Variation in patterns of second primary malignancies across U.S. race and ethnicity groups: a Surveillance, Epidemiology, and End Results (SEER) analysis.

PURPOSE: One in six incident cancers in the U.S. is a second primary cancer (SPC). Although primary cancers vary considerably by race and ethnicity, little is known about the population-based occurrence of SPC across these groups. METHODS: Using Surveillance, Epidemiology, and End Results (SEER) 12 data and relative to the general population, we calculated standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) for SPC among 2,457,756 Hispanics, non-Hispanic Asian American/Pacific Islanders (NHAAPI), non-Hispanic black (NHB), and non-Hispanic whites (NHW) cancer survivors aged 45 years or older when diagnosed with a first primary cancer (FPC) from 1992 to 2015. RESULTS: The risk of second primary bladder cancer after first primary prostate cancer was higher than expected in Hispanic (SIR = 1.18, 95% CI: 1.01-1.38) and NHAAPI (SIR = 1.41, 95% CI: 1.20-1.65) men than NHB and NHW men. Among women with a primary breast cancer, Hispanic, NHAAPI, and NHB women had a nearly 1.5-fold higher risk of a second primary breast cancer, while NHW women had a 6% lower risk. Among men with prostate cancer whose SPC was diagnosed 2 to <12 months, NHB men were at higher risk for colorectal cancer and Hispanic and NHW men for non-Hodgkin's lymphoma. In the same time frame for breast cancer survivors, Hispanic and NHAAPI women were significantly more likely than NHB and NHW women to be diagnosed with a second primary lung cancer. CONCLUSION: Future studies of SPC should investigate the role of shared etiologies, stage of diagnosis, treatment, and lifestyle factors after cancer survival across different racial and ethnic populations.

Patient and physician perspectives on treatments for low-risk prostate cancer: a qualitative study.

BACKGROUND: Patients diagnosed with low-risk prostate cancer (PCa) are confronted with a difficult decision regarding whether to undergo definitive treatment or to pursue an active surveillance protocol. This is potentially further complicated by the possibility that patients and physicians may place different value on factors that influence this decision. We conducted a qualitative investigation to better understand patient and physician perceptions of factors influencing treatment decisions for low-risk PCa. METHODS: Semi-structured interviews were conducted among 43 racially and ethnically diverse patients diagnosed with low-risk PCa, who were identified through a population-based cancer registry, and 15 physicians who were selected to represent a variety of practice settings in the Greater San Francisco Bay Area. RESULTS: Patients and physicians both described several key individual (e.g., clinical) and interpersonal (e.g., healthcare communications) factors as important for treatment decision-making. Overall, physicians' perceptions largely mirrored patients' perceptions. First, we observed differences in treatment preferences by age and stage of life. At older ages, there was a preference for less invasive options. However, at younger ages, we found varying opinions among both patients and physicians. Second, patients and physicians both described concerns about side effects including physical functioning and non-physical considerations. Third, we observed differences in expectations and the level of difficulty for clinical conversations based on information needs and resources between patients and physicians. Finally, we discovered that patients and physicians perceived patients' prior knowledge and the support of family/friends as facilitators of clinical conversations. CONCLUSIONS: Our study suggests that the gap between patient and physician perceptions on the influence of clinical and communication factors on treatment decision-making is not large. The consensus we observed points to the importance of developing relevant clinical communication roadmaps as well as high quality and accessible patient education materials.

Factors that influence treatment decisions: A qualitative study of racially and ethnically diverse patients with low- and very-low risk prostate cancer.

BACKGROUND: Factors that influence prostate cancer treatment decisions are complex, multifaceted, and personal, and may vary by race/ethnicity. Although research has been published to quantify factors involved in decision-making, these studies have been limited to primarily white, and to a lesser extent, Black patients, and quantitative studies are limited for discerning the cultural and contextual processes that shape decision-making. METHODS: We conducted 43 semi-structured interviews with a racially and ethnically diverse sample of patients diagnosed with low- and very-low risk prostate cancer who had undergone treatment for their prostate cancer. Interviews were transcribed, independently coded, and analyzed to identify themes salient for decision-making, with attention to sociocultural differences. RESULTS: We found racial and ethnic differences in three areas. First, we found differences in how socialized masculinity influenced patient's feelings about different treatment options. Second, we found that for some men, religion and spirituality alleviated anxiety associated with the active surveillance protocol. Finally, for racially and ethnically minoritized patients, we found descriptions of how historic and social experiences within the healthcare system influenced decision-making. CONCLUSIONS: Our study adds to the current literature by expounding on racial and ethnic differences in the multidimensional, nuanced factors related to decision-making. Our findings suggest that factors associated with prostate cancer decision-making can manifest differently across racial and ethnic groups, and provide some guidance for future research.

