine and O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Kevin C. Ward
- Georgia Cancer Registry, Emory University, Atlanta GA
| | - Andrew Berchuck
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham NC
| | - Maria J. Schymura
- New York State Cancer Registry, New York State Department of Health, Albany NY
| | - Bin Huang
- Division of Cancer Biostatistics and Kentucky Cancer Registry, Univ of Kentucky, Lexington KY
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19
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Lipscomb J, Switchenko JM, Flowers CR, Gillespie TW, Wortley PM, Bayakly AR, Almon L, Ward KC. Impact of multi-agent systemic therapy on all-cause and disease-specific survival for people living with HIV who are diagnosed with non-Hodgkin lymphoma: population-based analyses from the state of Georgia. Leuk Lymphoma 2023; 64:151-160. [PMID: 36308021 PMCID: PMC9905298 DOI: 10.1080/10428194.2022.2133539] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/20/2022] [Accepted: 09/26/2022] [Indexed: 01/12/2023]
Abstract
For people living with HIV (PLWH) who are subsequently diagnosed with non-Hodgkin lymphoma (NHL), we investigate the impact of standard-of-care (SoC) cancer treatment on all-cause, NHL-specific, and HIV-specific survival outcomes. The focus is on a registry-derived, population-based sample of HIV + adults diagnosed with NHL within 2004-2012 in the state of Georgia. SoC treatment is defined as receipt of multi-agent systemic therapy (MAST). In multivariable survival analyses, SoC cancer treatment is significantly associated with better all-cause and NHL-specific survival, but not better HIV-specific survival across 2004-2017. Having a CD4 count <200 near the time of cancer diagnosis and Ann Arbor stage III/IV disease are associated with worse all-cause and HIV-specific survival; the effects on NHL survival trend negative but are not significant. Future work should expand the geographic base and cancers examined, deepen the level of clinical detail brought to bear, and incorporate the perspectives and recommendations of patients and providers.
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Affiliation(s)
- Joseph Lipscomb
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jeffrey M Switchenko
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Christopher R Flowers
- Division of Cancer Medicine, Department of Lymphoma/Myeloma, MD Anderson Cancer Center, Houston, TX, USA
| | - Theresa W Gillespie
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Surgical Oncology, Emory University School of Medicine, Atlanta, GA, USA
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Lyn Almon
- Georgia Center for Cancer Statistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kevin C Ward
- Georgia Center for Cancer Statistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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20
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Anyanwu MC, Ohamadike O, Wilson LE, Meernik C, Huang B, Pisu M, Liang M, Previs RA, Joshi A, Ward KC, Tucker T, Schymura MJ, Berchuck A, Akinyemiju T. Race, Affordability and Utilization of Supportive Care in Ovarian Cancer Patients. J Pain Symptom Manage 2022; 64:537-545. [PMID: 36058401 PMCID: PMC10083071 DOI: 10.1016/j.jpainsymman.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/12/2022] [Accepted: 08/24/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Lack of access to supportive care (SC) among cancer patients have been well documented. However, the role of affordability in this disparity among ovarian cancer (OC) patients remain poorly understood. METHODS Patients with OC between 2008 and 2015 were identified from the SEER-Medicare dataset. Racial disparities in utilization of SC medications within the six months of OC diagnosis among patients with Medicare Part D coverage was examined. Multivariable log-binomial regression models were used to examine the associations of race, affordability and SC medications after adjusting for clinical covariates among all patients and separately among patients with advanced-stage disease. RESULTS The study cohort included 3697 patients: 86% non-Hispanic White (NHW), 6% non-Hispanic Black (NHB), and 8% Hispanic. In adjusted models, NHB and Hispanic patients were less likely to receive antidepressants compared to NHW patients (NHB: aOR 0.46; 95% CI 0.33-0.63 and Hispanic: aOR 0.79; 95% CI 0.63-0.99). This association persisted for NHB patients with advanced-stage disease (aOR 0.42; 95% CI 0.28-0.62). Patients dual enrolled in Medicaid were more likely to receive antidepressants (overall: aOR 1.34; 95% CI 1.17-1.53 and advanced-stage: aOR 1.29; 95% CI 1.10-1.52). However, patients residing in areas with higher vs. lower proportions of lower educated adults (overall: aOR 0.82; 95% CI 0.70-0.97 and advanced-stage: aOR 0.82; 95% CI 0.68-0.99) were less likely to receive antidepressants. CONCLUSION Black OC patients and those living in lower educated areas were less likely to receive antidepressants as SC. Given the importance of post-primary treatment quality of life for cancer patients, interventions are needed to enhance equitable access to SC.
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Affiliation(s)
- Mercy C Anyanwu
- Department of Internal Medicine (M.C.A.), Pennsylvania Hospital of the University of Pennsylvania, Pennsylvania, USA
| | - Onyinye Ohamadike
- Duke University School of Medicine (O.O.), Durham, North Carolina, USA
| | - Lauren E Wilson
- Department of Population Health Sciences (L.E.W., C.M., A.J., T.A.), Duke University School of Medicine, Durham, North Carolina, USA
| | - Clare Meernik
- Department of Population Health Sciences (L.E.W., C.M., A.J., T.A.), Duke University School of Medicine, Durham, North Carolina, USA
| | - Bin Huang
- Department of Biostatistics and Kentucky Cancer Registry (B.H., T.T.), University of Kentucky, Lexington Kentucky, USA
| | - Maria Pisu
- Division of Preventive Medicine and O'Neal Comprehensive Cancer Center (M.P., M.L.), University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Margaret Liang
- Division of Preventive Medicine and O'Neal Comprehensive Cancer Center (M.P., M.L.), University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Gynecologic Oncology, Department of Obstetrics and Gynecology (M.L.), University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rebecca A Previs
- Division of Gynecologic Oncology (R.A.P., A.B.), Duke Cancer Institute, Duke University School of Medicine, Durham North Carolina, USA
| | - Ashwini Joshi
- Department of Population Health Sciences (L.E.W., C.M., A.J., T.A.), Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin C Ward
- Georgia Cancer Registry (K.C.W.), Emory University, Atlanta Georgia, USA
| | - Tom Tucker
- Department of Biostatistics and Kentucky Cancer Registry (B.H., T.T.), University of Kentucky, Lexington Kentucky, USA
| | - Maria J Schymura
- New York State Cancer Registry, New York State Department of Health (M.J.S.), Albany New York, USA
| | - Andrew Berchuck
- Division of Gynecologic Oncology (R.A.P., A.B.), Duke Cancer Institute, Duke University School of Medicine, Durham North Carolina, USA
| | - Tomi Akinyemiju
- Department of Population Health Sciences (L.E.W., C.M., A.J., T.A.), Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine (T.A.), Durham, North Carolina, USA.
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21
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Montes de Oca MK, Wilson LE, Previs RA, Gupta A, Joshi A, Huang B, Pisu M, Liang M, Ward KC, Schymura MJ, Berchuck A, Akinyemiju TF. Healthcare Access Dimensions and Guideline-Concordant Ovarian Cancer Treatment: SEER-Medicare Analysis of the ORCHiD Study. J Natl Compr Canc Netw 2022; 20:1255-1266.e11. [PMID: 36351338 DOI: 10.6004/jnccn.2022.7055] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 07/14/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Racial disparities exist in receipt of guideline-concordant treatment of ovarian cancer (OC). However, few studies have evaluated how various dimensions of healthcare access (HCA) contribute to these disparities. METHODS We analyzed data from non-Hispanic (NH)-Black, Hispanic, and NH-White patients with OC diagnosed in 2008 to 2015 from the SEER-Medicare database and defined HCA dimensions as affordability, availability, and accessibility, measured as aggregate scores created with factor analysis. Receipt of guideline-concordant OC surgery and chemotherapy was defined based on the NCCN Guidelines for Ovarian Cancer. Multivariable-adjusted modified Poisson regression models were used to assess the relative risk (RR) for guideline-concordant treatment in relation to HCA. RESULTS The study cohort included 5,632 patients: 6% NH-Black, 6% Hispanic, and 88% NH-White. Only 23.8% of NH-White patients received guideline-concordant surgery and the full cycles of chemotherapy versus 14.2% of NH-Black patients. Higher affordability (RR, 1.05; 95% CI, 1.01-1.08) and availability (RR, 1.06; 95% CI, 1.02-1.10) were associated with receipt of guideline-concordant surgery, whereas higher affordability was associated with initiation of systemic therapy (hazard ratio, 1.09; 95% CI, 1.05-1.13). After adjusting for all 3 HCA scores and demographic and clinical characteristics, NH-Black patients remained less likely than NH-White patients to initiate systemic therapy (hazard ratio, 0.86; 95% CI, 0.75-0.99). CONCLUSIONS Multiple HCA dimensions predict receipt of guideline-concordant treatment but do not fully explain racial disparities among patients with OC. Acceptability and accommodation are 2 additional HCA dimensions which may be critical to addressing these disparities.
