National trends in neoadjuvant chemotherapy utilization in patients with early-stage node-negative triple-negative breast cancer: the impact of the CREATE-X trial.

PURPOSE: Neoadjuvant chemotherapy (NAC) for triple-negative breast cancer (TNBC) allows for assessment of tumor pathological response and has survival implications. In 2017, the CREATE-X trial demonstrated survival benefit with adjuvant capecitabine in patients TNBC and residual disease after NAC. We aimed to assess national rates of NAC for cT1-2N0M0 TNBC before and after CREATE-X and examine factors associated with receiving NAC vs adjuvant chemotherapy (AC). METHODS: A retrospective cohort study of women with cT1-2N0M0 TNBC diagnosed from 2014 to 2019 in the National Cancer Database (NCDB) was performed. Variables were analyzed via ANOVA, Chi-squared, Fisher Exact tests, and a multivariate linear regression model was created. RESULTS: 55,633 women were included: 26.9% received NAC, 52.4% AC, and 20.7% received no chemotherapy (median ages 53, 59, and 71 years, p < 0.01). NAC utilization significantly increased over time: 19.5% in 2014-15 (n = 3,465 of 17,777), 27.1% in 2016-17 (n = 5,140 of 18,985), and 33.6% in 2018-19 (n = 6,337 of 18,871, p < 0.001). On multivariate analysis, increased NAC was associated with younger age (< 50), non-Hispanic white race/ethnicity, lack of comorbidities, cT2 tumors, care at an academic or integrated-network cancer program, and diagnosis post-2017 (p < 0.05 for all). Patients with government-provided insurance were less likely to receive NAC (p < 0.01). Women who traveled > 60 miles for treatment were more likely to receive NAC (p < 0.01). CONCLUSION: From 2014 to 2019, NAC utilization increased for patients with cT1-2N0M0 TNBC. Racial, socioeconomic, and access disparities were observed in who received NAC vs AC and warrants interventions to ensure equitable care.

Does Neoadjuvant Chemotherapy in Clinical T1-T2 N0 Triple-Negative Breast Cancer Increase the Extent of Axillary Surgery?

BACKGROUND: Current management strategies for early-stage triple-negative breast cancer (TNBC) include upfront surgery to determine pathologic stage to guide chemotherapy recommendations, or neoadjuvant chemotherapy (NAC) to de-escalate surgery, elucidate tumor response, and determine the role of adjuvant chemotherapy. However, patients who receive NAC with residual pathological nodal (pN) involvement require axillary lymph node dissection (ALND) as they are Z11/AMAROS ineligible. We aimed to evaluate the impact of NAC compared with upfront surgery on pN status and ALND rates in cT1-2N0 TNBC. METHODS: The National Cancer Database (NCDB) was queried for women with operable cT1-2N0 TNBC from 2014 to 2019. Demographic, clinicopathologic, and treatment data were collected. Multivariable linear regression analysis was performed to assess the odds of pN+ disease and undergoing ALND. RESULTS: Overall, 55,624 women were included: 26.9% (n = 14,942) underwent NAC and 73.1% (n = 40,682) underwent upfront surgery. The NAC cohort was younger (mean age 52.9 vs. 61.3 years; p < 0.001) with more cT2 tumors (71.6% vs. 31.0%; p < 0.001), and had lower ALND rates (4.3% vs. 5.5%; p < 0.001). The upfront surgery cohort was more likely to have one to three pathologically positive nodes (12.1% vs. 6.5%; odds ratio [OR] 2.37, 95% confidence interval (CI) 2.17-2.58; p < 0.001) but there was no difference in the likelihood of ALND (OR 1.1, 95% CI 0.99-1.24; p = 0.08). CONCLUSION: Patients who underwent upfront surgery were more likely to be pN+; however, ALND rates were similar between the two cohorts. Thus, the use of NAC does not result in a higher odds of ALND and the decision for NAC should be individualized and based on modern guidelines and systemic therapy benefits.

Correlation Among Neighborhood-level Measures of the Tobacco Retail Environment.