Associations of Renal Cell Carcinoma Subtype with Patient Demographics, Comorbidities, and Neighborhood Socioeconomic Status in the California Population.

BACKGROUND: Renal cell carcinoma (RCC) subtypes differ in molecular characteristics and prognosis. We investigated the associations of RCC subtype with patient demographics, comorbidity, and neighborhood socioeconomic status (nSES). METHODS: Using linked California Cancer Registry and Office of Statewide Health Planning and Development data, we identified history of hypertension, diabetes, and kidney disease prior to RCC diagnosis in Asian/Pacific Islander, non-Latino Black, Latino, and non-Latino White adults diagnosed with their first pathologically confirmed RCC from 2005 through 2015. We used multinomial multivariable logistic regression to model the association of demographics, comorbidity, and nSES with clear-cell, papillary, and chromophobe RCC subtype. RESULTS: Of the 40,016 RCC cases included, 62.6% were clear cell, 10.9% papillary, and 5.9% chromophobe. The distribution of subtypes differed strikingly by race and ethnicity, ranging from 40.4% clear cell and 30.4% papillary in non-Latino Black adults to 70.7% clear cell and 4.5% papillary in Latino adults. In multivariable analysis, non-Latino Black individuals had a higher likelihood of presenting with papillary (OR, 3.99; 95% confidence interval, 3.61-4.42) and chromophobe (OR, 1.81; 1.54-2.13) versus clear-cell subtype compared with non-Latino White individuals. Both hypertension (OR, 1.19; 1.10-1.29) and kidney disease (OR, 2.38; 2.04-2.77 end-stage disease; OR, 1.52; 1.33-1.72 non-end-stage disease) were associated with papillary subtype. Diabetes was inversely associated with both papillary (OR, 0.63; 0.58-0.69) and chromophobe (OR, 0.61; 0.54-0.70) subtypes. CONCLUSIONS: RCC subtype is independently associated with patient demographics, and comorbidity. IMPACT: Targeted RCC treatments or RCC prevention efforts may have differential impact across population subgroups.

Patient-level factors influencing adherence to follow-up imaging recommendations.

PURPOSE: To determine which, if any, patient-level factors were associated with differences in completion of follow-up imaging recommendations at a tertiary academic medical center. METHODS: In this IRB-approved, retrospective cohort study, approximately one month of imaging recommendations were reviewed from 2017 at a single academic institution that contained key words recommending follow-up imaging. Age, gender, race/ethnicity, insurance, smoking history, primary language, BMI, and home address were recorded via chart extraction. Home addresses were geocoded to Census Block Groups and assigned to a quintile of neighborhood socioeconomic status. A multivariate logistic regression model was used to evaluate each predictor variable with significance set to p = 0.05. RESULTS: A total of 13,421 imaging reports that included additional follow-up recommendations were identified. Of the 1013 included reports that recommended follow-up, 350 recommended additional imaging and were analyzed. Three hundred eight (88.00%) had corresponding follow-up imaging present and the insurance payor was known for 266 (86.36%) patients: 146 (47.40%) had commercial insurance, 35 (11.36%) had Medicaid, and 85 (27.60%) had Medicare. Patients with Medicaid had over four times lower odds of completing follow-up imaging compared to patients with commercial insurance (OR 0.24, 95% CI 0.06-0.88, p = 0.032). Age, gender, race/ethnicity, smoking history, primary language, BMI, and neighborhood socioeconomic status were not independently associated with differences in follow-up imaging completion. CONCLUSION: Patients with Medicaid had decreased odds of completing follow-up imaging recommendations compared to patients with commercial insurance.

Survival of Patients With Primary Osseous Malignancies of the Mobile Spine Is Associated With Access to "Standard Treatment" Protocols.

