Recent cervical cancer incidence, stage at diagnosis, and mortality trends in Puerto Rico, 2001-2019.

BACKGROUND: Cervical cancer incidence is rising in Puerto Rico (PR). Whether the increase is real or reflective of increased diagnostic scrutiny remains unclear. METHODS: Using data from the PR Central Cancer Registry for 2001-2019, we estimated trends of hysterectomy-corrected cervical cancer incidence and mortality rates, overall, and by stage at diagnosis and age. RESULTS: Overall, cervical cancer incidence (per 100,000) increased 1.6%/year (95% CI, -0.5% to 3.8%) from 12.5 to 15.3, with a prominent increase in distant-stage disease (4.5%/year [95% CI, 1.6% to 8.0%]), particularly among screening age eligible (25-64-year-old) women (5.8%/year [95% CI, 2.1% to 10.6%]). Mortality rates in this age-group remained stable during the study period. CONCLUSIONS: Increased occurrence of distant-stage disease among screening-eligible women is troubling and may reflect a real increase. Future research is needed to elucidate the factors underlying these trends. Improved prevention is also an urgent priority to reverse the rising cervical cancer incidence in PR.

Screening History and Survival Among Women With Cervical Cancer in Puerto Rico.

OBJECTIVES: Cervical cancer incidence is rising in Puerto Rico (PR). Screening for cervical cancer could prevent the occurrence of the disease or lead to its early detection, translating to survival benefits. In this study, we evaluated the association of cervical cancer screening status with tumor diagnosis and survival among Hispanic women living in PR. METHODS: We analyzed data for 506 incident cases of primary cervical cancer diagnosed from the period 2011-2014, identified through the PR Central Cancer Registry. We ascertained screening status 3 years before cervical cancer diagnosis using data from the period 2008-2014 from the PR Central Cancer Registry-Health Insurance Linkage Database. Patients were followed until 2019. Our outcomes of interest were stage at diagnosis and survival. RESULTS: Most women (78.86%) were covered by public insurance (Medicare and/or Medicaid), and 69.57% underwent screening 3 years before their diagnosis. The proportion of cases diagnosed with localized stage was significantly greater among the screened group compared with those unscreened (43.5% vs 33.1%, p < .0001). Multivariate analysis showed that women insured through Medicaid were less likely to have been screened when compared with women with private insurance (odds ratio = 0.29; 95% CI = 0.16-0.52). Five-year survival was significantly greater among screened (72%) than unscreened (54%) women (p log-rank < 0.05). The multivariate Cox proportional hazards model showed that women who received screening had a 39% (hazard ratio [HR] = 0.61; 95% CI = 0.43-0.87) lower risk of death compared with unscreened women. CONCLUSION: Our findings exemplify survival benefits among women who underwent cervical cancer screening in PR. Interventions to improve screening uptake and adherence are a public health priority.

Trends in cause of death among patients with multiple myeloma in Puerto Rico and the United States SEER population, 1987-2013.

Multiple myeloma (MM) survival has improved due to recent developments in MM treatment. As a result, other co-morbid conditions may be of increasing importance to MM patients' long-term survival. This study examines trends in common causes of death among patients with MM in Puerto Rico, and in the US Surveillance, Epidemiology, and End Results (SEER) population. We analyzed the primary cause of death among incident MM cases recorded in the Puerto Rico Central Cancer Registry (n = 3,018) and the US SEER Program (n = 67,733) between 1987 and 2013. We calculated the cumulative incidence of death due to the eight most common causes and analyzed temporal trends in mortality rates using joinpoint regression. Analyses of SEER were also stratified by Hispanic ethnicity. MM accounted for approximately 72% of all reported deaths among persons diagnosed with MM in Puerto Rico and in SEER. In both populations, the proportion of patients who died from MM decreased with increasing time since diagnosis. Age-standardized temporal trends showed a decreased MM-specific mortality rate among US SEER (annual percent change [APC] = -5.0) and Puerto Rican (APC = -1.8) patients during the study period, and particularly after 2003 in non-Hispanic SEER patients. Temporal decline in non-MM causes of death was also observed among US SEER (APC = -2.1) and Puerto Rican (APC = -0.1) populations. MM-specific mortality decreased, yet remained the predominant cause of death for individuals diagnosed with MM over a 26-year period. The most pronounced decreases in MM-specific death occurred after 2003, which suggests a possible influence of more recently developed MM therapies.