INTRODUCTION: Tobacco retailer density and distance to tobacco retailers are understood to influence tobacco-related behaviors; however, there is no general agreement on how to best characterize or measure the tobacco retail environment (TRE). In this data-driven analysis, we examine similarities among neighborhood-level measures of the TRE and assess how geographic resolution of the neighborhood units may affect them. METHODS: We used locations of likely tobacco retailers in the United States (US) to calculate multiple retailer count, density, and distance measures. Measures were calculated at the Census block group, tract, and county (including county equivalents) levels of geographic aggregation. Spearman's correlation was used to evaluate similarity among the TRE measures. RESULTS: At the block group and tract level, correlation among all TRE measures ranged from slightly negative (ρ = -0.03) to nearly perfect (ρ = 0.99). At both levels of aggregation, distance-based TRE measures were highly correlated (ρ > 0.76). At the block group level, simple count of retailers was highly correlated with the density measures (ρ > 0.83), and at the tract level, simple count was moderately to highly correlated with the density measures (ρ > 0.5). Findings were generally similar at the county level; a notable deviation was that retailers per person was negatively correlated with all other TRE measures (range from ρ = -0.08 to ρ = -0.32). CONCLUSIONS: Some common measures were not correlated, suggesting they capture different aspects of the TRE; similarity among the various measures also varied by level of geographic aggregation. IMPLICATIONS: Because the tobacco retail environment shapes people's tobacco-related behaviors, using appropriate measures to characterize it at a neighborhood-level is paramount. Our work highlights both the similarities and differences among a set of common measures, thereby suggesting the measures may be capturing different aspects of the overall retail environment. Our findings regarding geographic level of aggregation underscore the importance of neighborhood definition in any tobacco retail environment analysis.

Spatial Clustering of Tobacco Retailers Near US Public Schools.

INTRODUCTION: Previous studies have found that tobacco retailers cluster near schools. However, all retail outlets may be located near each other and near schools due to existing infrastructure and zoning policies. We assessed whether tobacco retailers cluster near schools in the United States more than expected when accounting for existing retail locations. AIMS AND METHODS: We identified 322 056 probable tobacco retailers, 95 110 public schools, and more than 3.8 million businesses comparable to tobacco retailers in land use and business type. We created 500 simulated tobacco retailer datasets by randomly selecting from the larger list of businesses. For each simulated dataset, we calculated the distance from schools to the nearest tobacco retailer (proximity) and the count of tobacco retailers within 800 m of schools (density). Observed proximity and density values were compared to 95% coverage intervals from the 500 simulations. We stratified analyses by urbanicity, percentage of students in the free and reduced-priced lunch program (FRLP), and percentage of Hispanic/Latino, non-Hispanic Black, and non-Hispanic white students. RESULTS: Tobacco retailers were closer to schools in rural areas, cities, and towns and more dense around schools in rural areas, cities, and suburbs compared to random locations in potential retail space. Schools with more students receiving FRLP had higher density than expected while schools with fewer students receiving FRLP had lower density than expected. Within rural areas, clustering did not vary across sociodemographic groups. Within non-rural areas, there were inequities in clustering by racial, ethnic, and socioeconomic school composition. CONCLUSIONS: Tobacco retailers cluster near schools after accounting for existing business patterns. There are inequities in clustering by sociodemographic school composition. IMPLICATIONS: This study provides compelling evidence that tobacco retailers cluster near US public schools and that there are racial, ethnic, and socioeconomic inequities in clustering, even when accounting for overall retail location patterns. Given that public schools tend to reflect neighborhood demographics, policies to limit tobacco retailers near schools may reduce both school-based and neighborhood-based inequities.

"If You Just Tell Me You're 18, I'll Still Sell to You": A Qualitative Study of Underage Tobacco Product Purchasing Experiences in a Tobacco 21 Compliance Study.

BACKGROUND: Tens of thousands of underage tobacco buy attempts are conducted each year for research, compliance, and public health surveillance. However, little research has qualitatively examined the perceptions and experiences of underage buyers participating in these programs. We sought to understand underage buyers' experiences and gather recommendations for protocol improvements. METHODS: We conducted semi-structured interviews in the fall of 2022 to assess experiences with underage tobacco product purchasing. Participants (N = 19, 58% male, 42% White) were research assistants aged 18-20 in New Jersey, New York, or North Carolina. Interviews examined purchasing experiences in relation to store characteristics, clerk interactions, and buyer identities. We used deductive and inductive thematic coding to explore key themes related to buyer experiences. RESULTS: We identified four themes: (1) non-chain stores lacked consistency in verifying age; (2) female data collectors experienced uncomfortable situations more frequently than male data collectors; (3) not identifying with the store's typical demographics impacted purchase attempts; and (4) participants suggested improvements for inspections and research during training. DISCUSSION: Retailer education, widespread adoption of ID scanners, and enforcement could increase standardization of ID requests and verification. Male and female buyers can be trained on what they might expect based on their gender, as well as how to maneuver through unwanted situations. Consideration of shared identity is important for future waves of data collection and research. Efforts to improve training include more extensive mock purchase training with supervisors well-versed in this area. IMPLICATIONS: Electronic ID verification and promoting compliance at non-chain retailers could impact access to tobacco products for underage buyers. Training for underage buyers in research and compliance assessments should focus on ways to enhance data collectors' confidence when making a purchase attempt, which may improve the validity of the rate of sales to individuals under 21.