INTRODUCTION: Malignancies of the mobile spine carry high morbidity and mortality. This study sought to examine factors associated with receipt of "standard" treatment and survival for patients with primary mobile spine tumors in the California Cancer Registry (CCR). METHODS: The CCR (1988 to 2016) data were obtained for patients with primary tumors of the mobile spine and at least 1-year follow-up. Sacrum/pelvis tumors were excluded. Age at diagnosis, sex, race, neighborhood socioeconomic status, insurance, Charlson Comorbidity Index, histologic diagnosis, stage at diagnosis, and treatment at a National Cancer Institute-designated Cancer Center (NCICC) were collected. Multivariate analyses were done to identify factors associated with all-cause mortality and receipt of "standard" treatment. RESULTS: Four hundred eighty-four patients (64% White, 56% low neighborhood socioeconomic status, and 36% privately insured) were included. Chordoma (37%) was the most common diagnosis. Only 16% had metastatic disease at presentation. Only 29% received treatment at an NCICC. Lower age, Charlson Comorbidity Index, less extensive stage of disease, and private insurance were associated with lower all-cause mortality (all P < 0.05). Medicaid/public insurance (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.13 to 2.41) and Medicare (HR, 1.80; 95% CI, 1.25 to 2.59) were associated with higher mortality compared with private insurance. Patients who received no known treatment (HR, 2.41; CI, 1.51 to 3.84) or treatment other than the "standard" (HR, 1.45; CI, 1.11 to 1.91) had higher mortality compared with those who received the standard protocols. A critical predictor of receiving the standard treatment protocol was being treated at an NCICC. If patients did not receive care at such institutions, they received optimal treatment only 40% of the time (HR, 0.5; P = 0.004). CONCLUSIONS: Receipt of defined "standard treatment" protocols was associated with care received at an NCICC and lower all-cause mortality in patients with primary osseous malignancies of the mobile spine. Patients with public insurance are vulnerable to worse outcomes, regardless of age, disease burden, or receipt of standard treatment. LEVEL OF EVIDENCE: III.

Contributions of Social Factors to Disparities in Prostate Cancer Risk Profiles among Black Men and Non-Hispanic White Men with Prostate Cancer in California.

BACKGROUND: Black men are more likely than Non-Hispanic White (NHW) men to be diagnosed with high-risk prostate cancer. We examined the extent to which social factors were associated with differences in prostate cancer risk profiles between Black men and NHW men [using a modification to the original D'Amico risk groups based on prostate specific antigen (PSA), Gleason score (GS), and TNM stage (stage)], based on individual and combined clinicopathologic characteristics. METHODS: We conducted a cross-sectional population-based study of 23,555 Black men and 146,889 NHW men diagnosed with prostate cancer in the California Cancer Registry from 2004 to 2017. We conducted multivariable logistic regression to examine the association of year of diagnosis, block group-level neighborhood socioeconomic status (nSES), marital status, and insurance type on differences in prostate cancer risk profiles between Black and NHW men. RESULTS: High PSA (>20 ng/mL), GS, stage, individually and combined prostate cancer risk profiles were more common among Black men versus NHW men. In fully adjusted models, relative to NHW men, we observed a persistent 67% increased odds of high PSA among Black men. nSES was the factor most strongly associated with racial disparity in high PSA, accounting for 25% of the difference. Marital status was the factor that was second most associated with a racial disparity. CONCLUSIONS: nSES was the factor most strongly associated with racial disparities in high PSA prostate cancer. IMPACT: The influence of nSES on racial disparities in PSA, GS, stage, and prostate cancer risk profiles warrants further consideration.

Integrating Electronic Health Record, Cancer Registry, and Geospatial Data to Study Lung Cancer in Asian American, Native Hawaiian, and Pacific Islander Ethnic Groups.