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Affiliation(s)
| | - Lauren E Wilson
- 2Department of Population Health Sciences, Duke University School of Medicine, and
| | - Rebecca A Previs
- 3Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
| | - Anjali Gupta
- 2Department of Population Health Sciences, Duke University School of Medicine, and
| | - Ashwini Joshi
- 2Department of Population Health Sciences, Duke University School of Medicine, and
| | - Bin Huang
- 4Department of Biostatistics and Kentucky Cancer Registry, University of Kentucky, Lexington, Kentucky
| | | | - Margaret Liang
- 6Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kevin C Ward
- 7Georgia Cancer Registry, Emory University, Atlanta, Georgia
| | - Maria J Schymura
- 8New York State Cancer Registry, New York State Department of Health, Albany, New York; and
| | - Andrew Berchuck
- 3Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
| | - Tomi F Akinyemiju
- 2Department of Population Health Sciences, Duke University School of Medicine, and
- 9Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
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22
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Veenstra CM, Ellis KR, Abrahamse P, Ward KC, Morris AM, Hawley ST. A dyadic survey study of partner engagement in and patient receipt of guideline-recommended colorectal cancer surveillance. BMC Cancer 2022; 22:1060. [PMID: 36229796 PMCID: PMC9559022 DOI: 10.1186/s12885-022-10131-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/21/2022] [Indexed: 11/25/2022] Open
Abstract
Background We investigated whether partner (spouse or intimate partner) engagement in colorectal cancer (CRC) surveillance is associated with patient receipt of surveillance. Methods From 2019 to 2020 we surveyed Stage III CRC survivors diagnosed 2014–2018 at an academic cancer center, a community oncology practice and the Georgia SEER registry, and their partners. Partner engagement was measured across 3 domains: Informed about; Involved in; and Aware of patient preferences around surveillance. We evaluated bivariate associations between domains of partner engagement and independent partner variables. Analysis of variance and multivariable logistic regression were used to compare domains of engagement with patient-reported receipt of surveillance. Results 501 patients responded (51% response rate); 428 had partners. 311 partners responded (73% response rate). Partners were engaged across all domains. Engagement varied by sociodemographics. Greater partner involvement was associated with decreased odds of receipt of composite surveillance (OR 0.67, 95% CI 0.48–0.93) and trended towards significance for decreased odds of receipt of endoscopy (OR 0.60, 95% CI 0.34–1.03) and CEA (OR 0.75, 95% CI 0.55–1.04). Greater partner awareness was associated with increased odds of patients’ receipt of endoscopy (OR 2.18, 95% CI 1.15–4.12) and trended towards significance for increased odds of receipt of composite surveillance (OR 1.30, 95% CI 0.91–2.04). Conclusion Partners are engaged (informed, involved, and aware) in CRC surveillance. Future research to develop dyadic interventions that capitalize on the positive aspects of partner engagement may help partners effectively engage in surveillance to improve patient care. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10131-3.
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Affiliation(s)
- Christine M Veenstra
- University of Michigan, 300 North Ingalls, NIB, Room 3A22, 48109, Ann Arbor, MI, USA.
| | - Katrina R Ellis
- University of Michigan, 300 North Ingalls, NIB, Room 3A22, 48109, Ann Arbor, MI, USA
| | - Paul Abrahamse
- University of Michigan, 300 North Ingalls, NIB, Room 3A22, 48109, Ann Arbor, MI, USA
| | | | | | - Sarah T Hawley
- University of Michigan, 300 North Ingalls, NIB, Room 3A22, 48109, Ann Arbor, MI, USA
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23
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Moubadder L, Collin LJ, Nash R, Switchenko JM, Miller-Kleinhenz JM, Gogineni K, Ward KC, McCullough LE. Drivers of racial, regional, and socioeconomic disparities in late-stage breast cancer mortality. Cancer 2022; 128:3370-3382. [PMID: 35867419 DOI: 10.1002/cncr.34391] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/08/2022] [Accepted: 06/01/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The authors identified tumor, treatment, and patient characteristics that may contribute to differences in breast cancer (BC) mortality by race, rurality, and area-level socioeconomic status (SES) among women diagnosed with stage IIIB-IV BC in Georgia. METHODS Using the Georgia Cancer Registry, 3084 patients with stage IIIB-IV primary BC (2013-2017) were identified. Cox proportional hazards regression was used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) comparing mortality among non-Hispanic Black (NHB) versus non-Hispanic White (NHW), residents of rural versus urban neighborhoods, and residents of low- versus high-SES neighborhoods by tumor, treatment, and patient characteristics. The mediating effects of specific characteristics on the association between race and BC mortality were estimated. RESULTS Among the study population, 41% were NHB, 21% resided in rural counties, and 72% resided in low SES neighborhoods. The authors observed mortality disparities by race (HR, 1.27; 95% CI, 1.13, 1.41) and rurality (HR, 1.14; 95% CI, 1.00, 1.30), but not by SES (HR, 1.04; 95% CI, 0.91, 1.19). In the stratified analyses, racial disparities were the most pronounced among women with HER2 overexpressing tumors (HR, 2.30; 95% CI, 1.53, 3.45). Residing in a rural county was associated with increased mortality among uninsured women (HR, 2.25; 95% CI, 1.31, 3.86), and the most pronounced SES disparities were among younger women (<40 years: HR, 1.46; 95% CI, 0.88, 2.42). CONCLUSIONS There is considerable variation in racial, regional, and socioeconomic disparities in late-stage BC mortality by tumor, treatment, and patient characteristics.
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Affiliation(s)
- Leah Moubadder
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lindsay J Collin
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Keerthi Gogineni
- Department of Hematology and Medical Oncology, Emory School of Medicine, Atlanta, Georgia, USA
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lauren E McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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24
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Akinyemiju TF, Wilson LE, Diaz N, Gupta A, Huang B, Pisu M, Deveaux A, Liang M, Previs RA, Moss HA, Joshi A, Ward KC, Schymura MJ, Berchuck A, Potosky AL. Associations of Healthcare Affordability, Availability, and Accessibility with Quality Treatment Metrics in Patients with Ovarian Cancer. Cancer Epidemiol Biomarkers Prev 2022; 31:1383-1393. [PMID: 35477150 PMCID: PMC9250633 DOI: 10.1158/1055-9965.epi-21-1227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/02/2022] [Accepted: 04/18/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Differential access to quality care is associated with racial disparities in ovarian cancer survival. Few studies have examined the association of multiple healthcare access (HCA) dimensions with racial disparities in quality treatment metrics, that is, primary debulking surgery performed by a gynecologic oncologist and initiation of guideline-recommended systemic therapy. METHODS We analyzed data for patients with ovarian cancer diagnosed from 2008 to 2015 in the Surveillance, Epidemiology, and End Results-Medicare database. We defined HCA dimensions as affordability, availability, and accessibility. Modified Poisson regressions with sandwich error estimation were used to estimate the relative risk (RR) for quality treatment. RESULTS The study cohort was 7% NH-Black, 6% Hispanic, and 87% NH-White. Overall, 29% of patients received surgery and 68% initiated systemic therapy. After adjusting for clinical variables, NH-Black patients were less likely to receive surgery [RR, 0.83; 95% confidence interval (CI), 0.70-0.98]; the observed association was attenuated after adjusting for healthcare affordability, accessibility, and availability (RR, 0.91; 95% CI, 0.77-1.08). Dual enrollment in Medicaid and Medicare compared with Medicare only was associated with lower likelihood of receiving surgery (RR, 0.86; 95% CI, 0.76-0.97) and systemic therapy (RR, 0.94; 95% CI, 0.92-0.97). Receiving treatment at a facility in the highest quartile of ovarian cancer surgical volume was associated with higher likelihood of surgery (RR, 1.12; 95% CI, 1.04-1.21). CONCLUSIONS Racial differences were observed in ovarian cancer treatment quality and were partly explained by multiple HCA dimensions. IMPACT Strategies to mitigate racial disparities in ovarian cancer treatment quality must focus on multiple HCA dimensions. Additional dimensions, acceptability and accommodation, may also be key to addressing disparities.
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Affiliation(s)
- Tomi F. Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
- Duke Cancer Institute, Duke University School of Medicine, Durham NC
| | - Lauren E. Wilson
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
| | - Nicole Diaz
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
| | - Anjali Gupta
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
| | - Bin Huang
- Department of Biostatistics and Kentucky Cancer Registry, Univ of Kentucky, Lexington KY
| | - Maria Pisu
- Division of Preventive Medicine and O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - April Deveaux
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
| | - Margaret Liang
- Division of Preventive Medicine and O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Rebecca A. Previs
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham NC
| | - Haley A. Moss
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham NC
| | - Ashwini Joshi
- Department of Population Health Sciences, Duke University School of Medicine, Durham NC
| | - Kevin C. Ward
- Georgia Cancer Registry, Emory University, Atlanta GA
| | - Maria J. Schymura
- New York State Cancer Registry, New York State Department of Health, Albany NY
| | - Andrew Berchuck
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University School of Medicine, Durham NC
| | - Arnold L. Potosky
- Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington DC
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Abstract
OBJECTIVE The aim of this study was to determine physician-reported use of and barriers to active surveillance for thyroid cancer. SUMMARY BACKGROUND DATA It is not clear whether active surveillance for thyroid cancer is widely used. METHODS Surgeons and endocrinologists identified by thyroid cancer patients from the Surveillance, Epidemiology, and End Results (SEER) registries of Georgia and Los Angeles County were surveyed between 2018 and 2019. Multivariable weighted logistic regression analyses were conducted to determine physician acceptance and use of active surveillance. Results: Of the 654 eligible physicians identified, 448 responded to the survey (69% response rate). The majority (76%) believed that active surveillance was an appropriate management option, but only 44% used it in their practice. Characteristics of physicians who stated that active surveillance was appropriate management, but did not report using it included more years in practice (reference group <10 years in practice): 10 to 19 years [odds ratio, OR 0.50 [95% confidence interval, CI 0.28-0.92]; 20 to 29 years [OR 0.31 (95% CI 0.15-0.62)]; >30 years [OR 0.30 (95% CI 0.15-0.61)] and higher patient volume 11 to 30 patients per year [OR 0.39 (95% CI 0.21 -0.70)] and >50 patients per year [OR 0.33 (95% CI 0.16-0.71)] compared to < 10, with no significant difference in those seeing 31 to 50 patients. Physicians reported multiple barriers to implementing active surveillance including patient does not want (80.3%), loss to follow-up concern (78.4%), more patient worry (57.6%), and malpractice lawsuit concern (50.9%). CONCLUSION AND RELEVANCE Despite most physicians considering active surveillance to be appropriate management, more than half are not using it. Addressing existing barriers is key to improving uptake.