Incidence of thyroid cancer in Puerto Rico and the US by racial/ethnic group, 2011-2015.

BACKGROUND: Puerto Rico has the highest incidence rate of thyroid cancer (TC) in the Americas and the third highest rate worldwide. The purpose of this study was to compare the burden of TC between the population of PR and United States (US) non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB), and US Hispanics (USH) during the period 2011-2015. METHODS: TC data for the period 2011-2015 was obtained from the Puerto Rico Central Cancer Registry (PRCCR) and the Surveillance Epidemiology and Ends Results Program (SEER) 18 Registries Research Data. TC was categorized in: papillary carcinoma (PTC), and other TC histologic types. Data was analyzed by sex, age groups, and histologic type. Racial/ethnic differences by sex, age, and histologic types were assessed using the Standardized Rate Ratio (SRR) and its 95% CI. RESULTS: During the period 2011-2015 there were 5175 and 65,528 cases of TC diagnosed in PR and the US, respectively. The overall age-adjusted incidence rate of PTC was almost two-fold higher in PR than in the US (25.8/100,000 vs. 12.9/100,000). Among PR women, the incidence rate of PTC was 40.0/100,000 compared to 19.4/100,000 in US. PR women had 83% increased risk of being diagnosed with PTC than NHW women, a 2.25-fold increased risk than USH, and 3.45-fold increased risk than NHB women. For men, PR had 34% increased risk of being diagnosed with PTC than NHW men, 2.2-fold increased risk than USH men, and 3.2-fold higher risk than in NHB men. CONCLUSION: Further research is needed to understand this disparity in the island. This research should address the extent of overdiagnosis in PR, the role of health insurance status and insurance type, characteristics of the healthcare delivery system as well as the role of patient and environmental factors.

Risk of Anal Cancer in Women With a Human Papillomavirus-Related Gynecological Neoplasm: Puerto Rico 1987-2013.

OBJECTIVE: The aim of the study was to estimate the magnitude of the association between HPV-related gynecological neoplasms and secondary anal cancer among women in Puerto Rico (PR). MATERIALS AND METHODS: We identified 9,489 women who had been diagnosed with a primary cervical, vaginal, or vulvar tumor during 1987-2013. To describe the trends of invasive cervical, vulvar, vaginal, and anal cancer, the age-adjusted incidence rates were estimated using the direct method (2000 US as Standard Population). Standardized incidence ratios (observed/expected) were computed using the indirect method; expected cases were calculated using 2 methods based on age-specific rates of anal cancer in PR. The ratio of standardized incidence ratios of anal cancer was estimated using the Poisson regression model to estimate the magnitude of the association between HPV-gynecologic neoplasms and secondary anal cancer. RESULTS: A significant increase in the incidence trend for anal cancer was observed from 1987 to 2013 (annual percent change = 1.1, p < .05), whereas from 2004 to 2013, an increase was observed for cervical cancer incidence (annual percent change = 3.3, p < .05). The risk of secondary anal cancer among women with HPV-related gynecological cancers was approximately 3 times this risk among women with non-HPV-related gynecological cancers (relative risk = 3.27, 95% CI = 1.37 to 7.79). CONCLUSIONS: Anal cancer is increasing among women in PR. Women with gynecological HPV-related tumors are at higher risk of secondary anal cancer as compared with women from the general population and with those with non-HPV-related gynecological cancers. Appropriate anal cancer screening guidelines for high-risk populations are needed, including women with HPV-related gynecological malignancies and potentially other cancer survivors.

Invasive cancer incidence - Puerto Rico, 2007-2011.

