Characteristics of childhood cancer survivors attending a specialized survivorship clinic in the Deep South.

PURPOSE: Childhood cancer survivors carry a high burden of late-occurring treatment-related morbidity. Long-term risk-based anticipatory surveillance allows for early detection and management of complications. We sought to examine demographic, clinical, and social characteristics associated with survivorship clinic attendance at the Taking on Life after Cancer (TLC) Clinic at the Children's Hospital of Alabama. METHODS: The cohort included 1122 TLC-eligible patients diagnosed with cancer between 2000 and 2016. The outcome of interest was ≥1 TLC visit. Univariable logistic regression modeling assessed cancer type, treatment era, age, sex, race/ethnicity, payer type, rural/urban residency, and distance from clinic. Significant variables (P<0.1) were retained in multivariable modeling. RESULTS: The median age at diagnosis was 7 years old (0-19); 47% were female, 69% non-Hispanic White, 25% African American; 45% leukemia or lymphoma, 53% solid or CNS tumor, 3% other. We found that among 1122 survivors eligible to attend a survivorship clinic in the Deep South, only 52% attended. Odds of attendance were lower among survivors diagnosed at an older age, those with cancers other than leukemia/lymphoma, those lacking private insurance, and those living farther from the clinic. Race/ethnicity and rurality were not associated with clinic attendance. CONCLUSION: Just over half of eligible survivors attended survivorship clinic. Factors associated with non-attendance can be used to guide development of intervention strategies to ensure that childhood cancer survivors receive optimal long-term follow-up care. IMPLICATIONS FOR CANCER SURVIVORS: Measures of healthcare access (insurance status and distance to care) were identified as potential intervention targets to improve uptake of survivorship care.

The impact of deprivation on colorectal cancer-stage distribution in a setting with high hospital bed density: A Japanese multilevel study.

BACKGROUND: A methodology for determining the appropriate balance between medical access and combating poverty remains undetermined. To address the boundary conditions for exceedingly good medical access, this study examined whether the impact of deprivation on cancer stage distribution could be eliminated in Japan, which has the highest hospital bed density in the world. METHODS: A nationwide medical claims-based database was used to evaluate the influence of municipality-level hospital bed density and the postal code-level areal deprivation index on cancer stage at diagnosis. Given the limited number of similar studies in Japan, we focused on colorectal cancer (CRC), for which disparities have been reported in a prefecture-level study. Multilevel multivariate logistic regression models were used, with odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for baseline and socioeconomic factors. RESULTS: Regardless of the early/advanced-stage definitions, CRC consistently tended to be detected at more advanced stages in more deprived areas. In the analysis of stages 0-I/II-IV, the OR (95% CI) was 1.09 (1.05, 1.14) (p < 0.001). In the analyses of stages 0-I/II-IV and 0-II/III-IV, gradients were observed, and later detections were observed for more deprived segments. Hospital bed density was not significantly associated with the stage distribution. CONCLUSION: The results indicate that inequalities in CRC detection due to deprivation persist even in the country with the highest hospital bed density worldwide, suggesting that poverty measures remain indispensable regardless of hospital bed access. Further investigation of various regions and cancers is required to develop a practical framework.

Social factors associated with the risk of glaucoma suspect conversion to glaucoma: analysis of the nationwide All of Us Program.

PURPOSE: To examine social factors associated with the 5-year risk of glaucoma suspects (GS) converting to open-angle glaucoma (OAG). DESIGN: Retrospective cohort analysis. SUBJECTS: We screened for participants diagnosed with GS in the All of Us database. Cases that converted to OAG within 5 years of GS diagnosis (the "conversion group") were compared with control cases that did not convert. METHODS: Demographic, socioeconomic and healthcare utilization data of the cases were extracted and compared between the conversion group and the control group. Multivariable Cox proportional hazards modeling was used to identify potential factors associated with the risk of conversion. MAIN OUTCOME MEASURES: Hazard ratios (HRs) of significant factors associated with the risk of conversion. RESULTS: A total of 5274 GS participants were identified, and 786 (15%) cases converted to OAG within 5-year follow-up. The two groups showed significant differences in age, race, gender, employment status, income/education level, history of intra-ocular surgery, and healthcare utilization patterns. In the multivariable model, African American/Black race (HR [95% confidence interval] =1.70 [1.44-2.00]), older age at GS diagnosis (1.17 [1.09-1.25]), male gender (1.30 [1.13-1.50], no history of recreational drug use (1.23 [1.07-1.42]), history of intra-ocular surgery (1.60 [1.02-1.53]) and having more reasons for delayed healthcare access (2.27 [1.23-4.18]) were associated with a greater hazard of conversion, while being employed (0.71 [0.60-0.86]) was associated with a smaller hazard of conversion (P<0.05 for all). CONCLUSIONS: Several social factors were associated with the conversion from GS to OAG, which may help to identify patients at higher risk of disease progression. Future studies are needed to examine the basis for these findings and the potential interventions that could address them.