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Affiliation(s)
- David T Hughes
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - David Reyes-Gastelum
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Megan R Haymart
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
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Kurian AW, Abrahamse P, Hamilton AS, Caswell-Jin JL, Gomez SL, Hofer TJ, Ward KC, Katz SJ. Chemotherapy Regimens Received by Women With BRCA1/2 Pathogenic Variants for Early Stage Breast Cancer Treatment. JNCI Cancer Spectr 2022; 6:6611726. [PMID: 35723570 PMCID: PMC9305849 DOI: 10.1093/jncics/pkac045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 06/06/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Genetic testing is widespread among breast cancer patients; however, no guideline recommends using germline genetic testing results to select a chemotherapy regimen. It is unknown whether breast cancer patients who carry pathogenic variants (PVs) in BRCA1 and/or 2 (BRCA1/2) or other cancer-associated genes receive different chemotherapy regimens than noncarriers. METHODS We linked Surveillance, Epidemiology, and End Results registry records from Georgia and California to germline genetic testing results from 4 clinical laboratories. Patients who 1) had stages I-III breast cancer, either hormone receptor (HR) positive and HER2 negative or triple negative (TNBC), diagnosed in 2013-2017; 2) received chemotherapy; and 3) were linked to genetic results were included. Chemotherapy details were extracted from Surveillance, Epidemiology, and End Results text fields completed by registrars. We examined whether PV carriers received more intensive regimens (HR-positive,HER2-negative: ≥3 drugs including an anthracycline; TNBC: ≥4 drugs including an anthracycline and platinum) and/or less standard breast cancer agents (a platinum). All statistical tests were 2-sided. RESULTS Among 2293 patients, 1451 had HR-positive, HER2-negative disease, and 842 had TNBC. On multivariable analysis of women with HR-positive, HER2-negative disease, receipt of a more intensive chemotherapy regimen varied statistically significantly by genetic results (P = .02), with platinum receipt more common among BRCA1/2 PV carriers (odds ratio = 2.44, 95% confidence interval = 1.36 to 4.38; P < .001). Among women with TNBC, chemotherapy agents did not vary significantly by genetic results. CONCLUSION BRCA1/2 PV carriers with HR-positive, HER2-negative breast cancer had twofold higher odds than noncarriers of receiving a platinum, as part of a more intensive chemotherapy regimen. This likely represents overtreatment and emphasizes the need to monitor how genetic testing results are managed in oncology practice.
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Affiliation(s)
- Allison W Kurian
- Correspondence to: Allison W. Kurian, MD, MSc, Department of Medicine and Epidemiology and Population Health, Stanford University School of Medicine, Alway Building, Room M121M, Stanford, CA 94305-5405, USA (e-mail: )
| | - Paul Abrahamse
- Department of Health Management and Policy, School of Public Health and Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ann S Hamilton
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Scarlett L Gomez
- Department of Epidemiology & Biostatistics and Hellen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Timothy J Hofer
- Department of Internal Medicine, University of Michigan and Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Moubadder L, Collin LJ, Nash R, Switchenko J, Miller-Kleinhenz J, Gogineni K, Ward KC, McCullough LE. Abstract 3678: Drivers of racial, regional, and socioeconomic disparities in metastatic breast cancer mortality. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-3678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Despite an overall decline in breast cancer (BC) mortality due to advancements in cancer therapy, mortality disparities by race, rurality, and socioeconomic status (SES) persist among women diagnosed with metastatic disease in the US. Women residing in high-poverty or rural areas or who are non-Hispanic Black (NHB) experience higher rates of BC mortality relative to their counterparts. Although mortality disparities among late-stage BC patients are well-documented, few studies have examined the drivers of these disparities, which are likely multifactorial. We sought to identify tumor, treatment, and patient characteristics that may contribute to differences in BC mortality by race, rurality, and SES among women diagnosed with a first primary stage IIIB - IV BC in Georgia.Using the Georgia Cancer Registry, we identified 3085 patients with an initial diagnosis of stage IIIB-IV primary BC between January 2013 and December 2017. Cox proportional hazards regression was used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) to compare NHB vs. non-Hispanic White (NHW), rural vs. urban residents, and residents of low- vs. high-SES neighborhoods by tumor (stage, grade, ER status, and molecular subtype), treatment (surgery type, receipt of chemotherapy, radiation, hormonal, neoadjuvant, and immunotherapy), and patient (race, insurance, age group, marital status, region, SES) characteristics. Using an extension of the counterfactual framework, we estimated the mediating effects of subtype, stage, SES, rurality, and insurance on the association between race and BC mortality. Among the study population, 41% were NHB, 21% resided in rural counties, and 72% resided in low SES neighborhoods. Overall, we observed mortality disparities by race (HR=1.27, 95% CI: 1.13, 1.41) and rurality (HR=1.14, 95% CI: 1.00, 1.30), but not by SES (HR=1.04, 95% CI: 0.91, 1.19). In the stratified analyses, racial disparities were the most pronounced among women with HER2 overexpressing tumors (HR=2.30, 95% CI: 1.53, 3.45). Residing in a rural neighborhood was associated with increased mortality among uninsured women (HR=2.25, 95% CI: 1.31, 3.86) or receipt of breast-conserving surgery (HR=2.21, 95 CI%: 1.32, 3.71). The most pronounced socioeconomic disparities were among younger women (<40 years: HR=1.46, 95% CI: 0.88, 2.42) and patients who received neoadjuvant therapy (HR=1.44, 95% CI: 1.01, 2.05). The mediation analysis demonstrated that 48% of the effect between race and BC mortality was mediated by subtype.There is considerable variation in racial, regional, and socioeconomic disparities in metastatic BC mortality by tumor, treatment, and patient characteristics. For each, we’ve identified patient groups where disparities are most pronounced. Understanding specific barriers within these patient groups will inform future interventions aimed at reducing disparities in metastatic BC mortality.
Citation Format: Leah Moubadder, Lindsay J. Collin, Rebecca Nash, Jeffrey Switchenko, Jasmine Miller-Kleinhenz, Keerthi Gogineni, Kevin C. Ward, Lauren E. McCullough. Drivers of racial, regional, and socioeconomic disparities in metastatic breast cancer mortality [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3678.
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Katz SJ, Tocco R, Hawley ST, An L, Hodan R, Ward KC, Kurian AW. A pilot study to increase cascade genetic testing in families with hereditary cancer syndromes. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.10602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10602 Background: There is great need to build and evaluate tools and strategies to improve cascade genetic risk evaluation in families at high risk for hereditary cancer. The Genetic Information and Family Testing (GIFT) Trial (CA254822) is a population-based intervention that examines features of a virtual platform that provides genetic risk education (GRE) and low-cost genetic testing (GT) to relatives of adult patients diagnosed with cancer in 2018-19 in Georgia and California and tested positive for a clinically relevant germline pathogenic variant (PV). We present findings of a pilot study intended to inform the GIFT Trial protocol and platform features. Methods: We surveyed 277 women diagnosed with breast cancer in 2017, reported to the Georgia SEER registry, and received genetic testing (95% of whom had a clinically relevant PV). We then invited respondent patients to enroll in the intervention phase which provided online GRE, human pretest genetic navigator support, and an offer of low-cost GT through Color Health, Inc. to all untested 1st or 2nd degree relatives. Respondent patients were eligible for the intervention if they reported a PV on genetic testing and had at least one relative who had not received GT. Enrolled patients invited relatives through the platform by providing email addresses. Family clusters were block randomized to free vs $50 test costs at the time of the initial patient invitation. Results: At study midpoint, 117 of 277 patients (42%) had returned surveys: median age was 51 and 22% were African American. The most frequent PVs reported by the patients were BRCA1/2 (41%), CHEK2 (21%), and PALB2 (8%). Half (54%) had previously encouraged all of their brothers to get GT and 71% had encouraged all of their sisters to get GT. Three-quarters (78%) strongly agreed it was important for relatives to understand their genetic risk for cancer, and half (54%) strongly agreed they would like to make it easier for relatives to get genetic testing. The median number of patient-reported untested relatives in a family was 8.5 (25th-75th percentile: 4-14). Most respondent patients were eligible for the intervention phase (N = 108, 93%). About one-quarter had enrolled in the intervention at midpoint (16 of 53 in no-cost arm vs 16 of 55 in $50 arm). Patients in the no-cost arm invited 21 relatives, 10 of whom had enrolled with 8 ordering GT (38% of invited relatives). Patients in the $50 arm invited 38 relatives, 18 of whom had enrolled with 17 ordering GT (45% of invited relatives). Overall, about half of enrolled relatives (46%) were men. Conclusions: Breast cancer patients with PVs make substantial efforts to communicate with family members about genetic risk; but they strongly endorse the need for additional support to facilitate this complex communication. Interim pilot findings suggest that a low-cost online navigator-supported intervention can directly engage relatives with little difference in GT uptake by test cost arms.
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Affiliation(s)
| | | | - Sarah T. Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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Kurian AW, Abrahamse P, Caswell-Jin JL, Hamilton AS, Hofer T, Ward KC, Katz S. Association of germline genetic testing results with chemotherapy regimens received by women with early-stage breast cancer. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.10518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10518 Background: Germline genetic testing is widespread after breast cancer diagnosis and increasingly informs treatment decisions; however, guidelines do not advise selecting chemotherapy regimens based on genetic testing results. It is unknown whether women with pathogenic variants (PVs) in BRCA1, BRCA2 ( BRCA1/2) or other cancer risk genes receive different chemotherapy regimens than women with negative genetic testing results. Methods: We linked Surveillance, Epidemiology and End Results (SEER) registry records from Georgia and California to clinical germline genetic testing results from four participating laboratories (Ambry, Bioreference/GeneDx, Invitae, and Myriad). For this analysis, we included patients who: 1) were diagnosed with stages I-III breast cancer, either hormone receptor-positive and HER2-negative (HR+HER2-) or triple-negative, in Georgia or California from 2013-2017; 2) received chemotherapy based on SEER records; and 3) linked to a genetic testing result. We further selected cases by genetic testing results: 50% PVs in BRCA1/2 or another cancer risk gene, 25% variant of uncertain significance (VUS) only and 25% negative. We extracted details of chemotherapy regimens from SEER text fields completed by registrars. We categorized regimens by drug classes reported (anthracycline, taxane, platinum, nitrogen mustard, other). We used multivariable models that controlled for age, race/ethnicity, stage, grade, surgical procedure, radiotherapy receipt and geographic site to test whether PV carriers received a more intensive chemotherapy regimen. For HR+HER2-, a more intensive regimen was defined as at least three drugs including an anthracycline and for triple-negative, as at least four drugs including an anthracycline and a platinum (versus fewer drugs). Results: 2,293 women were included, 1,451 with HR+HER2- and 842 with triple-negative disease. On multivariable analysis, receipt of a more intensive chemotherapy regimen was associated with having a BRCA1/2 PV among women with HR+HER2- disease (odds ratio 1.22, p = 0.036), but not among women with triple-negative disease. Moreover, platinum use was elevated in BRCA1/2 PV carriers with HR+HER2- disease (from an adjusted model: BRCA1/2 PV 10.9%, other PV 3.6%, VUS 5.6%, negative 5.7%), while in BRCA1/2 PV carriers with triple-negative disease, platinum use did not vary significantly by genetic results ( BRCA1/2 27.7%, other PV 27.7%, VUS 20.9%, negative 20.7%; p = 0.025 for interaction between genetic result and subtype). Conclusions: Compared to women with negative genetic testing results, women with BRCA1/2 PVs more often received a platinum and/or an anthracycline in chemotherapy regimens for early-stage, HR+HER2- breast cancer. This suggests potential over-treatment. No differences in chemotherapy regimen by genetic testing result were observed in triple-negative disease.