UNLABELLED: Cancer is a leading cause of morbidity and death in Puerto Rico. To set a baseline for identifying new trends and patterns of cancer incidence, Puerto Rico Central Cancer Registry staff and CDC analyzed data from Puerto Rico included in U.S. Cancer Statistics (USCS) for 2007-2011, the most recent data available. This is the first report of invasive cancer incidence rates for 2007-2011 among Puerto Rican residents by sex, age, cancer site, and municipality. Cancer incidence rates in Puerto Rico were compared with those in the U.S. population for 2011. A total of 68,312 invasive cancers were diagnosed and reported in Puerto Rico during 2007-2011. The average annual incidence rate was 330 cases per 100,000 persons. The cancer sites with the highest cancer incidence rates included prostate (152), female breast (84), and colon and rectum (43). Cancer incidence rates varied by municipality, particularly for prostate, lung and bronchus, and colon and rectum cancers. In 2011, cancer incidence rates in Puerto Rico were lower for all cancer sites and lung and bronchus, but higher for prostate and thyroid cancers, compared with rates within the U.S. POPULATION: Identifying these variations can aid evaluation of factors associated with high incidence, such as cancer screening practices, and development of targeted cancer prevention and control efforts. Public health professionals can monitor cancer incidence trends and use these findings to evaluate the impact of prevention efforts, such as legislation prohibiting tobacco use in the workplace and public places and the Puerto Rico Cessation Quitline in decreasing lung and other tobacco-related cancers.

Effect of type of health insurance coverage on leukemia survival in adults in Puerto Rico.

OBJECTIVE: In Puerto Rico, leukemia is among the top 10 cancers in terms of incidence and mortality. The aim of the study described herein was to establish the overall leukemia survival rate in Puerto Rico and determine whether there are differences in leukemia survival by type of health insurance coverage. METHODS: Data for adult patients (aged > or = 20 years) diagnosed with leukemia were provided by the Puerto Rico Central Cancer Registry. The relative survival rates (1, 3, and 5 years) were estimated for leukemia patients (diagnosed from 2004 through 2006) by type of health insurance (government health plan [GHP] or non-government health plan [NGHP]). Relative survival is defined as observed survival in the cohort divided by expected survival in the cohort. A Poisson regression model was used to analyze the relative excess risk of death for both the GHP and the NGHP groups. RESULTS: A total of 516 leukemia patients were eligible for analysis. The overall survival rates of leukemia patients in PR for 1, 3, and 5 years after diagnosis were 55.8%, 40.5%, and 34.7%, respectively. Relative survival rates were lower for patients with GHP (1 year = 52.8%; 3 years = 36.4%; 5 years = 32.2%) than they were in people with NGHP (1 year = 57.5%; 3 years = 42.8%; 5 years = 36.1%). Among patients aged 65+ years, those with GHP had a 1.58-fold (95% CI: 1.11-2.27) higher risk of death than did those patients with NGHP. CONCLUSION: Several factors could explain the disparities observed in leukemia survival rates (as grouped by health insurance status) in PR. Some of them include differences in patterns of healthcare coverage, in delays in treatment, in quality of service, in risk factors, and co-morbidities present in the older population studied.

Treatment Patterns and Health Care Resource Utilization of Patients With Non-Small Cell Lung Cancer in Puerto Rico: The TREATLINES-ONCOLUNG Study.

PURPOSE: Lung cancer remains one of the leading causes of cancer-related mortality worldwide. It is the third cause of death among patients with cancer in Puerto Rico (PR) and non-small cell lung cancer (NSCLC) is the most prevalent. This study aims to describe the first-line treatment (1LT) and health care resource utilization (HCRU) among patients with NSCLC in PR. METHODS: A retrospective cohort study was conducted using the PR Central Cancer Registry Health Insurance Linkage Database to describe patients with NSCLC from 2012 to 2016. It describes sociodemographic and clinical characteristics on the basis of stage and histology and includes 1LT patterns and HCRU. RESULTS: A total of 1,011 patients met the inclusion criteria. Most were male (57.1%), married (54.1%), and had no comorbidities (55.8%). A significant proportion of patients (71.1%) were diagnosed at stages III and IV, with nonsquamous cell carcinoma being the most prevalent histology group (75.9%). About 61.7% received systemic therapy, 36.7% received radiotherapy, and 21.9% underwent surgery. Platinum (Pt)-based combinations were the most common 1LT (82.9%). On average, patients had 4.7 emergency room visits, nearly six hospitalizations, and 22.4 outpatient visits annually. The mean frequencies of positron emission tomography, ultrasounds, computerized tomography scans, and magnetic resonance imaging were 0.95, 0.11, 4.88, and 0.91, respectively. CONCLUSION: To our knowledge, this study provides the first description of 1LT patterns, HCRU, and sociodemographic information among patients with NSCLC in PR. A significant number of patients were diagnosed at stage III or higher and received Pt-based systemic therapy as their 1LT. More research is required to investigate treatment patterns beyond the 1LT and to gain a comprehensive understanding of optimal care interventions and factors associated with early NSCLC diagnosis.