Neighborhood Inequities in Tobacco Product Descriptors, Washington, DC, 2018-2019.

BACKGROUND: The tobacco industry uses product descriptors to communicate reduced harm and increase appeal. This cross-sectional study assessed store-level racial, ethnic, and socioeconomic inequities in the distribution of retail tobacco product descriptors in a convenience sample of retailers in Washington, DC. METHODS: Young adults (n = 146) who did not currently use tobacco reported real-time store visits over 14 days. Trained data collectors took high-resolution photographs of all tobacco (including e-cigarette) marketing in each store (n = 96) participants visited. We coded text descriptors on tobacco product advertisements and displays into descriptor categories (eg, fruit, sweet, concept). We fit multilevel models to examine relationships between store neighborhood census tract-level racial, ethnic, and socioeconomic characteristics and tobacco product descriptors in stores. As a supplementary analysis, we used geospatial methods to model predicted patterns of descriptors at the census tract level. RESULTS: Stores located in census tracts with the highest versus lowest percentage of Black residents had a greater count of fruit, sweet or dessert, alcohol, and concept descriptors (p < .05), similar to findings from the geospatial approach. Adjusted models also indicated some inequities in stores in census tracts with higher percentages of Hispanic or Latino residents for fruit, alcohol, and concept descriptors; however, tract-level models showed opposite results for concept flavors. CONCLUSIONS: In this convenience sample, fruit, alcohol, sweet/dessert, and concept FTP descriptors were prevalent in stores in neighborhoods with more Black residents demonstrated through two analytic approaches. Surveillance using representative samples of tobacco retailers could improve the ability to track the extent of this inequity. IMPLICATIONS: We document inequities in the amount of fruit, sweet or dessert, alcohol, and concept flavor descriptors in stores across neighborhoods in Washington, DC. Federal, state, and local regulatory action is needed to reduce inequities in flavored tobacco product availability and marketing, including for concept flavors.

Comparison of Tobacco Product Prices at Fort Liberty Army Installation and Surrounding Community Areas, 2021.

INTRODUCTION: High rates of tobacco use persist in the U.S. military, with 18.4% of service members smoking cigarettes in 2018. The Department of Defense's (DoD) 2017 policy required that tobacco retailers on military installations set tobacco product prices equal to the most common community price, including tax, but there is limited evidence confirming whether local retailers are adhering to this policy. We examined tobacco product pricing in tobacco retailers on- and off-post at the largest U.S. Army installation, Fort Liberty, and Cumberland County, North Carolina. METHODS: Between June-August 2021, we collected data on tobacco product availability, price, and promotions from retailers on Fort Liberty (n=14) and a random sample of off-post retailers within 10-miles of installation gates (n=52). We calculated the mode, mean, and median price of each product, plus the difference in these prices at on- and off-post retailers. We used Welch's t-test to test differences in mean prices between on- vs. off-post retailers. RESULTS: The mode, mean, and median prices of cigarette packs and cartons were lower on-post than off-post (e.g., $0.51-$0.55 cheaper for Marlboro cigarette packs on-post). However, the mode, mean, and median prices of smokeless tobacco products and little cigars were higher on-post than off-post (e.g., $0.82-$0.89 more costly for Swisher Sweets 2-packs on-post). CONCLUSION: Results highlight the need for continued enforcement to ensure compliance with the 2017 DoD policy. Comprehensive policy action to reduce tobacco price disparities on- and off-post is critical to reducing high rates of tobacco use among service members. IMPLICATIONS: Despite the implementation of the 2017 DoD pricing policy, some tobacco products remain cheaper at tobacco retailers on-post compared to off-post retailers. Our results highlight the need for greater routine surveillance to increase implementation of the policy-particularly for cigarettes-to reduce high rates of tobacco use among service members.

Supply and demand effects between tobacco retailer density and smoking prevalence.