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Affiliation(s)
| | | | | | | | - Timothy Hofer
- University of Michigan School of Medicine, Ann Arbor, MI
| | | | - Steven Katz
- University of Michigan School of Medicine, Ann Arbor, MI
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Collin LJ, Ross-Driscoll K, Nash R, Miller-Kleinhenz JM, Moubadder L, Osborn C, Subhedar PD, Gabram-Mendola SGA, Switchenko JM, Ward KC, McCullough LE. ASO Visual Abstract: Time to Surgical Treatment and Facility Characteristics as Potential Drivers of Racial Disparities in Breast Cancer Mortality: Delay, Facilities, and Breast Cancer Mortality. Ann Surg Oncol 2022. [PMID: 35474558 DOI: 10.1245/s10434-022-11794-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Lindsay J Collin
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
| | - Katie Ross-Driscoll
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Leah Moubadder
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Catherine Osborn
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Preeti D Subhedar
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Sheryl G A Gabram-Mendola
- Emory University, Atlanta, GA, USA.,Georgia Center for Oncology Research and Education, Atlanta, GA, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lauren E McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Collin LJ, Ross-Driscoll K, Nash R, Miller-Kleinhenz JM, Moubadder L, Osborn C, Subhedar PD, Gabram-Mendola SGA, Switchenko JM, Ward KC, McCullough LE. Time to Surgical Treatment and Facility Characteristics as Potential Drivers of Racial Disparities in Breast Cancer Mortality. Ann Surg Oncol 2022; 29:4728-4738. [PMID: 35435562 PMCID: PMC9703360 DOI: 10.1245/s10434-022-11720-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/21/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Black women are more likely to die of breast cancer than White women. This study evaluated the contribution of time to primary surgical management and surgical facility characteristics to racial disparities in breast cancer mortality among both Black and White women. METHODS The study identified 2224 Black and 3787 White women with a diagnosis with stages I to III breast cancer (2010-2014). Outcomes included time to surgical treatment (> 30 days from diagnosis) and breast cancer mortality. Odds ratios (ORs) and 95% confidence intervals (CIs) associating surgical facility characteristics with surgical delay were computed, and Cox proportional hazards regression was used to compute hazard ratios (HRs) and 95% CIs associating delay and facility characteristics with breast cancer mortality. RESULTS Black women were two times more likely to have a surgical delay (OR, 2.15; 95% CI, 1.92-2.41) than White women. Racial disparity in surgical delay was least pronounced among women treated at a non-profit facility (OR, 1.95; 95% CI, 1.70-2.25). The estimated mortality rate for Black women was two times that for White women (HR, 2.00; 95% CI, 1.83-2.46). Racial disparities in breast cancer mortality were least pronounced among women who experienced no surgical delay (HR, 1.81; 95% CI, 1.28-2.56), received surgery at a government facility (HR, 1.31; 95% CI, 0.76-2.27), or underwent treatment at a Commission on Cancer-accredited facility (HR, 1.82; 95% CI, 1.38-2.40). CONCLUSIONS Black women were more likely to experience a surgical delay and breast cancer death. Persistent racial disparities in breast cancer mortality were observed across facility characteristics except for government facilities.
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Affiliation(s)
- Lindsay J Collin
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
| | - Katie Ross-Driscoll
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Leah Moubadder
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Catherine Osborn
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Preeti D Subhedar
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Sheryl G A Gabram-Mendola
- Emory University, Atlanta, GA, USA.,Georgia Center for Oncology Research and Education, Atlanta, GA, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lauren E McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Berlin NL, Abrahamse P, Momoh AO, Katz SJ, Jagsi R, Hamilton AS, Ward KC, Hawley ST. Perceived financial decline related to breast reconstruction following mastectomy in a diverse population-based cohort. Cancer 2022; 128:1284-1293. [PMID: 34847259 PMCID: PMC8882150 DOI: 10.1002/cncr.34048] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/19/2021] [Accepted: 11/12/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite mandated insurance coverage for breast reconstruction following mastectomy, health care costs are increasingly passed on to women through cost-sharing arrangements and high-deductible health plans. In this population-based study, the authors assessed perceived financial and employment declines related to breast reconstruction following mastectomy. METHODS Women with early-stage breast cancer (stages 0-II) diagnosed between July 2013 and May 2015 who underwent mastectomy were identified through the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles and were surveyed. Primary outcome measures included patients' appraisal of their financial and employment status after cancer treatment. Multivariable models evaluated the association between breast reconstruction and primary outcomes. RESULTS Among 883 patients with breast cancer who underwent mastectomy, 44.2% did not undergo breast reconstruction, and 55.8% underwent reconstruction. Overall, 21.9% of the cohort reported being worse off financially since their diagnosis (25.8% with reconstruction vs 16.6% without reconstruction; P = .002). Women who underwent reconstruction reported higher out-of-pocket medical expenses (32.1% vs 15.6% with expenses greater than $5000; P < .001). Reconstruction was independently associated with a perceived decline in financial status (odds ratio, 1.92; 95% confidence interval, 1.15-3.22; P = .013). Among women who were employed at the time of their diagnosis, there was no association between reconstruction and a perceived decline in employment status (P = .927). CONCLUSIONS In this diverse cohort of women who underwent mastectomy, those who elected to undergo reconstruction experienced higher out-of-pocket medical expenses and self-reported financial decline. Patients, providers, and policymakers should be aware of the potential financial implications related to reconstruction despite mandatory insurance coverage.
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Affiliation(s)
- Nicholas L Berlin
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan.,National Clinician Scholars Program, Institute for Health Policy and Innovation, Ann Arbor, Michigan
| | - Paul Abrahamse
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Adeyiza O Momoh
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven J Katz
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.,Health Care Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
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Filson CP, Modi PK, Ward KC. Characteristics of prostate cancer patients captured by facility-based versus geography-based cancer registries. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.6_suppl.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
237 Background: Cancer registries provide valuable information related to cancer epidemiology, treatment, and outcomes. However, the sampling for inclusion can impact generalizability of findings to other settings. We use a population-based cancer registry to evaluate demographics, cancer factors, and treatment patterns based on eligibility for a facility-based cancer registry. Methods: We used the Surveillance, Epidemiology, and End Results (SEER) database to identify men diagnosed with prostate cancer (site = C61.9) in 2018. Exposure was whether data were reported from a facility accredited by American College of Surgeons’ Commission on Cancer (CoC), providing eligibility for the National Cancer Database (NCDB) (i.e., NCDB-eligible). Outcomes of interest included demographics, tumor factors (e.g., biopsy grade), and treatment. Bivariate testing and multivariable regression analyses tested for significant associations between exposure and outcomes of interest. Results: We identified 57,713 men diagnosed with prostate cancer in 2018, of which 32,384 (61.9%) were eligible for inclusion in NCDB. NCDB-eligible men were younger (66.6 vs 67.8 years, p < 0.001), less likely to be Hispanic/Latino (8.0% vs 14.4%, p < 0.001), and more likely to reside in a county with median income over $75,000 (39.7% vs 33.3%, p < 0.001). NCDB eligibility varied widely by registry, from 96.1% in Connecticut to 44.7% in Utah. The proportion of localized cancer patients with Grade Group 1 cancer on biopsy was higher among men ineligible for NCDB (41.4% vs 26.9%, p < 0.001). The proportion of patients with more advanced disease at presentation was higher among NCDB-eligible patients (metastatic: 9.4% vs 6.8%; regional: 18.7% vs 8.7%; p < 0.001). For patients with localized or regional cancer, treatment was identified more frequently among NCDB-eligible patients for both low-risk (38.5% vs 22.7%, p < 0.001) and high-risk tumors (84.9% vs 64.2%). Among treated patients, use of radical prostatectomy was more common among NCDB-eligible patients (low risk: 58.9% vs 43.1%; high risk: 53.7% vs 43.4%, p < 0.001). Conclusions: Prostate cancer patients eligible for inclusion in the facility based NCDB have important differences in demographics, severity of cancer risk, and treatment patterns compared to those who are not eligible. Generalizations related to epidemiologic trends, practice patterns, and outcomes for prostate cancer patients in the NCDB should be interpreted with caution.
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Affiliation(s)
| | - Parth K. Modi
- University of Chicago Department of Urology, Chicago, IL
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Radhakrishnan A, Reyes-Gastelum D, Abrahamse P, Gay B, Hawley ST, Wallner LP, Chen DW, Hamilton AS, Ward KC, Haymart MR. Physician Specialties Involved in Thyroid Cancer Diagnosis and Treatment: Implications for Improving Health Care Disparities. J Clin Endocrinol Metab 2022; 107:e1096-e1105. [PMID: 34718629 PMCID: PMC8852205 DOI: 10.1210/clinem/dgab781] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Indexed: 02/07/2023]
Abstract
CONTEXT Little is known about provider specialties involved in thyroid cancer diagnosis and management. OBJECTIVE Characterize providers involved in diagnosing and treating thyroid cancer. DESIGN/SETTING/PARTICIPANTS We surveyed patients with differentiated thyroid cancer from the Georgia and Los Angeles County Surveillance, Epidemiology and End Results registries (N = 2632, 63% response rate). Patients identified their primary care physicians (PCPs), who were also surveyed (N = 162, 56% response rate). MAIN OUTCOME MEASURES (1) Patient-reported provider involvement (endocrinologist, surgeon, PCP) at diagnosis and treatment; (2) PCP-reported involvement (more vs less) and comfort (more vs less) with discussing diagnosis and treatment. RESULTS Among thyroid cancer patients, 40.6% reported being informed of their diagnosis by their surgeon, 37.9% by their endocrinologist, and 13.5% by their PCP. Patients reported discussing their treatment with their surgeon (71.7%), endocrinologist (69.6%), and PCP (33.3%). Physician specialty involvement in diagnosis and treatment varied by patient race/ethnicity and age. For example, Hispanic patients (vs non-Hispanic White) were more likely to report their PCP informed them of their diagnosis (odds ratio [OR]: 1.68; 95% CI, 1.24-2.27). Patients ≥65 years (vs <45 years) were more likely to discuss treatment with their PCP (OR: 1.59; 95% CI, 1.22-2.08). Although 74% of PCPs reported discussing their patients' diagnosis and 62% their treatment, only 66% and 48%, respectively, were comfortable doing so. CONCLUSIONS PCPs were involved in thyroid cancer diagnosis and treatment, and their involvement was greater among older patients and patients of minority race/ethnicity. This suggests an opportunity to leverage PCP involvement in thyroid cancer management to improve health and quality of care outcomes for vulnerable patients.