Multiple myeloma incidence, mortality, and survival differences at the intersection of sex, age, and race/ethnicity: A comparison between Puerto Rico and the United States SEER population.

BACKGROUND: Multiple myeloma (MM) survival has increased during the last decades due to the introduction of new therapies. We investigated the intersectionality among age, sex, and race/ethnicity to better understand the pattern of MM incidence, mortality, and survival. METHODS: Puerto Rico (PR) Central Cancer Registry and the United States of America (US) Surveillance, Epidemiology, and End Results (SEER) Program databases were used. We analyzed MM incidence and mortality trends from 2001 to 2019 using Joinpoint regression models to calculate annual percent change (APC). Age-standardized rate ratios (SRR) for incidence and mortality were used to compare PR with US SEER racial/ethnic groups during 2015-2019. Five-year survival analyses were also performed stratified by age and sex. RESULTS: Regardless of age and race/ethnicity, males had higher MM incidence and mortality rates than females. PR had a higher increase in incidence rates of MM than other ethnic groups, regardless of sex and age (PR APC = 4.3 among males <65, 3.1 among males ≥65, 6.3 among females <65, and 2.6 among females ≥65 years old). No significant change in mortality APCs (p > 0.05) was observed in PR when stratified by age or sex while other groups showed a decrease. Among males < 65 years, PR had significantly higher incidence rates than non-Hispanic Whites (NHW), and US Hispanics (USH). However, among both males and females ≥ 65 years, PR had significantly lower MM mortality rates than NHW, non-Hispanic Blacks (NHB), USH, and US Overall. In terms of survival, PR showed the lowest 5-year overall survival among males < 65 years (54.6%, 95% CI: 47.2-61.5) and males ≥ 65 years (34.5%, 95% CI: 29.2-39.9) but not among females. CONCLUSION: The incidence of MM in PR increased significantly over the study period, particularly among younger women. Despite the introduction of new therapies, mortality rates in PR have remained stable while other ethnic groups show significant decreases among all intersections of sex and age.

Treatment Interruptions and Mortality Among Puerto Rican Women With Gynecologic Cancers in Puerto Rico After Hurricanes Irma and María: A Retrospective Cohort Study.

OBJECTIVE: Cancer patients are among the most vulnerable populations during and after a disaster. We evaluated the impact of treatment interruption on the survival of women with gynecologic cancer in Puerto Rico following Hurricanes Irma and María. METHODS: A retrospective cohort study among a clinic-based sample of women with gynecological cancer diagnosed between January 2016 and September 2017 (n = 112) was done. Women were followed from their diagnosis until December 2019, to assess vital status. Kaplan-Meier survival curves and Cox proportional hazards models were performed. RESULTS: Mean age was 56 (± 12.3) years; corpus uteri (58.9%) was the most common gynecologic cancer. Predominant treatments were surgery (91.1%) and chemotherapy (44.6%). Overall, 75.9% were receiving treatment before the hurricanes, 16.1% experienced treatment interruptions, and 8.9% died during the follow-up period. Factors associated with treatment interruption in bivariate analysis included younger age (≤55 years), having regional/distant disease, and receiving > 1 cancer treatment (P < 0.05). Crude analysis revealed an increased risk of death among women with treatment interruption (HR: 3.88, 95% CI: 1.09-13.77), persisting after adjusting for age and cancer stage (HR: 2.49, 95% CI: 0.69-9.01). CONCLUSIONS: Findings underscore the detrimental impact of treatment interruption on cancer survival in the aftermath of hurricanes, emphasizing the need for emergency response plans for this vulnerable population.

Racial/ethnic disparities in gastric cancer: A 15-year population-based analysis.