BACKGROUND: A relatively high proportion of Asian American, Native Hawaiian, and Pacific Islander (AANHPI) females with lung cancer have never smoked. We used an integrative data approach to assemble a large-scale cohort to study lung cancer risk among AANHPIs by smoking status with attention to representation of specific AANHPI ethnic groups. METHODS: We leveraged electronic health records (EHRs) from two healthcare systems-Sutter Health in northern California and Kaiser Permanente Hawai'i-that have high representation of AANHPI populations. We linked EHR data on lung cancer risk factors (i.e., smoking, lung diseases, infections, reproductive factors, and body size) to data on incident lung cancer diagnoses from statewide population-based cancer registries of California and Hawai'i for the period between 2000 and 2013. Geocoded address data were linked to data on neighborhood contextual factors and regional air pollutants. RESULTS: The dataset comprises over 2.2 million adult females and males of any race/ethnicity. Over 250,000 are AANHPI females (19.6% of the female study population). Smoking status is available for over 95% of individuals. The dataset includes 7,274 lung cancer cases, including 613 cases among AANHPI females. Prevalence of never-smoking status varied greatly among AANHPI females with incident lung cancer, from 85.7% among Asian Indian to 14.4% among Native Hawaiian females. CONCLUSION: We have developed a large, multilevel dataset particularly well-suited to conduct prospective studies of lung cancer risk among AANHPI females who never smoked. IMPACT: The integrative data approach is an effective way to conduct cancer research assessing multilevel factors on cancer outcomes among small populations.

Disparities in PET Imaging for Prostate Cancer at a Tertiary Academic Medical Center.

The purpose of this study was to evaluate differences between patients receiving 18F-fluciclovine and 68Ga-prostate-specific membrane antigen (68Ga-PSMA-11) for biochemically recurrent prostate cancer at a tertiary medical center. Methods: All 18F-fluciclovine and 68Ga-PSMA-11 PET studies performed at the University of California San Francisco from October 2015 to January 2020 were reviewed. Age, race/ethnicity, primary language, body mass index, insurance type, and home address were obtained through the electronic medical record. A logistic regression model was used to evaluate the predictor variables. Results: In total, 1,502 patients received 68Ga-PSMA-11 and 254 patients received 18F-fluciclovine. Black patients had increased odds of receiving imaging with 18F-fluciclovine versus 68Ga-PSMA-11 compared with non-Hispanic White patients (odds ratio, 3.88; 95% CI, 1.90-7.91). There were no other statistically significant differences. Conclusion: In patients receiving molecular imaging for prostate cancer at a single U.S. tertiary medical center, access to 68Ga-PSMA-11 for Black patients was limited, compared with non-Hispanic White patients, by a factor of nearly 4.

Testicular cancer in Hispanics: incidence of subtypes over time according to neighborhood sociodemographic factors in California.

PURPOSE: Hispanic men in the USA experience the second-highest incidence rate of testicular germ cell tumors (TGCTs), behind non-Hispanic (NH) White men, and have experienced steep increases in TGCT in recent decades. It is unknown whether increases in incidence differ according to neighborhood sociodemographic factors. METHODS: We conducted a population-based study of n = 3759 Hispanic and n = 8469 NH White men (n = 12,228 total) diagnosed with TGCT in California during the three most recent pericensal periods. We calculated incidence rates according to neighborhood socioeconomic status (nSES) and among Hispanics, according to ethnic enclave. We calculated incidence rate ratios to compare rates across nSES and ethnic enclave and to examine changes in rates over pericensal time periods according to these neighborhood factors for major histologic types (i.e., seminoma and nonseminoma). RESULTS: Hispanic men residing in high SES, compared to low SES, neighborhoods had greater incidence of seminoma and nonseminoma testicular cancer across pericensal periods, as did Hispanic men in low enclave (less ethnic), compared to high enclave, neighborhoods. Between the periods 1998-2002 and 2008-2012, Hispanic men residing in low SES neighborhoods experienced a 39% increased incidence of seminoma, while those residing in low and middle SES neighborhoods experienced 87% and 48% increased incidence of nonseminoma, respectively. CONCLUSION: While TGCT incidence has increased among all Hispanic men, incidence increases appear to be driven disproportionately by those residing in lower SES and lower enclave neighborhoods, particularly for nonseminoma.

Population-Based Registry Linkages to Improve Validity of Electronic Health Record-Based Cancer Research.