OBJECTIVE: Places with more tobacco retailers have higher smoking prevalence levels, but whether this is because retailers locate where people who smoke live or whether tobacco availability prompts tobacco use is unknown. In this study, we compare the role of consumer demand with that of tobacco supply in longitudinal, area-based associations of tobacco retailer density with smoking prevalence. METHODS: We merged annual adult smoking prevalence estimates derived from the USA Behavioural Risk Factor Surveillance System data with annual county estimates of tobacco retailer density calculated from the National Establishment Time Series data for 3080 counties between 2000 and 2010. We analysed relationships between retailer density and smoking in 3080 counties, using random intercept cross-lagged panel models and employing two measures of tobacco retailer density capturing the number of likely tobacco retailers in a county divided by either the population or land area. RESULTS: Both density models provided evidence of significant demand and supply effects; in the population-based model, the association of smoking prevalence in 1 year with tobacco retailer density in the next year (standardised coefficient=0.038, p<0.01) was about double the association between tobacco retailer density with subsequent smoking prevalence (0.017, p<0.01). The reverse was true in the land area-based model, where the supply effect (0.042, p<0.01) was more than 10 times stronger than the demand effect (0.003, p<0.01). CONCLUSIONS: Policies that restrict access to retail tobacco have the potential to reduce smoking prevalence, but pairing such policies with interventions to reduce consumer demand remains important.

Neighbourhood inequities in the availability of retailers selling tobacco products: a systematic review.

OBJECTIVE: To examine inequities in tobacco retailer availability by neighbourhood-level socioeconomic, racial/ethnic and same-sex couple composition. DATA SOURCES: We conducted a 10 November 2022 search of PubMed, PsycINFO, Global Health, LILACS, Embase, ABI/Inform, CINAHL, Business Source Complete, Web of Science and Scopus. STUDY SELECTION: We included records from Organisation for Economic Co-operation and Development member countries that tested associations of area-level measures of tobacco retailer availability and neighbourhood-level sociodemographic characteristics. Two coders reviewed the full text of eligible records (n=58), including 41 records and 205 effect sizes for synthesis. DATA EXTRACTION: We used dual independent screening of titles, abstracts and full texts. One author abstracted and a second author confirmed the study design, location, unit of analysis, sample size, retailer data source, availability measure, statistical approach, sociodemographic characteristic and unadjusted effect sizes. DATA SYNTHESIS: Of the 124 effect sizes related to socioeconomic inequities (60.5% of all effect sizes), 101 (81.5%) indicated evidence of inequities. Of 205 effect sizes, 69 (33.7%) tested associations between retailer availability and neighbourhood composition of racially and ethnically minoritised people, and 57/69 (82.6%) documented inequities. Tobacco availability was greater in neighbourhoods with more Black, Hispanic/Latine and Asian residents (82.8%, 90.3% and 40.0% of effect sizes, respectively). Two effect sizes found greater availability with more same-sex households. CONCLUSIONS: There are stark inequities in tobacco retailer availability. Moving beyond documenting inequities to partnering with communities to design, implement, and evaluate interventions that reduce and eliminate inequities in retail availability is needed to promote an equitable retail environment. PROSPERO REGISTRATION NUMBER: CRD42019124984.

Tobacco retailer density and its association with birth outcomes in the USA: 2000-2016.

INTRODUCTION: Significant progress has been made in reducing maternal exposure to tobacco smoke and subsequent adverse birth outcomes, however, reductions may require strategies that reduce the availability of tobacco retailers. In this study, we investigated the relationship between tobacco retailer density and birth outcomes across the USA and predicted the potential impact of a tobacco retailer density cap on these outcomes. METHODS: Annual US county (n=3105), rates of preterm birth, low birth weight, small-for-gestational age, all-cause infant mortality and sudden infant death syndrome (SIDS) were calculated using National Vital Statistics System data. Tobacco retailers were identified from the National Establishment Time-Series Database. We used Poisson regression to estimate the effect of capping retailer density at 1.4 retailers per 1000 population, controlling for county demographics and air pollution, using propensity score weighting. RESULTS: Tobacco retailer density was positively associated with most adverse birth outcomes. We estimate that a nationwide cap on tobacco retailer density, implemented in 2016, would have resulted in a reduction of 4275 (95% CI 2210 to 6392) preterm births, 6096 (95% CI 4421 to 7806) small-for-gestational-age births, 3483 (95% CI 2615 to 4378) low birthweight births, 538 (95% CI 345 to 733) all-cause infant deaths and 107 (95% CI 55 to 158) SIDS deaths in that year. CONCLUSION: Higher rates of adverse birth outcomes were seen in counties with high tobacco retailer density compared with those with low density. These results provide further support for regulating tobacco retail density to reduce adverse health outcomes associated with tobacco use.