BACKGROUND AND AIMS: Disparities in gastric cancer incidence and mortality have been reported among ethnic/racial groups. While gastric cancer is not common in the U.S., it is among the top 10 causes of cancer-related death among Hispanics living in Puerto Rico (PRH). This study compared gastric cancer incidence rates during a 15-year period (2002-2006, 2007-2011, and 2012-2016) between PRH and racial/ethnic groups in the mainland U.S., including Non-Hispanic Whites (NHW), Non-Hispanics Blacks (NHB), Hispanics (USH), and Non-Hispanic Asian or Pacific Islanders (NHAPI). METHODS: Primary gastric cancer cases (ICD-O-3 codes C16.0 to C16.9) from the Puerto Rico Central Cancer Registry and SEER diagnosed from January 1, 2002 to December 31, 2016 were included in the analysis. The Joinpoint Regression Program and standardized rate ratios were used to estimate Annual Percent Changes (APC) and differences in gastric cancer incidence among racial/ethnic groups, respectively. RESULTS: Our analysis included 83,369 gastric cancer cases (PRH n = 4202; NHW n = 43,164; NHB n = 10,414; NHAPI n = 11,548; USH n = 14,041). USH had the highest number of cases among individuals <50 years, whereas NHW and PRH had the highest percentage among individuals ≥50 years. PRH and USH were the only groups with increasing APCs among individuals <50 years. CONCLUSIONS: Gastric cancer continues to be a common cancer among PRH, despite the overall decrease in incidence among other racial/ethnic groups. Studies evaluating the gastric cancer risk factors among high-risk groups are necessary to establish health policy and modify gastric cancer screening algorithms among Hispanics.

Patterns of use of biological and genetic markers for chronic lymphocytic leukemia and acute myeloid leukemia in Puerto Rico.

BACKGROUND: The use of markers has stimulated the development of more appropriate targeted therapies for chronic lymphocytic leukemia (CLL) and acute myeloid leukemia (AML). We assessed the use and prevalence of biological and genetic markers of CLL and AML in the homogeneous Hispanic population of Puerto Rico. METHODS: We used the Puerto Rico CLL/AML Population-Based Registry, which combines information from linked databases. Logistic regression models were used to examine factors associated with biological and genetic testing. RESULTS: A total of 926 patients 18 years or older diagnosed with CLL (n = 518) and AML (n = 408) during 2011-2015 were included in this analysis. Cytogenetic testing (FISH) was reported for 441 (85.1%) of the CLL patients; of those, 24.0% had the presence of trisomy 12, 9.5% carried deletion 11q, 50.3% carried deletion 13q, and 6.3% carried deletion 17p. Regarding AML, patients with cytogenetics and molecular tests were considered to determine the risk category (254 patients), of which 39.8% showed poor or adverse risk. Older age and having more comorbidities among patients with CLL were associated with a lower likelihood of receiving a FISH test. CONCLUSIONS: Although prognostic genetic testing is required for treatment decisions, the amount of testing in this Hispanic cohort is far from ideal. Furthermore, some tests were not homogeneously distributed in the population, which requires further exploration and monitoring. This study contributes to the field by informing the medical community about the use and prevalence of biological and genetic markers of CLL and AML. Similarly, it has the potential to improve the management of CLL and AML through benchmarking.

Incidence and Mortality Rates for Childhood Acute Lymphoblastic Leukemia in Puerto Rican Hispanics, 2012-2016.

BACKGROUND: Acute lymphoblastic leukemia (ALL) accounts for 80% of all leukemias diagnosed in children. Although ALL age patterns are consistent across racial/ethnic groups, their incidence and mortality rates are highly variable. We assessed the age-standardized ALL incidence and mortality rates of Puerto Rican Hispanic (PRH) children and compared them with those of US mainland Hispanics (USH), non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB), and Non-Hispanic Asian or Pacific Islanders (NHAPI). METHODS: Differences between racial/ethnic groups were assessed by estimating the standardized rate ratio (SRR) for 2010 to 2014. Secondary data analyses of the Puerto Rico Central Cancer Registry and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) databases were performed for the 2001 to 2016 period. RESULTS: PRH children had 31% lower incidence rates than USH, but 86% higher incidence rates than NHB. In addition, the incidence trends of ALL increased significantly from 2001 to 2016 among PRH and USH, with 5% and 0.9% per year, respectively. Moreover, PRH have a lower 5-year overall survival (81.7%) when compared with other racial/ethnic groups. CONCLUSIONS: PRH children were found to have disparities in ALL incidence and mortality rates compared with other racial/ethnic groups in the US. Additional research is warranted to identify the genetic and environmental risk factors that may be associated with the disparities observed. IMPACT: This is the first study reporting the incidence and mortality rates of childhood ALL for PRH and making comparisons with other racial/ethnic groups in the US. See related commentary by Mejía-Aranguré and Núñez-Enríquez, p. 999.