BACKGROUND: There is tremendous potential to leverage the value gained from integrating electronic health records (EHR) and population-based cancer registry data for research. Registries provide diagnosis details, tumor characteristics, and treatment summaries, while EHRs contain rich clinical detail. A carefully conducted cancer registry linkage may also be used to improve the internal and external validity of inferences made from EHR-based studies. METHODS: We linked the EHRs of a large, multispecialty, mixed-payer health care system with the statewide cancer registry and assessed the validity of our linked population. For internal validity, we identify patients that might be "missed" in a linkage, threatening the internal validity of an EHR study population. For generalizability, we compared linked cases with all other cancer patients in the 22-county EHR catchment region. RESULTS: From an EHR population of 4.5 million, we identified 306,554 patients with cancer, 26% of the catchment region patients with cancer; 22.7% of linked patients were diagnosed with cancer after they migrated away from our health care system highlighting an advantage of system-wide linkage. We observed demographic differences between EHR patients and non-EHR patients in the surrounding region and demonstrated use of selection probabilities with model-based standardization to improve generalizability. CONCLUSIONS: Our experiences set the foundation to encourage and inform researchers interested in working with EHRs for cancer research as well as provide context for leveraging linkages to assess and improve validity and generalizability. IMPACT: Researchers conducting linkages may benefit from considering one or more of these approaches to establish and evaluate the validity of their EHR-based populations.See all articles in this CEBP Focus section, "Modernizing Population Science."

Differential use of medical versus surgical androgen deprivation therapy for patients with metastatic prostate cancer.

BACKGROUND: Surgical and medical androgen deprivation therapy (ADT) strategies are comparable in their ability to suppress serum testosterone levels as treatment in patients with metastatic prostate cancer but differ with regard to cost and impact on quality of life. Medical ADT is associated with better long-term quality of life due to the flexibility of possible therapy interruption but comes with a higher cumulative cost. In the current study, the authors examined whether surgical ADT (ie, bilateral orchiectomy) was used differentially by race/ethnicity and other social factors. METHODS: The authors identified patients with metastatic disease at the time of diagnosis through the California Cancer Registry. The association between race/ethnicity and receipt of surgical ADT was modeled using multivariable Firth logistic regression adjusting for age, Gleason score, prostate-specific antigen level, clinical tumor and lymph node classification, neighborhood socioeconomic status (SES), insurance, marital status, comorbidities, initial treatment (radiotherapy, chemotherapy), location of care, rural/urban area of residence, and year of diagnosis. RESULTS: The authors examined a total of 10,675 patients with metastatic prostate cancer, 11.4% of whom were non-Hispanic black, 8.4% of whom were Asian/Pacific Islander, 18.5% of whom were Hispanic/Latino, and 60.5% of whom were non-Hispanic white. In the multivariable model, patients found to be more likely to receive surgical ADT were Hispanic/Latino (odds ratio [OR], 1.32; 95% confidence interval [95% CI], 1.01-1.72), were from a low neighborhood SES (OR, 1.96; 95% CI, 1.34-2.89) or rural area (OR, 1.49; 95% CI, 1.15-1.92), and had Medicaid/public insurance (OR, 2.21; 95% CI, 1.58-3.10). Patients with military/Veterans Affairs insurance were significantly less likely to receive surgical ADT compared with patients with private insurance (OR, 0.34; 95% CI, 0.13-0.88). CONCLUSIONS: Race/ethnicity, neighborhood SES, and insurance status appear to be significantly associated with receipt of surgical ADT. Future research will need to characterize other differences in initial treatments among men with advanced prostate cancer based on race/ethnicity and aim to better understand what factors drive the association between surgical ADT among men of Hispanic origin or those from areas with low neighborhood SES.

Survival after diffuse large B-cell lymphoma among children, adolescents, and young adults in California, 2001-2014: A population-based study.

BACKGROUND: This population-based study considered the influence of rituximab on the survival of children (0-19 years), adolescents, and young adults (AYAs, 20-39 years) with diffuse large B-cell lymphoma (DLBCL), including patients with human immunodeficiency virus (HIV) infection. METHODS: Data on 642 children and AYAs diagnosed with DLBCL during 2001-2014 were obtained from the Greater Bay Area Cancer Registry in California. Facility-level reports provided treatment details. The Kaplan-Meier method estimated survival and Cox regression models examined the association between survival and rituximab use, adjusting for sociodemographic and clinical factors. RESULTS: Rituximab use increased from 2001-2007 to 2008-2014 among children (from 32% to 48%), AYAs (from 68% to 84%), and HIV patients (from 57% to 67%). Five-year survival was higher among children (91%) than AYAs (82%). On multivariable analysis, the hazard of death was 44% lower among rituximab recipients, and higher among uninsured patients, those with HIV, and those with advanced stage at diagnosis. HIV patients who received rituximab were 60% less likely to die than nonrecipients. CONCLUSIONS: Our study suggests a benefit of rituximab on the treatment of AYAs and HIV patients with DLBCL. The worse survival observed among HIV-positive and uninsured patients is of concern and calls for further investigation. Careful consideration should be given on whether to recommend rituximab more often on the front-line treatment of children and HIV-positive patients with DLBCL.