Geographical differences in the financial impacts of different forms of tobacco licence fees on small retailers in Scotland.

OBJECTIVE: Retailer licencing fees are a promising avenue to regulate tobacco availability. However, they face strong opposition from retailers and the tobacco industry, who argue significant financial impacts. This study compares the impacts of different forms of tobacco licence schemes on retailers' profits in Scotland. METHODS: We calculated gross profits from tobacco sales in 179 convenience stores across Scotland using 1 099 697 electronic point-of-sale records from 16 weeks between 2019 and 2022. We estimated different fees using universal, volumetric and separate urban/rural schemes. We identified the point at which 50% of retailers would no longer make a gross profit on tobacco sales for each scheme and modelled the financial impact of 10 incremental fee levels. The financial impact was assessed based on changes in retailers' tobacco gross profits. Differences by neighbourhood deprivation and urban/rural status were examined. RESULTS: The gross profit from tobacco per convenience store averaged £15 859/year. Profits were 2.29 times higher in urban (vs rural) areas and 1.59 times higher in high-deprivation (vs low-deprivation) areas, attributable to higher sales volumes. Tobacco gross profit decreased proportionally with increasing fee levels. Universal and urban/rural fees had greater gross profit reductions in rural and/or less deprived areas, where profits were lower, compared with volumetric fees. CONCLUSION: The introduction of tobacco licence fees offers a potential opportunity for reducing the availability of tobacco retailers. The likely impact of a tobacco licence fee is sensitive to the type of licence scheme implemented, the level at which fees are set and the retailers' location in relation to neighbourhood deprivation and rurality.

Retailers' Compliance with Federal Age of Cigarette Sales Policies -- Pitt County, North Carolina, January-March 2022.

BACKGROUND: Tobacco use remains a leading cause of preventable morbidity and premature mortality. In December 2019, the federal age of sale for tobacco products increased from 18 to 21 years of age. This study aimed to evaluate the implementation of federal tobacco 21 policies in Pitt County, North Carolina (NC), by conducting multiple purchase attempts for cigarettes. METHOD: Stores in Pitt County that sold cigarettes were randomly sampled and visited by up to six different underage (18-20) buyers who attempted to buy cigarettes from January-March 2022. Buyers made a total of 217 cigarette purchase attempts from 49 Pitt County retailers. Analyses were conducted using SPSS Complex Samples (v.28/Macintosh) and estimate retailer prevalence of requesting identification (ID) and selling to underage buyers across multiple purchase attempts. RESULTS: On average, retailers failed to request ID in 15.4% of purchase attempts (95% CI: 9.4%-21.3%) and sold to an underage buyer 34.2% of the time (95% CI: 27.0-41.4%). Additionally, 75.5% (95% CI: 63.4%-84.6%) of retailers sold to an underage buyer at least once. LIMITATIONS: This study is limited to a single county in NC and to underage buyers aged 18 to 20. CONCLUSION: There is widespread non-compliance with federal age of sale policies for tobacco products in Pitt County, NC. State enforcement is warranted, and NC's youth access law should be amended to match the federal age of sale. Changes to the law should allow research involving underage purchases.

Frequent upregulation of HER2 protein in hormone-receptor-positive HER2-negative breast cancer after short-term neoadjuvant endocrine therapy.

BACKGROUND: Endocrine resistant metastatic disease develops in ~ 20-25% of hormone-receptor-positive (HR+) breast cancer (BC) patients despite endocrine therapy (ET) use. Upregulation of HER family receptor tyrosine kinases (RTKs) represent escape mechanisms in response to ET in some HR+ tumors. Short-term neoadjuvant ET (NET) offers the opportunity to identify early endocrine escape mechanisms initiated in individual tumors. METHODS: This was a single arm, interventional phase II clinical trial evaluating 4 weeks (± 1 week) of NET in patients with early-stage HR+/HER2-negative (HER2-) BC. The primary objective was to assess NET-induced changes in HER1-4 proteins by immunohistochemistry (IHC) score. Protein upregulation was defined as an increase of ≥ 1 in IHC score following NET. RESULTS: Thirty-seven patients with cT1-T3, cN0, HR+/HER2- BC were enrolled. In 35 patients with evaluable tumor HER protein after NET, HER2 was upregulated in 48.6% (17/35; p = 0.025), with HER2-positive status (IHC 3+ or FISH-amplified) detected in three patients at surgery, who were recommended adjuvant trastuzumab-based therapy. Downregulation of HER3 and/or HER4 protein was detected in 54.2% of tumors, whereas HER1 protein remained low and unchanged in all cases. While no significant volumetric reduction was detected radiographically after short-term NET, significant reduction in tumor proliferation rates were observed. No significant associations were identified between any clinicopathologic covariates and changes in HER1-4 protein expression on multivariable analysis. CONCLUSION: Short-term NET frequently and preferentially upregulates HER2 over other HER family RTKs in early-stage HR+/HER2- BC and may be a promising strategy to identify tumors that utilize HER2 as an early endocrine escape pathway. CLINICAL TRIAL REGISTRY: Trial registration number: NCT03219476.

