A qualitative approach to understanding the drivers of unequal receipt of definitive therapy for Black men with prostate cancer in Massachusetts.

BACKGROUND: Despite mandated insurance coverage since 2006 and robust health infrastructure in urban settings with high concentrations of minority patients, race-based disparities in prostate cancer (PCa) treatment persist in Massachusetts. In this qualitative study, the authors sought to identify factors driving inequities in PCa treatment in Massachusetts. METHODS: Four hospitals offering PCa treatment in Massachusetts were selected using a case-mix approach. Purposive sampling was used to conduct semistructured interviews with hospital stakeholders. Additional interviews were conducted with representatives from grassroots organizations providing PCa education. Two study staff coded the interviews to identify major themes and recurrent patterns. RESULTS: Of the 35 informants invited, 25 participated in the study. Although national disparities in PCa outcomes were readily discussed, one half of the informants were unaware that PCa disparities existed in Massachusetts. Informants and grassroots organization representatives acknowledged that patients with PCa are willing to face transportation barriers to receive treatment from trusted and accommodating institutions. Except for chief equity officers, most health care providers lacked knowledge on accessing or using metrics regarding racial disparities in cancer outcomes. Although community outreach was recognized as a potential strategy to reduce treatment disparities and engender trust, informants were often unable to provide a clear implementation plan. CONCLUSIONS: This statewide qualitative study builds on existing quantitative data on the nature and extent of disparities. It highlights knowledge gaps in recognizing and addressing racial disparities in PCa treatment in Massachusetts. Improved provider awareness, the use of disparity metrics, and strategic community engagement may ensure equitable access to PCa treatment. PLAIN LANGUAGE SUMMARY: Despite mandated insurance and urban health care access, racial disparities in prostate cancer treatment persist in Massachusetts. This qualitative study revealed that, although national disparities were acknowledged, awareness about local disparities are lacking. Stakeholders highlighted the importance of ancillary services, including translators, rideshares, and navigators, in the delivery of care. In addition, whereas hospital stakeholders were aware of collected equity outcomes, they were unsure whether and who is monitoring equity metrics. Furthermore, stakeholders agreed that community outreach showed promise in ensuring equitable access to prostate cancer treatment. Nevertheless, most interviewed stakeholders lacked clear implementation plans.

Cavitary Hodgkin Lymphoma of the Lung.

It has been shown that some cases of Hodgkin lymphoma (HL) may present with pulmonary parenchymal involvement usually in the form of multiple irregularly marginated pulmonary nodules. Other radiographic patterns such as consolidation, interstitial infiltrates, and cavitary lesions are less common. We present a case of HL, nodular sclerosis type, with pulmonary involvement presenting as a large cavitary consolidation and axillary and mediastinal lymphadenopathy. Initial diagnostic work-up including sputum culture, bronchoscopy, and a fine needle aspiration of lymph node was not conclusive favoring a reactive process with a presumptive diagnosis of cavitary pneumonia. A follow-up chest imaging revealed worsening right upper lung mass, axillary adenopathy, and new nodular satellite lesions, and a repeat bronchoscopy with multiple biopsies remained non-diagnostic requiring an excisional biopsy of the axillary lymph node confirming HL. Further transthoracic core biopsies of the cavitary lung lesion were consistent with pulmonary lymphoma involvement.

Temporal Trends of Health Disparity in the Utilization of Curative-Intent Treatments for Hepatocellular Carcinoma- Are we making progress?

BACKGROUND: Liver-directed treatments: ablative therapy (AT), surgical resection (SR), liver transplantation (LT), as well Trans-Arterial Chemoembolization (TACE) improve OS for early-stage HCC. While racial and socioeconomic disparities impact access to liver-directed therapies, their temporal trends for the curative-intent treatment of HCC remain to be elucidated. METHODS: We performed chi-square, logistic regression, and temporal trends analyses on data from the Nationwide Inpatient Sample from 2011-2019. The outcome of interest was the rate of AT, SR, LT (curative-intent treatments), and TACE utilization, and the primary predictors were racial/ethnic group, and SES (insurance status). RESULTS: African-American and Hispanic patients had lower odds of receiving AT - (African-American: OR=0.78, p<0.001), (Hispanic: OR=0.84, p=0.005); and SR - (African-American: OR=0.71, p<0.001), (Hispanics: OR=0.64, p<0.001) compared with white patients. The odds of LT was lower for African-American (OR=0.76, p<0.001) but higher for Hispanic patients (OR=1.25, p=0.001) compared to white patients. Low SES had worse odds of AT (OR=0.79, p=0.001), SR (OR=0.66, p<0.001), and LT (OR=0.84, p=0.028) compared to high SES. While curative-intent treatments showed significant upward temporal trends among White (10.6% to 13.9%, p<0.001), and API/Other patients (14.4% to 15.7%, p=0.007), there were non-significant trends among African-American (10.9% to 10.1%, p=0.825) or Hispanic patients (12.2% to 13.7%, p=0.056). CONCLUSIONS: Our study demonstrates concerning disparities in the utilization of curative-intent treatment for HCC based on race/ethnicity, and socioeconomic status. Moreover, racial/ethnic disparities have widened rather than improved over time.