Undertreatment of High-Risk Localized Prostate Cancer in the California Latino Population.

Background: The NCCN Clinical Practice Guidelines in Oncology recommend definitive therapy for all men with high-risk localized prostate cancer (PCa) who have a life expectancy >5 years or who are symptomatic. However, the application of these guidelines may vary among ethnic groups. We compared receipt of guideline-concordant treatment between Latino and non-Latino white men in California. Methods: California Cancer Registry data were used to identify 2,421 Latino and 8,636 non-Latino white men diagnosed with high-risk localized PCa from 2010 through 2014. The association of clinical and sociodemographic factors with definitive treatment was examined using logistic regression, overall and by ethnicity. Results: Latinos were less likely than non-Latino whites to receive definitive treatment before (odds ratio [OR], 0.79; 95% CI, 0.71-0.88) and after adjusting for age and tumor characteristics (OR, 0.84; 95% CI, 0.75-0.95). Additional adjustment for sociodemographic factors eliminated the disparity. However, the association with treatment differed by ethnicity for several factors. Latino men with no health insurance were considerably less likely to receive definitive treatment relative to insured Latino men (OR, 0.34; 95% CI, 0.23-0.49), an association that was more pronounced than among non-Latino whites (OR, 0.63; 95% CI, 0.47-0.83). Intermediate-versus high-grade disease was associated with lower odds of definitive treatment in Latinos (OR, 0.75; 95% CI, 0.59-0.97) but not non-Latino whites. Younger age and care at NCI-designated Cancer Centers were significantly associated with receipt of definitive treatment in non-Latino whites but not in Latinos. Conclusions: California Latino men diagnosed with localized high-risk PCa are at increased risk for undertreatment. The observed treatment disparity is largely explained by sociodemographic factors, suggesting it may be ameliorated through targeted outreach, such as that aimed at younger and underinsured Latino men.

Long-Term Survivors of Pancreatic Cancer: A California Population-Based Study.

OBJECTIVES: Pancreatic cancer continues to carry a poor prognosis with survival rates that have had minimal improvement over the past 4 decades. We report a population-based, comprehensive analysis of long-term survivors of pancreatic adenocarcinoma diagnosed in the diverse population of California. METHODS: Data from the California Cancer Registry were used to evaluate long-term survival. A total of 70,442 patients diagnosed with pancreatic adenocarcinoma between 1988 and 2009 were identified. Logistic regression was used to identify factors associated with achieving 5-year survival. RESULTS: The overall 5-year survival was 2.5%, with minimal incremental improvements throughout the 3 decades. Age, stage, degree of differentiation, and surgical resection were associated with 5-year survival. Furthermore, younger age and receiving care at a National Cancer Institute-designated cancer center were similarly correlated with 5-year survival regardless of surgical intervention. In addition, we identified stage, differentiation, and adjuvant chemotherapy as significant factors for long-term survival in surgically resected patients. In the unresectable patients, Asian/Pacific islanders and Hispanics were significantly more likely to reach the 5-year milestone than non-Hispanic whites. CONCLUSIONS: Although pancreatic cancer mortality remains high, our study highlights baseline characteristics, treatment, biological factors, and ethnicity that are associated with long-term survival. These findings may serve as a springboard for further investigation.

Racial disparities in outcomes for high-grade uterine cancer: A California cancer registry study.