Associations Between Hospital Volume and Overall Survival After Surgery in Older Patients with Breast Cancer.

BACKGROUND: High-volume hospitals (HVHs) are associated with improved overall survival (OS) following surgery for breast cancer compared with low-volume hospitals (LVHs). We examined this association in patients age ≥ 80 years and described patient and treatment characteristics associated with HVHs. PATIENTS AND METHODS: The National Cancer Database was queried for women age ≥ 80 years who underwent surgery for stage I-III breast cancer between 2005 and 2014. Hospital volume was defined as the average number of cases during the year of the patient's index operation and the year prior. Hospitals were categorized into HVHs and LVHs using penalized cubic spline analysis of OS. A cutoff of ≥ 270 cases/year defined HVHs. RESULTS: Among 59,043 patients, 9110 (15%) were treated at HVHs and 49,933 (85%) at LVHs. HVHs were associated with more non-Hispanic Black and Hispanic patients, earlier stage disease (stage I 54.9% vs. 52.6%, p < 0.001), higher rates of breast-conserving surgery (BCS) (68.3% vs. 61.4%, p < 0.001), and adjuvant radiation (37.5% vs. 36.1%, p = 0.004). Improved OS was associated with surgery at a HVH (HR 0.85, CI 0.81-0.88), along with receipt of adjuvant chemotherapy (HR 0.73, CI 0.69-0.77), endocrine therapy (HR 0.70, CI 0.68-0.72), and radiation (HR 0.66, CI 0.64-0.68). CONCLUSIONS: Among patients with breast cancer age ≥ 80 years, undergoing surgery at a HVH was associated with improved OS. Patients who completed surgery at HVHs had earlier stage disease and more commonly received adjuvant radiation when appropriate. Processes of care at HVHs should be identified to improve outcomes in all settings.

National Trends in "Going Flat" After Mastectomy.

INTRODUCTION: The "Going Flat" movement became widely publicized in 2016 and provides information and support to women who choose to forego post-mastectomy breast reconstruction (PMBR). The objectives of this study were to evaluate temporal trends in PMBR to ascertain the potential impact of this movement and assess which factors are associated with going flat. METHODS: A retrospective cohort analysis was performed using the NCDB of women with non-metastatic breast cancer who underwent mastectomy between 2004 and 2019. Trends in going flat after mastectomy were examined and stratified by age (< 50, 50-69, ≥ 70). A multivariate logistic regression model was used to identify factors associated with going flat. RESULTS: 650,983 patients met the inclusion criteria: 244,201 (37.5%) underwent PMBR and 406,782 (62.5%) went flat. Among women < 70, rates of going flat steadily decreased from 2004 to 2015 and then stabilized after 2015, coinciding with the rise of the "Going Flat" movement. In multivariate analysis, non-White race, older age, increasing comorbidities, government provided insurance, treatment at a community program, radiotherapy, and adjuvant chemotherapy were associated with a higher likelihood of going flat (p < 0.001). CONCLUSION: In the first 2 years after the "Going Flat" movement, the number of women going flat after mastectomy has stabilized in women < 70 for the first time in over a decade. These trends suggest that the social and cultural impact of this movement may have contributed to the stabilization of PMBR rates.

Identifying disparities in suicidal thoughts and behaviors among US adolescents during the COVID-19 pandemic.