A comparative analysis of endometrial cancer disparities in incidence, mortality, and survival between women living in Puerto Rico, Non-Hispanic Blacks, Non-Hispanic Whites, and US Hispanics between 2000-2018.

Objective:  Endometrial cancer diagnosis in younger women is increasing in Puerto Rico and the United States. The study aims to evaluate the endometrial cancer trends in incidence, mortality, and survival by comparing US ethnic groups (NHW, NHB, and Hispanic) to women living in PR to assess whether disparities exist by age and stage at diagnosis on outcomes of interest. Methods:  We performed a secondary data analysis and comparison of the age-specific and age-adjusted incidence rates, mortality rates, and the survival of endometrial cancer in PR with that of NHB, NHW, and Hispanic using data from the PR Central Cancer Registry, the SEER Program, and PR Demographic Registry from 2000 to 2018. Results:  PR had the highest incidence rates (41.3 per 100,000 women) of endometrial cancer, followed by NHW, NHB, and Hispanic. Women in PR younger than 65 years old had higher incidence rates of endometrial cancer than compared groups. NHB have higher overall mortality rates (12.5 per 100,000 women). Between ages 20-34 and 35-49, women in PR have the highest mortality rates, and after age 50, mortality rates are higher for NHB. Conclusions: Women in PR had higher endometrial cancer incidence rates in increasing trend from 2000 to 2018 compared to similar NHB, Hispanic, and NHW cohorts. Also, women in PR experienced higher incidence and mortality rates below 50 years old among all races and ethnicities. Future studies are needed to evaluate histology, obesity trends, and the impact on the quality of life for this cohort.

Racial/ethnic disparities for leukemias in Puerto Rico and the United States of America, 2015-2019.

BACKGROUND: Leukemia is a cancer of the early-forming cells. Over the past decade, leukemia racial/ethnic disparities have been documented in the United States of America (USA). Although the Puerto Rican population in the USA represents the second-largest Hispanic population in the nation, most of the existing studies do not include Puerto Rico. We compared the incidence and mortality rates for leukemia and its subtypes in Puerto Rico and four racial/ethnic groups in the USA. METHODS: We used data from the Puerto Rico Central Cancer Registry and the Surveillance, Epidemiology, and End Results Program (2015-2019). The racial/ethnic groups studied were non-Hispanic whites (NHW), non-Hispanic blacks (NHB), Hispanics (USH), and Asian/Pacific Islanders (NHAPI) living in the USA and the Puerto Rico population. We calculated the incidence and mortality rates. The relative risk of developing or dying due to leukemia was also calculated. RESULTS: Compared with Puerto Rico, NHW [standardized incidence rate (SIR) = 1.47; 95%CI = 1.40-1.53; standardized mortality rates (SMR) = 1.55; 95%CI = 1.45-1.65)] and NHB (SIR = 1.09; 95%CI = 1.04-1.15; SMR = 1.27; 95%CI = 1.19-1.35) had higher incidence and mortality rates; but lower than the NHAPI (SIR = 0.78; 95%CI = 0.74-0.82; SMR = 0.83; 95%CI = 0.77-0.89); and similar to USH. However, we found differences among leukemia subtypes. For example, NHAPI and USH had lower risk of developing chronic leukemias than Puerto Rico. We found a lower risk to develop acute lymphocytic leukemia in NHB than in Puerto Rico. CONCLUSIONS: Our study provides a better understanding of leukemia's racial/ethnic disparities and fills a knowledge gap by examining the incidence and mortality rates in Puerto Rico. Future studies are needed to better understand the factors influencing the differences found in the incidence and mortality of leukemia among different racial/ethnic groups.

Patterns of End-of-Life Care as Measured by Emergency Room Visits Among Cancer Patients in Puerto Rico.