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Affiliation(s)
| | - David Reyes-Gastelum
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Paul Abrahamse
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Brittany Gay
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Lauren P Wallner
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Debbie W Chen
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, GA 30322, USA
| | - Megan R Haymart
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
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Nash RJ, McCullough LE, Pierce T, Collin LJ, Gaglioti AH, Ward KC, Kramer M, Switchenko J. Abstract PO-173: Spatial heterogeneity and rural-urban differences in the Black-White breast cancer mortality disparity in Georgia. Cancer Epidemiol Biomarkers Prev 2022. [DOI: 10.1158/1538-7755.disp21-po-173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Introduction: Breast cancer mortality in the US is 40% higher among Black than White women. Even among patients with prognostically favorable tumors, disparities persist, suggesting clinical features do not fully account for mortality differences. Area-level factors (e.g., rurality) influence health outcomes and may explain spatial variation in mortality disparities. Rurality can impact access to and quality of care, and socioeconomic status. Georgia is an ideal place to study spatial heterogeneity in race disparities because of the diverse population (>30% Black), large number of counties (159), and pronounced disparities in breast cancer mortality in the Atlanta area. Methods: Race-specific standardized mortality ratios (SMRs) were calculated for each county in Georgia to account for sparsely populated areas and areas with high residential segregation. Observed deaths among women diagnosed with localized or regional breast cancer between 2005 and 2013 were obtained from the Georgia Cancer Registry. To ensure equal follow-up, only deaths within five years of diagnosis were included. Expected deaths were estimated using race-specific population counts, race-specific breast cancer incidence rates, and the pooled (Black and White) mortality rate among Georgia women, with indirect age adjustment (20–44, 45–54, 55+ years). Spatial smoothing methods, including adding neighboring data to meet a threshold and Bayesian models with conditionally autoregressive priors, were used to stabilize local estimates. Counties were classified by 2013 RUC codes (urban: 1–3, rural: 4–9). Results: A total of 3,235 breast cancer deaths were observed during the study period, with 42% among Black women. The median SMR was lower for White (0.8, IQR: 0.7, 1.1) than Black women (1.4, IQR: 1.1, 2.0). Among Black women only, median SMR was greater in rural (1.7, IQR: 1.1, 2.5) than urban counties (1.3, IQR: 1.1, 1.6). After sequentially adding neighboring data to meet a race-specific threshold of 30 observed deaths, smoothed median SMRs were 0.9 (IQR: 0.8, 0.9) and 1.4 (IQR: 1.2, 1.6) for White and Black women, respectively. For Black women, median SMR was attenuated in rural counties (1.4, IQR: 1.2, 1.7) but unchanged in urban counties (1.3, IQR: 1.2, 1.5). The greatest SMRs for Black women were observed in urban counties comprising the Atlanta area and rural southeast Georgia. For example, Fulton County SMRs were 1.6 and 0.7, for Black and White women, respectively. Highest SMRs for White women were observed in southwest Georgia, but were similar to SMRs among Black women in this region. The spatial distribution of SMRs using same neighbor smoothing and Bayesian models were similar. Conclusion: Breast cancer mortality race disparities vary widely across Georgia. These results highlight specific areas for public health intervention, especially among Black women. This work presents a potential mechanism to monitor trends in small area cancer mortality race disparities over time. Future work will model the impact of area-level factors on the disparity magnitude.
Citation Format: Rebecca J. Nash, Lauren E. McCullough, T.J. Pierce, Lindsay J. Collin, Anne H. Gaglioti, Kevin C. Ward, Michael Kramer, Jeffrey Switchenko. Spatial heterogeneity and rural-urban differences in the Black-White breast cancer mortality disparity in Georgia [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-173.
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Kurian AW, Abrahamse P, Ward KC, Hamilton AS, Deapen D, Berek JS, Hoang L, Yussuf A, Dolinsky J, Brown K, Slavin T, Hofer TP, Katz SJ. Association of Family Cancer History With Pathogenic Variants in Specific Breast Cancer Susceptibility Genes. JCO Precis Oncol 2021; 5:PO.21.00261. [PMID: 34977446 PMCID: PMC8710333 DOI: 10.1200/po.21.00261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/12/2021] [Accepted: 11/22/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Family cancer history is an important component of genetic testing guidelines that estimate which patients with breast cancer are most likely to carry a germline pathogenic variant (PV). However, we do not know whether more extensive family history is differentially associated with PVs in specific genes. METHODS All women diagnosed with breast cancer in 2013-2017 and reported to statewide SEER registries of Georgia and California were linked to clinical genetic testing results and family history from two laboratories. Family history was defined as strong (suggestive of PVs in high-penetrance genes such as BRCA1/2 or TP53, including male breast, ovarian, pancreatic, sarcoma, or multiple female breast cancers), moderate (any other cancer history), or none. Among established breast cancer susceptibility genes (ATM, BARD1, BRCA1, BRCA2, CDH1, CHEK2, NF1, PALB2, PTEN, RAD51C, RAD51D, and TP53), we evaluated PV prevalence according to family history extent and breast cancer subtype. We used a multivariable model to test for interaction between affected gene and family history extent for ATM, BRCA1/2, CHEK2, and PALB2. RESULTS A total of 34,865 women linked to genetic results. Higher PV prevalence with increasing family history extent (P < .001) was observed only with BRCA1 (3.04% with none, 3.22% with moderate, and 4.06% with strong history) and in triple-negative breast cancer with PALB2 (0.75% with none, 2.23% with moderate, and 2.63% with strong history). In a multivariable model adjusted for age and subtype, there was no interaction between family history extent and PV prevalence for any gene except PALB2 (P = .037). CONCLUSION Extent of family cancer history is not differentially associated with PVs across established breast cancer susceptibility genes and cannot be used to personalize genes selected for testing.
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Affiliation(s)
- Allison W. Kurian
- Departments of Medicine and of Epidemiology & Population Health, Stanford University, Stanford, CA,Allison W. Kurian, MD, MSc, Department of Medicine and of Epidemiology & Population Health, Stanford University School of Medicine, HRP Redwood Building, Room T254A, 150 Governor's Lane, Stanford, CA 94305; e-mail:
| | - Paul Abrahamse
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI,Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Ann S. Hamilton
- Department of Preventive Medicine in the Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Dennis Deapen
- Department of Preventive Medicine in the Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jonathan S. Berek
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, and Stanford Women's Cancer Center, Stanford University, Stanford, CA
| | | | | | | | | | | | - Timothy P. Hofer
- Department of Internal Medicine, University of Michigan and Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Steven J. Katz
- Department of Internal Medicine, University of Michigan and Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
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Abstract
Background: Current guidelines recommend against thyrotropin (TSH) suppression in low-risk differentiated thyroid cancer patients; however, physician practices remain underexplored. Our objective was to understand treating physicians' approach to TSH suppression in patients with papillary thyroid cancer. Methods: Endocrinologists and surgeons identified by thyroid cancer patients from the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles were surveyed in 2018-2019. Physicians were asked to report how likely they were to recommend TSH suppression (i.e., TSH <0.5 mIU/L) in three clinical scenarios: patients with intermediate-risk, low-risk, and very low-risk papillary thyroid cancer. Responses were measured on a 4-point Likert scale (extremely unlikely to extremely likely). Multivariable logistic regressions were performed to determine physician characteristics associated with recommending TSH suppression in each of the aforementioned scenarios. Results: Response rate was 69% (448/654). Overall, 80.4% of physicians were likely/extremely likely to recommend TSH suppression for a patient with an intermediate-risk papillary thyroid cancer, 48.8% for a patient with low-risk papillary thyroid cancer, and 29.7% for a patient with very low-risk papillary thyroid cancer. Surgeons were less likely to recommend TSH suppression for an intermediate-risk papillary thyroid cancer patient (odds ratio [OR] = 0.36 [95% confidence interval, CI, 0.19-0.69]) compared with endocrinologists. Physicians with higher thyroid cancer patient volume were less likely to suppress TSH in low-risk and very low-risk papillary thyroid cancer patients (i.e., >40 patients per year, OR = 0.53 [CI 0.30-0.96]; OR = 0.49 [CI 0.24-0.99], respectively, compared with 0-20 patients per year). Physicians who estimated higher likelihood of recurrence were more likely to suppress TSH in a patient with very low-risk papillary thyroid cancer (OR = 2.34 [CI 1.91-4.59]). Conclusions: Many patients with low-risk thyroid cancer continue to be treated with suppressive doses of thyroid hormone, emphasizing the need for more high-quality research to guide thyroid cancer management, as well as better understanding of barriers that hinder guideline adoption.
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Affiliation(s)
- Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Debbie W. Chen
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - David Reyes-Gastelum
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ann S. Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Megan R. Haymart
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Address correspondence to: Megan R. Haymart, MD, Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Building 16, Room 408E, Ann Arbor, MI 48109, USA.