BACKGROUND: Suicidal thoughts and behaviors (STBs) became more common among racial and ethnic minorities and sexual and gender minorities (SGM) during the COVID-19 pandemic relative to White and non-SGM adolescents. This study examines associations between pandemic-related stressors and STBs among a nationally representative sample of adolescents to identify vulnerable subpopulations. METHODS: We analyzed data from 6769 high school students using the 2021 Adolescent Behaviors and Experiences Survey. Pandemic-related stressors were assessed via seven items related to negative experiences (e.g., parent job loss; food insecurity) during the COVID-19 pandemic. Logistic regression analyses estimated the association between pandemic-related stressors and four outcomes: (1) sadness/hopelessness; (2) suicidal ideation; (3) suicide planning; and (4) recent suicide attempt (i.e., past 12 months). Interactions were modeled by sex, race/ethnicity, and sexual identity. RESULTS: A greater number of pandemic-related stressors was associated with higher odds for sadness and hopelessness (aOR: 1.55; 95% CI:1.44-1.67), suicidal ideation (aOR: 1.48; 95% CI:1.39-1.57), suicide planning (aOR:1.47; 95% CI: 1.36-1.59), and recent suicide attempt (aOR: 1.64; 95% CI:1.42-1.88). Pandemic-related stressors were also more strongly associated with some types of STBs in males (relative to females) and SGM females (relative to heterosexual females). CONCLUSION: Study findings indicate that pandemic-related stressors are associated with STBs within the US adolescent population, particularly among male and SGM female adolescents. Researchers are encouraged to use this knowledge to ensure nationwide suicide prevention efforts adequately address inequities in suicide risk.

Exploring the Presence and Type of Premium Cigar Retailers With Neighborhood Sociodemographic Correlates in the United States, 2019-2021.

INTRODUCTION: Little is known about the location and store type of premium cigar retailers in the United States. Different store types may expose people to secondhand smoke (eg, cigar bar or lounge) and may also have age restrictions (eg, tobacco shops) that could reduce youth exposure to products and marketing. AIMS AND METHODS: We obtained a national retailer dataset from the Premium Cigar Association (PCA) from 2019 to 2021. We coded store type using nine categories and used generalized estimating equations to examine associations between census tract sociodemographic characteristics and PCA store type. RESULTS: Of the 1279 PCA retailers, the majority were cigar stores (39%), followed by tobacco shops (26%), cigar bars or lounges (20%), and beer, wine, or liquor stores (15%). Overall, there were no statistically significant associations between tract-level sociodemographic characteristics and the odds that a retailer was a specific store type versus another store type. However, PCA retailers located in tracts with a higher percentage of non-Hispanic Black residents were associated with 1.12 times the odds of being a cigar bar or lounge versus another type (95% CI, 1.02 to 1.22). CONCLUSIONS: The majority of PCA retailers are specialty cigar stores or cigar bars or lounges, and few are more traditional tobacco retailers, such as convenience stores. We document a higher odds of a store being a cigar bar or lounge for retailers located in neighborhoods with a higher proportion of Black residents, which may contribute to inequities in tobacco-related disease and disability because of potentially greater secondhand smoke exposure. IMPLICATIONS: Specialized retailers account for most premium cigar stores. One in five PCA retailers was a cigar bar or lounge, which raises public health concerns around exposure to secondhand smoke for patrons and employees. Local jurisdictions should examine zoning ordinances in tandem with sociodemographic characteristics to ensure inequities in the location of cigar bars or lounges are not produced or sustained given the potential harms associated with secondhand smoke exposure.

Tobacco Cessation and Prevention Interventions for Sexual and/or Gender Minority-Identified People and the Theories That Underpin Them: A Scoping Review.

INTRODUCTION: This scoping review takes stock of the social and behavior change theories that have underpinned tobacco interventions tailored to sexual and/or gender minority (SGM) people and reflects on the need to target contextually based drivers of SGM tobacco use inequities. AIMS AND METHODS: Data sources were Medline (Ovid), Scopus, PubMed, and Google Scholar (January 01, 1946 to October 27, 2022). Peer-reviewed publications in English from anywhere in the world describing SGM-tailored tobacco cessation and/or prevention interventions were independently identified by a librarian and screened by the first and third authors. Three hundred and sixty-seven articles were extracted; an additional two were found by hand searching. A total of 369 articles were assessed for eligibility. Exclusion criteria were: Not an intervention, review article, not SGM-tailored, or tobacco-focused. We documented the intervention name, intervention components, theoretical frameworks cited in reference to intervention design and/or implementation, and evaluation outcomes. All authors provided input on theoretical framework categorization. RESULTS: We identified 22 publications corresponding to 15 unique interventions. Individual-level behavior change theories (ie, those focusing on within-person behavior change processes) were the most prominent. Among these, the Transtheoretical Model was the most frequently utilized, while Social Inoculation Theory, Theory of Reasoned Action, and Theory of Psychological Reactance were also employed. A minority of interventions referenced frameworks that more explicitly engaged with SGM people's social contexts, namely, Theory of Diffusion of Innovations and Minority Stress Model. CONCLUSIONS: Future SGM-tailored tobacco interventions should leverage both the strengths of individual-level behavior change theories and those of frameworks that understand tobacco use inequities as indivisible from place, context, and policy. IMPLICATIONS: This scoping review describes the theoretical underpinnings of sexual and/or gender minority (SGM)-tailored tobacco interventions published in the peer-review literature in English. It reflects on the need for greater utilization of social and behavior change theoretical frameworks that can engage with unique drivers of SGM tobacco use and barriers to cessation.