BACKGROUND: Endometrial cancer (EC) is the most common gynecologic malignancy. We examined factors affecting overall prognosis and survival among different racial groups diagnosed with high-grade EC. METHODS: We utilized the California Cancer Registry database (CCR) to identify women with high-grade II EC from 1998 to 2009. Using the Kaplan-Meier method, we described disease-specific survival. Survival by stage, race, and time to treatment category was compared using the log-rank test. The associations of race with disease-specific survival were modeled using Cox proportional hazards regression. Covariates were selected a priori. RESULTS: A total of 10 647 patients met study eligibility criteria. The majority of patients in this cohort of high-grade EC were non-Hispanic (NH) white (64.1%), followed by Hispanic (15.7%), Asian (10.4%), and NH black (9.8%). NH black women had higher incidence of certain aggressive histologic subtypes in comparison with NH whites, including serous carcinomas and carcinosarcoma. Non-Hispanic black patients had a worse 5-year disease-specific survival (DSS) when compared to other racial groups. The five-year DSS for NH black women was 54% (51%-57%), compared to NH white women 66% (65%-67%), Hispanic 67% (64%-69%), and Asians 69% (67%-72%) (P < 0.0001). This clear survival disadvantage of NH black women persisted when controlling for other factors. CONCLUSIONS: Non-Hispanic black women have a higher incidence of more aggressive histologic subtypes even among a cohort of women high-grade EC and have a disproportionately worse disease-specific survival after controlling for factors such as age, histologic subtype, stage, time to treatment, and type of treatment.

Trends in incidence and 5-year mortality in men with newly diagnosed, metastatic prostate cancer-A population-based analysis of 2 national cohorts.

BACKGROUND: Early detection has increased prostate cancer (PCa) incidence. Randomized trials have demonstrated that early detection reduces the incidence of de novo metastatic PCa. Concurrently, life-prolonging treatments have been introduced for patients with advanced PCa. On a populations-based level, the authors analyzed whether early detection and improved treatments changed the incidence and 5-year mortality of men with de novo metastatic PCa. METHODS: Men diagnosed with PCa during the periods 1980 to 2011 and 1995 to 2011 were identified in the US Surveillance, Epidemiology, and End Results (SEER) program and the Danish Prostate Cancer Registry (DaPCaR), respectively, and stratified according to period of diagnosis. Age-standardized incidence rates were calculated. Five-year mortality rates for de novo metastatic PCa were analyzed using competing risk analysis. RESULTS: Totals of 426,266 and 47,024 men were identified in SEER and DaPCaR, respectively. Of these, 29,555 and 6874 had de novo metastatic PCa. The incidence of de novo metastatic PCa decreased (from 12.0 to 4.4 per 100,000 men) in the SEER cohort (1980-2011), whereas it increased (from 6.7 to 9.9 per 100,000 men) in the DaPCaR cohort (1995-2011). Five-year PCa mortality in the SEER cohort was stable for men diagnosed with de novo metastatic PCa from 1980 to 1994 and increased slightly in the latest periods studied (P < .0001), whereas it decreased by 16.6% (P < .0001) in the DaPCaR cohort. CONCLUSIONS: Despite earlier detection, de novo metastatic PCa remains associated with a high risk of 5-year disease-specific mortality. The reduced 5-year PCa mortality in the Danish cohort is largely explained by lead-time. Early detection strategies do indeed decrease the incidence of de novo metastatic PCa, as observed in the SEER cohort. This achievement, however, must be weighed against the unsolved issue of overdetection and overtreatment of indolent PCa. Cancer 2018;124:2931-8. © 2018 American Cancer Society.

Validation Study of the American Joint Committee on Cancer Eighth Edition Prognostic Stage Compared With the Anatomic Stage in Breast Cancer.