BACKGROUND: Community palliative care (PC) services are scarce in Puerto Rico (PR). Patients with advanced cancer commonly visit the emergency department(ED) at the end of life (EoL). Recognition of patients with limited life expectancies and PC needs may improve the EoL trajectory of these patients. Our objective was to characterize ED visits of cancer patients at the EoL by examining the patterns of ED visits in PR using the PR Central Cancer Registry-Health Insurance Linkage Database (PRCCR-HILD). METHODS: The cohort consisted of patients aged ≥18 years with a primary invasive that died between 2011- 2017, with a recorded date of death, and who had insurance claims during their last three months. EoL indicators were ED visits, ED death, and hospice care use. RESULTS: The study cohort included 10,755 cancer patients. 49.6% had ≥1 ED visit, 20.3% had ≥2 ED visits, and 9.7% died in the ED. In the adjusted model, female patients (aOR 0.80; 95% CI 0.68-0.93; p-value < 0.01), patients aged ≥80 years (aOR 0.47; 95% CI 0.36-0.63; p-value < 0.01), being enrolled in Medicare (aOR 0.74; 95% CI 0.61-0.90; p-value < 0.01) or being enrolled in Medicaid/Medicare (aOR 0.76; 95% CI 0.62-0.93; p-value = 0.01) were less likely to have an ED visit the date of death. Patients with distant stage are more likely to have ED ≥ 2visits (p-value < 0.05). Conclusions: ED visits at EoL can be interpreted as poor quality cancer care and awareness of the potential of ED-initiated PC is needed in PR.

Induction Therapy and Survival for Acute Myeloid Leukemia in Hispanic Adults from Puerto Rico.

BACKGROUND: Acute myeloid leukemia (AML) is the most common type of leukemia in adults. There are no previous studies evaluating AML treatment patterns in Puerto Rico. We describe the first-line therapy patterns and survival of patients diagnosed with AML in Puerto Rico using the Puerto Rico Central Cancer Registry Health Insurance Linkage Database (2011-2015). METHODS: We describe patient characteristics according to intensive, non-intensive, and non-treatment status. We used Cox proportional hazard models to evaluate the factors associated with the risk of death stratified by intensive and non-intensive therapy. For this study, 385 patients with AML were included. RESULTS: The mean age was 67 years old and 50.1% were female. Nearly half of AML patients (46.8%) received intensive treatment, 23.6% received non-intensive treatment, and 26.2% did not receive treatment. The overall 3-year survival rate was 17.9%. Among those who received intensive therapy, the risk of death among females was lower than males (hazard ratio [HR]: 0.64, 95% confidence interval [CI]: 0.44-0.93). Patients 60 years or older who received intensive treatment had a higher risk of death than younger patients (HR: 1.67, 95% CI: 1.09-2.55). Patients with poor/adverse risk receiving intensive (HR: 3.43, 95% CI: 1.76-6.69) or non-intensive (HR: 4.32, 95% CI: 1.66-11.28) treatment had a higher risk of death than patients with a favorable risk category. CONCLUSION: Our findings are the first step to monitor the quality of care of patients with AML in Puerto Rico, particularly related to the administration of appropriate induction therapies, which is one of the most important predictors of AML survival.

High-Intensity End-of-Life Care Among Patients With GI Cancer in Puerto Rico: A Population-Based Study.

PURPOSE: High-intensity care with undue suffering among patients with cancer at the end of life (EoL) is associated with poor quality of life. We examined the pattern and predictors of high-intensity care among patients with GI cancer in Puerto Rico. METHODS: This population-based study of data from the Puerto Rico Central Cancer Registry-Health Insurance Linkage Database examined patients with GI cancer who died between 2009 and 2017. EoL care intensity indicators include the following services in the last month before death: emergency room (ER) visits, hospitalizations, intensive care unit (ICU) admissions, life-extending procedures, death in an acute care setting, and the use of chemotherapy in the last 14 days. We used logistic regression models to examine factors associated with EoL care. RESULTS: Four thousand six hundred twenty-nine patients with GI cancer were included in the analysis. We found that 11.0% of patients received chemotherapy, 17.3% had > 1 hospitalization, 9.3% were in the ICU, 18.0% had > 1 ER visit, 39.3% died in an acute care setting, and 8.6% received life-extending procedures. A compound indicator of the aggressiveness of care showed that 54.5% of patients had at least one of the selected aggressive indicators. The multivariable model showed that female patients, patients ≥ 60 years of age, patients enrolled in Medicaid, patients dually eligible for both Medicare and Medicaid, and patients who survived > 1 year were less likely to receive aggressive EoL care. CONCLUSION: Our findings support the urgent need to improve EoL care in Puerto Rico. Further studies are warranted to fully understand EoL care in patients with cancer in Puerto Rico.