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Collin LJ, Yan M, Jiang R, Gogineni K, Subhedar P, Ward KC, Switchenko JM, Lipscomb J, Miller-Kleinhenz J, Torres M, Lin J, McCullough LE. Receipt of Guideline-Concordant Care Does Not Explain Breast Cancer Mortality Disparities by Race in Metropolitan Atlanta. J Natl Compr Canc Netw 2021; 19:1242-1251. [PMID: 34399407 PMCID: PMC8847540 DOI: 10.6004/jnccn.2020.7694] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 12/02/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Racial disparities in breast cancer mortality in the United States are well documented. Non-Hispanic Black (NHB) women are more likely to die of their disease than their non-Hispanic White (NHW) counterparts. The disparity is most pronounced among women diagnosed with prognostically favorable tumors, which may result in part from variations in their receipt of guideline care. In this study, we sought to estimate the effect of guideline-concordant care (GCC) on prognosis, and to evaluate whether receipt of GCC modified racial disparities in breast cancer mortality. PATIENTS AND METHODS Using the Georgia Cancer Registry, we identified 2,784 NHB and 4,262 NHW women diagnosed with a stage I-III first primary breast cancer in the metropolitan Atlanta area, Georgia, between 2010 and 2014. Women were included if they received surgery and information on their breast tumor characteristics was available; all others were excluded. Receipt of recommended therapies (chemotherapy, radiotherapy, endocrine therapy, and anti-HER2 therapy) as indicated was considered GCC. We used Cox proportional hazards models to estimate the impact of receiving GCC on breast cancer mortality overall and by race, with multivariable adjusted hazard ratios (HRs). RESULTS We found that NHB and NHW women were almost equally likely to receive GCC (65% vs 63%, respectively). Failure to receive GCC was associated with an increase in the hazard of breast cancer mortality (HR, 1.74; 95% CI, 1.37-2.20). However, racial disparities in breast cancer mortality persisted despite whether GCC was received (HRGCC: 2.17 [95% CI, 1.61-2.92]; HRnon-GCC: 1.81 [95% CI, 1.28-2.91] ). CONCLUSIONS Although receipt of GCC is important for breast cancer outcomes, racial disparities in breast cancer mortality did not diminish with receipt of GCC; differences in mortality between Black and White patients persisted across the strata of GCC.
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Affiliation(s)
- Lindsay J. Collin
- Department of Epidemiology; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA,Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112
| | - Ming Yan
- Department of Epidemiology; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA
| | - Renjian Jiang
- Department of Epidemiology; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA,Winship Cancer Institute of Emory University
| | - Keerthi Gogineni
- Winship Cancer Institute of Emory University,Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - Preeti Subhedar
- Winship Cancer Institute of Emory University,Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - Kevin C. Ward
- Department of Epidemiology; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA,Winship Cancer Institute of Emory University
| | - Jeffrey M. Switchenko
- Winship Cancer Institute of Emory University,Department of Biostatistics and Bioinformatics; Rollins School of Public Health; Emory University; Atlanta, GA, 30322, USA
| | - Joseph Lipscomb
- Winship Cancer Institute of Emory University,Department of Health Policy and Management; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA
| | - Jasmine Miller-Kleinhenz
- Department of Epidemiology; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA
| | - Mylin Torres
- Winship Cancer Institute of Emory University,Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - Jolinta Lin
- Winship Cancer Institute of Emory University,Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - Lauren E. McCullough
- Department of Epidemiology; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA,Winship Cancer Institute of Emory University
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Kurian AW, Abrahamse P, Bondarenko I, Hamilton AS, Deapen D, Gomez SL, Morrow M, Berek JS, Hofer TP, Katz SJ, Ward KC. Association of Genetic Testing Results with Mortality Among Women with Breast Cancer or Ovarian Cancer. J Natl Cancer Inst 2021; 114:245-253. [PMID: 34373918 DOI: 10.1093/jnci/djab151] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/15/2021] [Accepted: 08/03/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Breast cancer and ovarian cancer patients increasingly undergo germline genetic testing. However, little is known about cancer-specific mortality among carriers of a pathogenic variant (PV) in BRCA1/2 or other genes in a population-based setting. METHODS Georgia and California Surveillance Epidemiology and End Results (SEER) registry records were linked to clinical genetic testing results. Women were included who had stages I-IV breast cancer or ovarian cancer diagnosed in 2013-2017; received chemotherapy; and linked to genetic testing results. Multivariable Cox proportional hazard models were used to examine the association of genetic results with cancer-specific mortality. RESULTS 22,495 breast and 4,320 ovarian cancer patients were analyzed, with a median follow-up of 41 months. PVs were present in 12.7% of breast cancer patients with estrogen and/or progesterone receptor-positive, HER2-negative cancer, 9.8% with HER2-positive cancer, 16.8% with triple-negative breast cancer and 17.2% with ovarian cancer. Among triple-negative breast cancer patients, cancer-specific mortality was lower with BRCA1 (hazard ratio [HR] = 0.49, 95% confidence interval [CI] = 0.35-0.69) and BRCA2 PVs (HR = 0.60, 95% CI = 0.41-0.89), and equivalent with PVs in other genes (HR = 0.65, 95% CI = 0.37-1.13), versus non-carriers. Among ovarian cancer patients, cancer-specific mortality was lower with PVs in BRCA2 (HR = 0.35, 95% CI = 0.25-0.49) and genes other than BRCA1/2 (HR = 0.47, 95% CI = 0.32-0.69). No PV was associated with higher cancer-specific mortality. CONCLUSIONS Among breast cancer and ovarian cancer patients treated with chemotherapy in the community, BRCA1/2 and other gene PV carriers had equivalent or lower short-term cancer-specific mortality than non-carriers. These results may reassure newly diagnosed patients and longer follow-up is ongoing.
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Affiliation(s)
- Allison W Kurian
- Departments of Medicine and of Epidemiology & Population Health, Stanford University, Stanford, California
| | - Paul Abrahamse
- Department of Health Management and Policy, School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Irina Bondarenko
- Department of Health Management and Policy, School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Ann S Hamilton
- Department of Preventive Medicine in the Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Dennis Deapen
- Department of Preventive Medicine in the Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Scarlett L Gomez
- Department of Epidemiology & Biostatistics and Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
| | - Monica Morrow
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York City, New York
| | - Jonathan S Berek
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, and Stanford Women's Cancer Center, Stanford University, Stanford, California
| | - Timothy P Hofer
- Department of Internal Medicine, University of Michigan and Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Steven J Katz
- Department of Health Management and Policy, School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Boehmer U, Ozonoff A, Winter M, Berklein F, Potter J, Hartshorn KL, Ward KC, Ceballos RM, Clark MA. Health-related quality of life among colorectal cancer survivors of diverse sexual orientations. Cancer 2021; 127:3847-3855. [PMID: 34237147 DOI: 10.1002/cncr.33762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND The purpose of this study was to examine the health-related quality of life of sexual minority survivors in comparison with heterosexual survivors. METHODS Four hundred eighty eligible survivors participated in a telephone survey that measured survivors' outcomes, which consisted of physical and mental quality of life and self-rated fair or poor health. These survivors were diagnosed with stage I, II, or III colorectal cancer an average of 3 years before the survey and were recruited from 4 cancer registries. Using forward selection with generalized linear models or logistic regression models, the authors considered 4 domains-personal factors, environmental factors, health condition characteristics, and body function and structure-as correlates for each survivorship outcome. RESULTS The authors found that unadjusted physical quality of life and self-rated fair/poor health were similar for all survivors. Sexual minority survivors had poorer unadjusted mental quality of life in comparison with heterosexual survivors. After adjustments for covariates, this difference was no longer statistically significant. Three domains (personal factors, health condition characteristics, and body function and structure) explained colorectal cancer survivors' fair/poor health and 46% of the variance in physical quality of life, whereas 56% of the variance in mental quality of life was explained by personal factors, body function and structure, and environmental factors. CONCLUSIONS This study has identified modifiable factors that can be used to improve cancer survivors' quality of life and are, therefore, relevant to ongoing efforts to improve the survivorship experience.
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Affiliation(s)
- Ulrike Boehmer
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Al Ozonoff
- Harvard Medical School, Boston, Massachusetts.,Boston Children's Hospital, Boston, Massachusetts
| | - Michael Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Flora Berklein
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Jennifer Potter
- Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Fenway Institute, Boston, Massachusetts
| | - Kevan L Hartshorn
- Section of Hematology Oncology, Boston University School of Medicine, Boston, Massachusetts
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Rachel M Ceballos
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Melissa A Clark
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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Rosko AJ, Gay BL, Reyes-Gastelum D, Hamilton AS, Ward KC, Haymart MR. Surgeons' Attitudes on Total Thyroidectomy vs Lobectomy for Management of Papillary Thyroid Microcarcinoma. JAMA Otolaryngol Head Neck Surg 2021; 147:667-669. [PMID: 33885723 DOI: 10.1001/jamaoto.2021.0525] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Andrew J Rosko
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor
| | - Brittany L Gay
- Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor
| | | | - Ann S Hamilton
- Department of Preventive Medicine, University of Southern California, Los Angeles
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Megan R Haymart
- Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor
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Yabroff KR, Wu XC, Negoita S, Stevens J, Coyle L, Zhao J, Mumphrey BJ, Jemal A, Ward KC. Association of the COVID-19 Pandemic with Patterns of Statewide Cancer Services. J Natl Cancer Inst 2021; 114:907-909. [PMID: 34181001 DOI: 10.1093/jnci/djab122] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/03/2021] [Accepted: 06/16/2021] [Indexed: 11/14/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic led to delayed medical care in the US. We examined changes in patterns of cancer diagnosis and surgical treatment between January 1 and December 31 in 2020 and 2019 with real-time electronic pathology report data from population-based Surveillance, Epidemiology, and End Results cancer registries from Georgia and Louisiana. During 2020, there were 29,905 fewer pathology reports than in 2019, representing a 10.2% decline. Declines were observed in all age groups, including children and adolescents less than18 years. The nadir was early April 2020, with 42.8% fewer reports than in April 2019. Numbers of reports through December 2020 never consistently exceeded those in 2019 after first declines. Patterns were similar by age group and cancer site. Findings suggest substantial delays in diagnosis and treatment services for cancers during the pandemic. Ongoing evaluation can inform public health efforts to minimize any lasting adverse effects of the pandemic on cancer diagnosis, stage, treatment, and survival.