IMPORTANCE: The American Joint Committee on Cancer (AJCC) eighth edition staging manual introduced a new prognostic stage for breast cancer incorporating biologic factors in addition to traditional anatomic factors. OBJECTIVE: To perform a validation study of the AJCC eighth edition prognostic stage in a single-institution cohort and a large population database. DESIGN, SETTING, AND PARTICIPANTS: Patients with breast cancer treated with surgery as an initial intervention were identified in a prospective institutional database from The University of Texas MD Anderson Cancer Center and the California Cancer Registry. Vital status data were complete through December 31, 2016, in The University of Texas MD Anderson cohort and through December 31, 2014, in the California Cancer Registry cohort. Patients receiving neoadjuvant systemic therapy, those with inflammatory or rare breast cancers, and those with unknown clinicopathologic factors were excluded. Factors evaluated included T, N, and M categories and tumor grade, as well as estrogen receptor, progesterone receptor, and HER2 status. MAIN OUTCOMES AND MEASURES: Disease-specific survival was calculated by the Kaplan-Meier method. The Harrell concordance index (C index) was used to quantify models' predictive performance, and the Akaike information criterion (AIC) was used to compare model fits. RESULTS: A total of 3327 patients with stage I to IIIC breast cancer treated between 2007 and 2013 at The University of Texas MD Anderson Cancer Center (median follow-up of 5 years) with complete clinicopathologic data were identified. Compared with the AJCC anatomic stage, the prognostic stage upstaged 29.5% of patients and downstaged 28.1%. The prognostic stage (C index, 0.8357 and AIC, 816.8) provided more accurate stratification with respect to disease-specific survival than the anatomic stage (C index, 0.737 and AIC, 1039.8) (P < .001 for the C index). A total of 54 727 patients with stage I to IV breast cancer treated between 2005 and 2009 were identified in the California Cancer Registry (median follow-up of 7 years). The prognostic stage upstaged 31.0% of patients and downstaged 20.6%. The prognostic stage (C index, 0.8426 and AIC, 80 661.68) performed better than the anatomic stage (C index, 0.8097 and AIC, 81 577.89) (P < .001 for the C index). CONCLUSIONS AND RELEVANCE: The prognostic stage provided more accurate prognostic information than the anatomic stage alone in both a single-institution cohort and a large population database, thereby supporting its use in breast cancer staging.

Comorbidity index in central cancer registries: the value of hospital discharge data.

BACKGROUND: The presence of comorbid medical conditions can significantly affect a cancer patient's treatment options, quality of life, and survival. However, these important data are often lacking from population-based cancer registries. Leveraging routine linkage to hospital discharge data, a comorbidity score was calculated for patients in the California Cancer Registry (CCR) database. METHODS: California cancer cases diagnosed between 1991 and 2013 were linked to statewide hospital discharge data. A Deyo and Romano adapted Charlson Comorbidity Index was calculated for each case, and the association of comorbidity score with overall survival was assessed with Kaplan-Meier curves and Cox proportional hazards models. Using a subset of Medicare-enrolled CCR cases, the index was validated against a comorbidity score derived using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data. RESULTS: A comorbidity score was calculated for 71% of CCR cases. The majority (60.2%) had no relevant comorbidities. Increasing comorbidity score was associated with poorer overall survival. In a multivariable model, high comorbidity conferred twice the risk of death compared to no comorbidity (hazard ratio 2.33, 95% CI: 2.32-2.34). In the subset of patients with a SEER-Medicare-derived score, the sensitivity of the hospital discharge-based index for detecting any comorbidity was 76.5. The association between overall mortality and comorbidity score was stronger for the hospital discharge-based score than for the SEER-Medicare-derived index, and the predictive ability of the hospital discharge-based score, as measured by Harrell's C index, was also slightly better for the hospital discharge-based score (C index 0.62 versus 0.59, P<0.001). CONCLUSIONS: Despite some limitations, using hospital discharge data to construct a comorbidity index for cancer registries is a feasible and valid method to enhance registry data, which can provide important clinically relevant information for population-based cancer outcomes research.

Regional Variability in Percentage of Breast Cancers Reported as Positive for HER2 in California: Implications of Patient Demographics on Laboratory Benchmarks.

OBJECTIVES: The expected regional variability in percent human epidermal growth factor receptor 2 (HER2)-positive breast cancers is not currently clear. METHODS: Data from the 2006 to 2011 California Cancer Registry were examined by county and health service area. The influence of demographic and pathologic features was used in a multivariable logistic regression model to compare expected with observed HER2-positive percentages by region. RESULTS: There was significant geographic variation by California counties (11.6%-26%). The reported HER2-positive percentage was higher when the population had higher stage, tumor size, grade, percent estrogen receptor negative, younger age, or lower socioeconomic status. Ethnic distribution of the population also influenced HER2-positive percentages. Using a multivariable logistic regression model, most regions had expected values based on their population characteristics; however, "outlier" regions were identified. CONCLUSIONS: These results deepen our understanding of population characteristics' influence on the distribution of HER2-positive breast cancers. Taking these factors into account can be useful when setting laboratory benchmarks and assessing test quality.