Squamous Cell Carcinoma of the Anus Incidence, Mortality, and Survival Among the General Population and Persons Living With HIV in Puerto Rico, 2000-2016.

PURPOSE: Squamous cell carcinoma of the anus (SCCA) is common among persons living with HIV (PLWH). We described SCCA incidence and survival among the general population and among PLWH in Puerto Rico (PR), along with mortality of anal cancer. METHODS: PR HIV/AIDS Surveillance Program and the PR Central Cancer Registry databases were linked (2000-2016). Incidence rates (IRs) and trends (annual percent change [APC]) in SCCA and mortality rates and trends for anal cancer were estimated. Relative survival and relative excess risk (RER) of death were calculated. RESULTS: From 2000 to 2016, 991 individuals in PR were diagnosed with anal cancer; 73% of cases were SCCA 9.1% of SCCA and 1.5% of non-SCCA cases were in PLWH (P < .0001). SCCA incidence was higher among PLWH than the general population (IR = 27.7/100,000). Among PLWH, SCCA incidence (per 100,000) was the highest among men who have sex with men (IR = 60.5). From 2001-2016, SCCA incidence increased among the general population (APC: 4.90, P < .05); however, no significant change was observed among PLWH (APC = 0.19 and P = .96). The APC for anal cancer mortality in the general population was positive (3.9%) from 2000 to 2016, but not significant (P > .05). The 5-year relative survival of SCCA was 56.9% among PLWH and 66.8% among the general population. In multivariate analysis, the RER of death for SCCA 5 years postdiagnosis was affected by stage at diagnosis (distant: RER = 7.6, 95% CI, 2.36 to 24.25) but not by PLWH status (RER = 1.4, 95% CI, 0.67 to 3.01). CONCLUSION: Our findings highlight the relevance of anal cancer screening in PLWH and HPV vaccination in both PLWH and the general population in PR, which could have an impact on the disease trend in the next few decades.

Use of adjuvant chemotherapy in patients with stage III colon cancer in Puerto Rico: A population-based study.

OBJECTIVE: This study aims to examine factors associated with the use of adjuvant chemotherapy and the use of oxaliplatin after curative resection in stage III colon cancer patients and assesses the effect of their use in three-year survival. METHODS: This retrospective cohort study was conducted using Puerto Rico Central Cancer Registry-Health Insurance Linkage Database. The study cohort consisted of stage III colon cancer patients with a curative surgery in the period 2008-2012. Multivariate logistic regression was used to estimate adjusted odds ratios. Kaplan-Meier methods and Cox proportional hazards models were used to assess the association between adjuvant chemotherapy and oxaliplatin use and overall survival and risk of death, respectively. RESULTS: Overall, 75% of the study population received adjuvant chemotherapy during the study period. Factors statistically associated with receiving adjuvant chemotherapy within four months after resection included being married (adjusted odds ratio [AOR] 1.64; 95% CI 1.18-2.28; p = 0.003), and being enrolled in Medicare (AOR 1.68; 95% CI: 1.03-2.75; p = 0.039) or Medicaid and Medicare dual eligible (AOR 1.66; 95% CI: 1.06-2.60; p = 0.028). However, patients aged ≥70 years were less likely to receive adjuvant chemotherapy (AOR 0.22; 95%CI 0.14-0.36; p<0.001). DISCUSSION: We observed a significant reduction in mortality in adjuvant chemotherapy treated patients. Similarly, patients <70 years treated with oxaliplatin had significantly lower risk of death than those who did not, although for patients ≥70 years no statistical significance was achieved. Future studies should assess effective interventions to reduce barriers to access guideline-based recommended colon cancer treatment.