Paraneoplastic Hypercholesterolemia Identified in an Adult Male Diagnosed With Metastatic Yolk Sac Tumor.

A few cases of paraneoplastic hypercholesterolemia have been reported in patients with primary or metastatic liver cancer. We report a case of paraneoplastic hypercholesterolemia in a patient with a metastatic yolk sack tumor. The patient was a 52-year-old man who presented with abdominal pain, nausea, and vomiting. A computed tomography (CT) scan demonstrated massive hepatomegaly with innumerable large ill-defined hypo-densities and innumerable pulmonary nodules. Blood work demonstrated elevated bilirubin to 3.1 mg/dL, aspartate aminotransferase (AST) to 384 U/L, alanine aminotransferase (ALT) to 126 U/L, gamma-glutamyl transferase (GGT) to 574 U/L, lipase to 100 U/L, low-density lipoprotein (LDL) of 579 mg/dL, and cholesterol of >800 mg/dL. Tumor markers revealed alpha-fetoprotein (AFP) was 24,760 ng/mL, carcinoembryonic antigen (CEA) was 1.9 ng/mL, and cancer antigen 19-9 (CA19-9) was 86 U/mL. The tumor makers were obtained during the initial stages of the patient's evaluation to help us narrow down the possible primary - focusing on the gastrointestinal tract and the pancreas. Although tumor markers are rarely of use in the early diagnosis of cancer due to their limited sensitivity and specificity; however, they can help diagnose the origin of cancer in patients presenting with advanced widespread disease such as our patient. Histopathology of his liver lesion biopsy demonstrated a metastatic yolk sac tumor (YST) with hepatoid differentiation. Since the patient succumbed rapidly, the primary tumor could not be ascertained, although the lack of a classic pattern for testicular tumor retroperitoneal lymphadenopathy makes extragonadal YST more likely. YSTs are major histologic subtypes of germ cell tumors (GCTs), and most frequently arise in the gonads. However, extragonadal GCT is sometimes seen and comprises about 2-5% of all GCTs in adult males aged 15-35 years. Extra gonadal GCT has been hypothesized to occur through aberrant migration of primordial germ cells or reverse migration of transformed germ cells from the testes, and persistence of pluripotent cells outside the gonads. Paraneoplastic syndromes associated with GCTs are rare. The pathophysiology of paraneoplastic hypercholesterolemia is hypothesized to involve the dysregulation of LDL receptors. Cancer-mediated mutations in the LDL receptor gene result in an abnormal LDL receptor, leading to autonomous cholesterol production by neoplastic cells. Also, tumor-secreted proprotein convertase subtilisin/kexin type 9 (PCSK9) has been implicated in the causation of paraneoplastic hypercholesterolemia. PCSK9 binds to and degrades the receptor for LDL particles on cell membranes. YST in adults is exceedingly rare. Paraneoplastic hypercholesterinemia is a very rare phenomenon reported in different cancers and we report the first case associated with YST.

Clinical outcomes and cost of open, laparoscopic, and percutaneous ablation for hepatocellular carcinoma.

BACKGROUND: Open (OA), laparoscopic (LA), and percutaneous (PA) ablation are all ablation approaches for hepatocellular carcinoma (HCC) utilized in the United States today. However, it remains unclear today which approach is (A) most effective, (B) cost-efficient, and (C) nationally practiced. METHODS: In-hospital mortality and cost were collected from the National Inpatient Sample (NIS) database for patients undergoing liver ablation from 2011 to 2018. Secondary outcomes included length of stay, disposition, and perioperative composite complications. We used inverse probability of treatment weighting (IPTW) to adjust for differences in patient and hospital baseline characteristics. RESULTS: One thousand and one hundred and twenty-five LA, 1221 OA, and 1068 PA liver ablations were analyzed. After IPTW, in-hospital mortality risk was significantly lower in PA versus OA cohorts (0.57% vs. 2.90%, p < 0.001) and reduced among PA patients, yet not significantly different from the LA cohort (0.57% vs. 1.64%, p = 0.056). The median length of hospital stay was significantly lower in the PA and LA group compared to OA (2 days vs. 6 days, p < 0.001). The median hospitalization costs were significantly lower for PA ($44,884 vs. $90,187, p < 0.001) and LA ($61,445 vs. $90,187, p < 0.001) compared to OA. Moreover, we found significant regional differences regarding the use of each ablation approach, with the Midwest having the lowest rates of PA and LA. CONCLUSIONS: Among patients hospitalized after ablation for HCC, PA leads to the lowest hospital cost. Both PA and LA result in lower peri-operative morbidity and mortality relative to OA. Despite these reported advantages, there are significant regional differences with respect to ablation availability suggesting the need to promote the standardization of best practices.