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Affiliation(s)
- K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Xiao-Cheng Wu
- Louisiana State University Health Sciences Center, School of Public Health, New Orleans, LA
| | - Serban Negoita
- Surveillance Research Program, National Cancer Institute, Rockville, MD
| | | | - Linda Coyle
- Information Management Services, Inc, Calverton, MD
| | - Jingxuan Zhao
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Brent J Mumphrey
- Louisiana State University Health Sciences Center, School of Public Health, New Orleans, LA
| | - Ahmedin Jemal
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA
| | - Kevin C Ward
- Rollins School of Public Health, Emory University, Atlanta, GA
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Kurian AW, Abrahamse P, Hamilton AS, Deapen D, Gomez SL, Morrow M, Berek JS, Katz SJ, Ward KC. Cancer-specific mortality associated with germline genetic testing results among women with breast cancer or ovarian cancer treated with chemotherapy. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.10517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10517 Background: Breast and ovarian cancer patients increasingly undergo germline genetic testing. While studies suggest a greater chemotherapy benefit for carriers of BRCA1/2 pathogenic variants, little is known about whether pathogenic variants in other genes are associated with cancer mortality. Methods: Georgia and California Surveillance, Epidemiology and End Results (SEER) registry records of women diagnosed with breast cancer or ovarian cancer from 2013-2017 were linked to results of clinical germline genetic testing from four participating laboratories. Patients were included if they linked to a genetic result, had stages I-III breast cancer or I-IV epithelial ovarian cancer and received chemotherapy. Multivariable Cox proportional hazard models were used to examine the association of genetic results, demographic and clinical factors with cancer-specific mortality. Results: 21,348 breast and 4,320 ovarian cancer patients were analyzed with median follow-up of 41 months. Pathogenic variants were present in 12% of patients with estrogen and progesterone receptor-positive, HER2-negative breast cancer, 9% with HER2-positive breast cancer, 17% with triple-negative breast cancer and 18% with ovarian cancer. Pathogenic variants were most common in BRCA1/2, CHEK2, PALB2, ATM and BRIP1. Among triple-negative breast cancer patients, mortality was lower with pathogenic variants in BRCA1 (hazard ratio (HR) 0.27, 95% confidence interval (CI) 0.17-0.45) and genes other than BRCA1/2 (HR 0.33, CI 0.13-0.81) versus no pathogenic variant. Genetic results were not associated with mortality in other breast cancer subtypes. Among ovarian cancer patients, mortality was lower with pathogenic variants in BRCA2 (HR 0.36, CI 0.26-0.49) and in genes other than BRCA1/2 (HR 0.48, CI 0.33-0.70). Conclusions: Among breast and ovarian cancer patients treated with chemotherapy, those with germline pathogenic variants in several cancer-associated genes had equivalent or lower short-term mortality than those testing negative. These results may guide patient counseling and clinical trial design.
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Affiliation(s)
- Allison W. Kurian
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | | | - Ann S. Hamilton
- Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | | | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan S. Berek
- Stanford Women's Cancer Center, Stanford Cancer Institute, Stanford, CA
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Yabroff RR, Wu XC, Negoita S, Stevens J, Coyle L, Zhao J, Mumphrey B, Jemal A, Ward KC. Association of the COVID-19 pandemic with patterns of cancer services. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.1514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1514 Background: The COVID-19 pandemic led to delays in medical care in the United States. We examined changes in patterns of cancer diagnosis and surgical treatment in 2020 using real-time electronic pathology report data from population-based SEER cancer registries in Georgia and Louisiana. Methods: Bi-weekly numbers, distributions, and patterns of pathology reports were compared between January 1st and December 31st in 2020 and the same period in 2019 by age group and cancer site. Results: During 2020, there were 29,905 fewer pathology reports than in 2019, representing a 10.2% decline. Absolute declines were greatest among adults aged ≥50 years (N=23,065); percentage declines were greatest among children and young adults ≤18 years (38.3%). By cancer site, percentage declines were greatest for lung cancer (17.4%), followed by colorectal (12.0%), breast (9.0%) and prostate (5.8%) cancers. Biweekly reports were statistically significantly lower in 2020 than in 2019 from late March through the end of December in most biweekly periods. The nadir was the month of April 2020 – the number of reports was at least 40% lower than in April 2019. The number of reports in 2020 compared with 2019 also declined sharply in early November (26.8%) and late December (32.0%). Numbers of reports in 2020 never consistently exceeded those in 2019 after the first decline. Patterns were similar by cancer site, with variation in magnitude and duration of declines. Conclusions: Significant declines in cancer pathology reports from population-based registries during 2020 suggest substantial delays in screening, evaluation of signs and symptoms, diagnosis, and treatment services for cancers with effective screening tests as well as in cancer sites and age groups without effective screening tests as an indirect result of the COVID-19 pandemic. Ongoing evaluation will be critical for informing public health efforts to minimize any lasting adverse effects of the pandemic on cancer screening, diagnosis, treatment, and survival.[Table: see text]
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Affiliation(s)
| | - Xiao-Cheng Wu
- LSU Health Sciences Center School of Public Health, New Orleans, LA
| | | | | | - Linda Coyle
- Information Management Services (IMS), Inc, Calverton, MD
| | | | - Brent Mumphrey
- Louisiana State University Health Sciences Center, New Orleans, LA
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Wallner LP, Banerjee M, Reyes-Gastelum D, Hamilton AS, Ward KC, Lubitz C, Hawley ST, Haymart MR. Multilevel Factors Associated With More Intensive Use of Radioactive Iodine for Low-Risk Thyroid Cancer. J Clin Endocrinol Metab 2021; 106:e2402-e2412. [PMID: 33687063 PMCID: PMC8118575 DOI: 10.1210/clinem/dgab139] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Indexed: 12/28/2022]
Abstract
CONTEXT The use of radioactive iodine (RAI) for low-risk thyroid cancer is common, and variation in its use exists, despite the lack of benefit for low-risk disease and potential harms and costs. OBJECTIVE To simultaneously assess patient- and physician-level factors associated with patient-reported receipt of RAI for low-risk thyroid cancer. METHODS This population-based survey study of patients with newly diagnosed differentiated thyroid cancer identified via the Surveillance Epidemiology and End Results (SEER) registries of Georgia and Los Angeles County included 989 patients with low-risk thyroid cancer, linked to 345 of their treating general surgeons, otolaryngologists, and endocrinologists. We assessed the association of physician- and patient-level factors with patient-reported receipt of RAI for low-risk thyroid cancer. RESULTS Among this sample, 48% of patients reported receiving RAI, and 23% of their physicians reported they would use RAI for low-risk thyroid cancer. Patients were more likely to report receiving RAI if they were treated by a physician who reported they would use RAI for low-risk thyroid cancer compared with those whose physician reported they would not use RAI (adjusted OR: 1.84; 95% CI, 1.29-2.61). The odds of patients reporting they received RAI was 55% lower among patients whose physicians reported they saw a higher volume of patients with thyroid cancer (40+ vs 0-20) (adjusted OR: 0.45; 0.30-0.67). CONCLUSIONS Physician perspectives and attitudes about using RAI, as well as patient volume, influence RAI use for low-risk thyroid cancer. Efforts to reduce overuse of RAI in low-risk thyroid cancer should include interventions targeted toward physicians, in addition to patients.
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Affiliation(s)
- Lauren P Wallner
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
- University of Michigan, Department of Epidemiology, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Mousumi Banerjee
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan, Department of Biostatistics, Ann Arbor, MI, USA
| | | | - Ann S Hamilton
- Keck School of Medicine, University of Southern California, Department of Preventive Medicine, Los Angeles, CA, USA
| | - Kevin C Ward
- Emory University, Department of Epidemiology, Atlanta, GA, USA
| | - Carrie Lubitz
- Massachusetts General Hospital, Department of Surgery, Boston, MA, USA
| | - Sarah T Hawley
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
- University of Michigan, Departments of Health Management and Policy and Health Behavior and Education, Ann Arbor, MI, USA
| | - Megan R Haymart
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
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Woolpert KM, Ward KC, England CV, Lash TL. Validation of LexisNexis Accurint in the Georgia Cancer Registry's Cancer Recurrence and Information Surveillance Program. Epidemiology 2021; 32:434-438. [PMID: 33591053 PMCID: PMC8012233 DOI: 10.1097/ede.0000000000001327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND LexisNexis Accurint is a database of ~84 billion public records that includes an individual's location of residence. Its ability to track residences longitudinally has not been validated. This study used the Georgia Cancer Registry's (GCR's) Cancer Recurrence and Information Surveillance Program (CRISP) to validate the U.S. state of residence and to examine characteristics of patients not included or who had an inaccurate entry in LexisNexis. METHODS The GCR is routinely linked to the National Death Index (NDI), providing information regarding the state of residence in which the patient died. We compared the state of residence reported in LexisNexis with the NDI gold standard state of residence at death. Multivariate logistic regression analyses estimated associations between demographic information and: (1) having a mismatch between LexisNexis and NDI and (2) being missed in LexisNexis. RESULTS Of the 69,494 patients in the CRISP cohort, 65,890 (95%) were found in LexisNexis and 9,597 (14%) had died. Among a subset of patients who were deceased, the sensitivity of LexisNexis for identifying persons who left Georgia was 42% and the specificity was 89%. Minority groups were more likely to be missed in the LexisNexis database as well as to have discordance between LexisNexis and NDI state of residence at death. CONCLUSIONS LexisNexis Accurint failed to identify the emigration of more than half of deceased CRISP patients who had left Georgia but correctly identified most who had remained. The validity of the state of residence is important for studies using LexisNexis as a tool for follow-up.