Increasing Rates of RSV Hospitalization among Preterm Infants: A Decade of Data.

OBJECTIVE: In 2014, the American Academy of Pediatrics (AAP) changed its policy on the use of respiratory syncytial virus immunoprophylaxis (RSV-IP) so that RSV-IP was no longer recommended for use among infants without other medical conditions born >29 weeks of gestational age (wGA). This study examines 10-year trends in RSV-IP and RSV hospitalizations among term infants and preterm infants born at 29 to 34 wGA, including the 5 RSV seasons before and 5 RSV seasons after the AAP guidance change. STUDY DESIGN: A retrospective observational cohort study of a convenience sample of infants less than 6 months of age during RSV season (November-March) born between July 1, 2008, and June 30, 2019, who were born at 29 to 34 wGA (preterm) or >37 wGA (term) in the IBM MarketScan Commercial and Multi-State Medicaid databases. We excluded infants with medical conditions that would independently qualify them for RSV-IP. We identified RSV-IP utilization along with RSV and all-cause bronchiolitis hospitalizations during each RSV season. A difference-in-difference model was used to determine if there was a significant change in the relative rate of RSV hospitalizations following the 2014 policy change. RESULTS: There were 53,535 commercially insured and 85,099 Medicaid-insured qualifying preterm infants and 1,111,670 commercially insured and 1,492,943 Medicaid-insured qualifying term infants. Following the 2014 policy change, RSV-IP utilization decreased for all infants, while hospitalization rates tended to increase for preterm infants. Rate ratios comparing preterm to term infants also increased. The relative rate for RSV hospitalization for infants born at 29 to 34 wGA increased significantly for both commercially and Medicaid-insured infants (1.95, 95% CI: 1.67-2.27, p <0.001; 1.70, 95% CI: 1.55-1.86, p <0.001, respectively). Findings were similar for all-cause bronchiolitis hospitalizations. CONCLUSION: We found that the previously identified increase in RSV hospitalization rates among infants born at 29 to 34 wGA persisted for at least 5 years following the policy change. KEY POINTS: · Immunoprophylaxis rates decreased after the 2014 American Academy of Pediatrics guidelines update.. · Rate of RSV hospitalization increased among preterm infants after the 2014 AAP guidelines update.. · Increase in RSV hospitalization persisted for at least 5 years after AAP guidelines update..

A Statewide Approach to Reducing Re-excision Rates for Women With Breast-conserving Surgery.

OBJECTIVE: Test the effectiveness of benchmarked performance reports based on existing discharge data paired with a statewide intervention to implement evidence-based strategies on breast re-excision rates. BACKGROUND: Breast-conserving surgery (BCS) is a common breast cancer surgery performed in a range of hospital settings. Studies have demonstrated variations in post-BCS re-excision rates, identifying it as a high-value improvement target. METHODS: Wisconsin Hospital Association discharge data (2017-2019) were used to compare 60-day re-excision rates following BCS for breast cancer. The analysis estimated the difference in the average change preintervention to postintervention between Surgical Collaborative of Wisconsin (SCW) and nonparticipating hospitals using a logistic mixed-effects model with repeated measures, adjusting for age, payer, and hospital volume, including hospitals as random effects. The intervention included 5 collaborative meetings in 2018 to 2019 where surgeon champions shared guideline updates, best practices/challenges, and facilitated action planning. Confidential benchmarked performance reports were provided. RESULTS: In 2017, there were 3692 breast procedures in SCW and 1279 in nonparticipating hospitals; hospital-level re-excision rates ranged from 5% to >50%. There was no statistically significant baseline difference in re-excision rates between SCW and nonparticipating hospitals (16.1% vs. 17.1%, P =0.47). Re-excision significantly decreased for SCW but not for nonparticipating hospitals (odds ratio=0.69, 95% confidence interval=0.52-0.91). CONCLUSIONS: Benchmarked performance reports and collaborative quality improvement can decrease post-BCS re-excisions, increase quality, and decrease costs. Our study demonstrates the effective use of administrative data as a platform for statewide quality collaboratives. Using existing data requires fewer resources and offers a new paradigm that promotes participation across practice settings.