Socioeconomic Disparities in the Utilization of Spinal Cord Stimulation Therapy in Patients with Chronic Pain.

OBJECTIVES: Spinal cord stimulation (SCS) therapies are used in the management of patients with complex regional pain syndrome I (CRPS I) and failed back surgery syndrome (FBSS). The purpose of this study was to investigate the racial and health insurance inequalities with SCS therapy in patients with chronic pain who had CRPS I and FBSS. METHODS: Patients with chronic pain who had a discharge diagnosis of FBSS and CRPS I were identified using the National Inpatient Sample database. Our primary outcome was defined as the history of SCS utilization by race/ethnicity, income quartile, and insurance status. Multivariable logistic regression was used to determine the variables associated with utilization of SCS therapy. RESULTS: Between 2011 and 2015, 40,858 patients who were hospitalized with a primary diagnosis of FBSS and/or CRPS I were identified. Of these patients, 1,082 (2.7%) had a history of SCS therapy. Multivariable regression analysis revealed that compared to White patients, Black and Hispanic patients had higher odds of having SCS therapy (Black patients: odds ratio [OR] = 1.41; 95% confidence interval [CI], 1.12 to 1.77; P = 0.003; Hispanic patients: OR = 1.41; 95% CI, 1.10 to 1.81; P = 0.007). Patients with private insurance had significantly higher odds of having SCS therapy compared with those with Medicare (OR = 1.24; 95% CI, 1.08 to 1.43; P = 0.003). Compared to patients with Medicare, Medicaid patients had lower odds of having SCS therapy (OR = 0.50; 95% CI, 0.36 to 0.70; P < 0.001). CONCLUSIONS: Our study suggests that socioeconomic disparities may exist in the utilization of SCS among hospitalized patients with CRPS I and FBSS the United States. However, confirming these data from other administrative databases, in the outpatient setting, may shed more insight.

Effects of exposure to anti-vaping public service announcements among current smokers and dual users of cigarettes and electronic nicotine delivery systems.

INTRODUCTION: Anti-vaping public service announcements (PSAs) are intended to discourage vaping or use of electronic nicotine delivery systems (ENDS). However, vaping portrayals in PSAs may have unintended effects if they increase smoking or vaping urges. This study examined benefits and unintended effects of anti-vaping PSAs with vapor portrayals on smoking and vaping-related outcomes. METHODS: Young adult smokers (N = 171) and dual users (N = 122) aged 21-30 years were randomly assigned to view: 1) anti-vaping PSAs with vapor; 2) anti-vaping PSAs without vapor; 3) physical activity PSAs; or 4) anti-smoking PSAs with smoking cues. Outcomes were changes in vaping and smoking urges before and after viewing PSAs, post-test vaping and smoking intentions in the next hour, and post-test intention to purchase ENDS and traditional cigarettes. RESULTS: Smokers only: Exposure to anti-vaping PSAs with vapor (vs. physical activity) was associated with lower intention to vape and to purchase ENDS (ps < 0.001) and lower intention to smoke and purchase cigarettes (ps < 0.05). Exposure to anti-vaping PSAs with vapor (vs. PSAs without vapor and vs. anti-smoking PSAs with smoking cues) was associated with lower intention to vape in the next hour (ps < 0.05). Exposure to anti-vaping PSAs without vapor (vs. physical activity) was associated with lower change in vaping urge (p < 0.05) and intention to purchase ENDS (p < 0.001). Dual users: Exposure to anti-vaping PSAs without vapor (vs. anti-smoking PSAs) was associated with lower intention to purchase ENDS (p < 0.05). CONCLUSION: Viewing anti-vaping PSAs with vapor was not associated with unintended effects and may have benefits on reducing smoking and vaping-related outcomes.