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Affiliation(s)
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, GA
| | | | - Timothy L Lash
- Department of Epidemiology, Emory University, Atlanta, GA
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Kurian AW, Ward KC, Abrahamse P, Bondarenko I, Hamilton AS, Deapen D, Morrow M, Berek JS, Hofer TP, Katz SJ. Time Trends in Receipt of Germline Genetic Testing and Results for Women Diagnosed With Breast Cancer or Ovarian Cancer, 2012-2019. J Clin Oncol 2021; 39:1631-1640. [PMID: 33560870 DOI: 10.1200/jco.20.02785] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Genetic testing is important for breast and ovarian cancer risk reduction and treatment, yet little is known about its evolving use. METHODS SEER records of women of age ≥ 20 years diagnosed with breast or ovarian cancer from 2013 to 2017 in California or Georgia were linked to the results of clinical germline testing through 2019. We measured testing trends, rates of variants of uncertain significance (VUS), and pathogenic variants (PVs). RESULTS One quarter (25.2%) of 187,535 patients with breast cancer and one third (34.3%) of 14,689 patients with ovarian cancer were tested; annually, testing increased by 2%, whereas the number of genes tested increased by 28%. The prevalence of test results by gene category for breast cancer cases in 2017 were BRCA1/2, PVs 5.2%, and VUS 0.8%; breast cancer-associated genes or ovarian cancer-associated genes (ATM, BARD1, BRIP1, CDH1, CHEK2, EPCAM, MLH1, MSH2, MSH6, NBN, NF1, PALB2, PMS2, PTEN, RAD51C, RAD51D, STK11, and TP53), PVs 3.7%, and VUS 12.0%; other actionable genes (APC, BMPR1A, MEN1, MUTYH, NF2, RB1, RET, SDHAF2, SDHB, SDHC, SDHD, SMAD4, TSC1, TSC2, and VHL) PVs 0.6%, and VUS 0.5%; and other genes, PVs 0.3%, and VUS 2.6%. For ovarian cancer cases in 2017, the prevalence of test results were BRCA1/2, PVs 11.0%, and VUS 0.9%; breast or ovarian genes, PVs 4.0%, and VUS 12.6%; other actionable genes, PVs 0.7%, and VUS 0.4%; and other genes, PVs 0.3%, and VUS 0.6%. VUS rates doubled over time (2013 diagnoses: 11.2%; 2017 diagnoses: 26.8%), particularly for racial or ethnic minorities (47.8% Asian and 46.0% Black, v 24.6% non-Hispanic White patients; P < .001). CONCLUSION A testing gap persists for patients with ovarian cancer (34.3% tested v nearly all recommended), whereas adding more genes widened a racial or ethnic gap in VUS results. Most PVs were in 20 breast cancer-associated genes or ovarian cancer-associated genes; testing other genes yielded mostly VUS. Quality improvement should focus on testing indicated patients rather than adding more genes.
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Affiliation(s)
- Allison W Kurian
- Departments of Medicine and of Epidemiology & Population Health, Stanford University, Stanford, CA
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Paul Abrahamse
- Department of Health Management and Policy, School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Irina Bondarenko
- Department of Health Management and Policy, School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Ann S Hamilton
- Department of Preventive Medicine in the Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Dennis Deapen
- Department of Preventive Medicine in the Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Monica Morrow
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jonathan S Berek
- Department of Obstetrics and Gynecology and Women's Cancer Center, Stanford University, Stanford, CA
| | - Timothy P Hofer
- Department of Internal Medicine, University of Michigan and Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Steven J Katz
- Department of Health Management and Policy, School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, MI
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Kurian AW, Ward KC, Abrahamse P, Hamilton AS, Katz SJ. Predicted Chemotherapy Benefit for Breast Cancer Patients With Germline Pathogenic Variants in Cancer Susceptibility Genes. JNCI Cancer Spectr 2021; 5:pkaa083. [PMID: 33426465 PMCID: PMC7785044 DOI: 10.1093/jncics/pkaa083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/31/2020] [Indexed: 11/30/2022] Open
Abstract
Breast cancer patients increasingly undergo genetic testing. To examine chemotherapy indications for germline pathogenic variant (PV) carriers, we linked results of germline testing to Georgia and California Surveillance, Epidemiology, and End Results registry records, including 21-gene recurrence score (RS) results, for breast cancer patients diagnosed in 2013-2017. All statistical tests were 2-sided. Patients (N=37 349) had RS results of whom 714 had BRCA1, BRCA2, CHEK2, ATM, PALB2, or Lynch syndrome (MLH1, MSH2, MSH6, PMS2) PVs. For women aged 50 years or older at breast cancer diagnosis, RS often exceeded the chemotherapy benefit threshold (≥26) with BRCA1 (71.7% vs 14.4% with none; P <.001), PALB2 (37.1%; P = .001), and BRCA2 (44.3%; P < .001) PVs. Results were similar for women diagnosed at younger than 50 years of age. PVs in BRCA1, but not BRCA2, PALB2, ATM, CHEK2, or Lynch syndrome genes, were associated with elevated RS on multivariable analysis (P < .001). Results may inform RS testing decisions in breast cancer patients with PVs.
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Affiliation(s)
- Allison W Kurian
- Department of Medicine and of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Paul Abrahamse
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Steven J Katz
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Collin LJ, Gaglioti AH, Beyer KM, Zhou Y, Moore MA, Nash R, Switchenko JM, Miller-Kleinhenz JM, Ward KC, McCullough LE. Neighborhood-Level Redlining and Lending Bias Are Associated with Breast Cancer Mortality in a Large and Diverse Metropolitan Area. Cancer Epidemiol Biomarkers Prev 2021; 30:53-60. [PMID: 33008873 PMCID: PMC7855192 DOI: 10.1158/1055-9965.epi-20-1038] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/29/2020] [Accepted: 09/28/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Structural inequities have important implications for the health of marginalized groups. Neighborhood-level redlining and lending bias represent state-sponsored systems of segregation, potential drivers of adverse health outcomes. We sought to estimate the effect of redlining and lending bias on breast cancer mortality and explore differences by race. METHODS Using Georgia Cancer Registry data, we included 4,943 non-Hispanic White (NHW) and 3,580 non-Hispanic Black (NHB) women with a first primary invasive breast cancer diagnosis in metro-Atlanta (2010-2014). Redlining and lending bias were derived for census tracts using the Home Mortgage Disclosure Act database. We calculated hazard ratios and 95% confidence intervals (CI) for the associations of redlining, lending bias on breast cancer mortality and estimated race-stratified associations. RESULTS Overall, 20% of NHW and 80% of NHB women lived in redlined census tracts, and 60% of NHW and 26% of NHB women lived in census tracts with pronounced lending bias. Living in redlined census tracts was associated with a nearly 1.60-fold increase in breast cancer mortality (hazard ratio = 1.58; 95% CI, 1.37-1.82) while residing in areas with substantial lending bias reduced the hazard of breast cancer mortality (hazard ratio = 0.86; 95% CI, 0.75-0.99). Among NHB women living in redlined census tracts, we observed a slight increase in breast cancer mortality (hazard ratio = 1.13; 95% CI, 0.90-1.42); among NHW women the association was more pronounced (hazard ratio = 1.39; 95% CI, 1.09-1.78). CONCLUSIONS These findings underscore the role of ecologic measures of structural racism on cancer outcomes. IMPACT Place-based measures are important contributors to health outcomes, an important unexplored area that offers potential interventions to address disparities.
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Affiliation(s)
- Lindsay J Collin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Anne H Gaglioti
- National Center for Primary Care, Department of Family Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Kristen M Beyer
- Division of Epidemiology, Institute for Health & Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yuhong Zhou
- Division of Epidemiology, Institute for Health & Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Miranda A Moore
- Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jeffrey M Switchenko
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lauren E McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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50
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Kovatch KJ, Reyes-Gastelum D, Sipos JA, Caoili EM, Hamilton AS, Ward KC, Haymart MR. Physician Confidence in Neck Ultrasonography for Surveillance of Differentiated Thyroid Cancer Recurrence. JAMA Otolaryngol Head Neck Surg 2020; 147:2774497. [PMID: 33355635 PMCID: PMC7758830 DOI: 10.1001/jamaoto.2020.4471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/05/2020] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Neck ultrasonography, a mainstay of long-term surveillance for recurrence of differentiated thyroid cancer (DTC), is routinely used by endocrinologists, general surgeons, and otolaryngologists; however, physician confidence in their ability to use ultrasonography to identify lymph nodes suggestive of cancer recurrence remains unknown. OBJECTIVE To evaluate physicians' posttreatment surveillance practices for DTC recurrence, specifically their use of and confidence in ultrasonography. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of 448 physicians in private and academic hospitals who completed a survey on DTC posttreatment practices from October 2018 to August 2019 (response rate, 69%) and self-reported involvement in long-term surveillance for thyroid cancer recurrence. Physicians were identified by patients affiliated with the Surveillance, Epidemiology, and End Results Program registries in Georgia State and Los Angeles County. Of the respondents, 320 physicians who reported involvement with DTC surveillance were included in the analysis. MAIN OUTCOMES AND MEASURES Physician-reported long-term surveillance practices for DTC, including frequency of use and level of confidence in ultrasonography for detecting lymph nodes suggestive of cancer recurrence. RESULTS In the cohort of 320 physicians who reported involvement with DTC surveillance, 186 (60%) had been in practice for 10 years to less than 30 years; 209 (68%) were White; and 212 (66%) were men. The physicians included 170 (56%) endocrinologists, 67 (21%) general surgeons, and 75 (23%) otolaryngologists. Just 84 (27%) physicians reported personally performing bedside ultrasonography. Only 57 (20%) had high confidence (rated quite or extremely confident) in their ability to use bedside ultrasonography to identify lymph nodes suggestive of recurrence; 94 (33%) did not report high confidence in either their ability or a radiologist's ability to use ultrasonography to detect recurrence. Higher confidence in ultrasonography was associated with the general surgery subspecialty (odds ratio [OR], 5.7; 95% CI, 2.2-14.4; reference endocrinology) and with treating a higher number of patients per year (>50 patients: OR, 14.4; 95% CI, 4.4-47.4; 31-50 patients: OR, 8.4; 95% CI, 2.6-26.7; 11-30 patients: OR, 4.3; 95% CI, 1.5-12.1; reference 0-10 patients). CONCLUSIONS AND RELEVANCE Given the importance of neck ultrasonography in long-term surveillance for thyroid cancer, these findings of physicians' low confidence in their own ability and that of radiologists to use ultrasonography to detect recurrence point to a major obstacle to standardizing long-term DTC surveillance practices.
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Affiliation(s)
- Kevin J. Kovatch
- Department of Otolaryngology–Head & Neck Surgery, Vanderbilt Bill Wilkerson Center, Vanderbilt University, Nashville, Tennessee
| | - David Reyes-Gastelum
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor
| | | | | | - Ann S. Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Megan R. Haymart
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor
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