Evaluating the Connection Between Rural Travel Time and Health: A Cross-Sectional Analysis of Older Adults Living in the Northeast United States.

INTRODUCTION: To characterize the impact of rural patients' travel time to obtain healthcare on their reported utilization of preventive healthcare services and personal health outcomes. METHODS: Online survey data from rural adults ages 50+ years living in the Northeastern United States were collected from February to August 2021. Study measures included self-reported travel time to obtain healthcare, use of preventive healthcare, and health outcomes. The associations between travel time with use of preventive care and health outcomes were assessed using linear, Poisson, and logistic regression analyses controlling for demographic variables. RESULTS: Our study population included 1052 rural adults, with a mean travel time of 18.5 min (range: 0-60). Travel time was greater for racial/ethnic minority participants and for higher-income participants (both P < .05), but it was not associated with use of preventive healthcare. Greater travel time was associated with poorer mental health and more comorbidities, including cancer and diabetes (all P < .05). CONCLUSIONS: Travel time varied by patient demographic factors, and it was associated with mental health and comorbidities. There was no association between travel time and preventive care use, suggesting that other barriers likely contribute to suboptimal use of these services within rural communities. Further research is needed to elucidate the causal pathways linking travel time to mental health and comorbidities within rural communities, as increased travel may exacerbate intrarural health disparities.

Impact of the economic crisis and drug shortage on Lebanese cancer patients' care.

BACKGROUND: As a consequence of the economic crisis, the sociopolitical instability and the advent of the coronavirus disease-19 pandemic, nested challenges faced the Lebanese healthcare system. These have resulted in critical shortages of essential resources, including medications vital for oncologic patients. AIM: To assess the ramifications of the ongoing economic crisis on oncology patient care focusing on our outpatient oncology department. METHODS: A questionnaire was distributed during the month of February 2022 to oncology patients in Hôtel Dieu de France University Hospital in Beirut during their outpatient therapy. The primary objective was to assess the far-reaching impact of the economic crisis on patient care and the resulting psychological implications. RESULTS: Among 182 interviewed patients, 31.87% experienced treatment interruption mainly due to acute drug shortages. Despite 87.91% of the patients benefiting from third-party coverage, 69.60% had to self-pay for their medications leading to 69.78% of patients perceiving that healthcare was more difficult to access after 2020. Psychologically, one-third of the patients exhibited symptoms of anxiety and/or depression, with 7 patients reporting suicidal ideations. Notably, 37.93% of patients who interrupted cancer treatment reported a history of comorbidities, and 89.66% who altered their treatment cited financial difficulties. CONCLUSION: Lebanese cancer patients face complex challenges spanning economic, healthcare, and psychological realms. Income inequalities exacerbated by the economic crisis hindered healthcare access.

Evaluating the web as a source of information for patients with chest wall deformities: insights into engagement and disparities.

BACKGROUND: Recent data highlight the internet's pivotal role as the primary information source for patients. In this study, we emulate a patient's/caregiver's quest for online information concerning chest deformities and assess the quality of available information. METHODS: We conducted an internet search using combination of the terms "pectus excavatum," "pectus excavatum surgery," "funnel chest," "pectus excavatum repair" and identified the first 100 relevant websites from the three most popular search engines: Google, Yahoo, and Bing. These websites were evaluated using the modified Ensuring Quality Information for Patients (EQIP) instrument. RESULTS: Of the 300 websites generated, 140 (46.7%) were included in our evaluation after elimination of duplicates, non-English websites, and those targeting medical professionals. The EQIP scores in the final sample ranged from 8 to 32/36, with a median score of 22. Most of the evaluated websites (32.8%) originated from hospitals, yet none met all 36 EQIP criteria. DISCUSSION: None of the evaluated websites pertaining to pectus excavatum achieved a flawless "content quality" score. The diverse array of websites potentially complicates patients' efforts to navigate toward high-quality resources. Barriers in accessing high-quality online patient information may contribute to disparities in referral, patient engagement, treatment satisfaction, and overall quality of life. LEVEL OF EVIDENCE: IV.

The impact of the California state lockdown during the COVID-19 pandemic on management of patients with pancreatic ductal adenocarcinoma.

BACKGROUND AND OBJECTIVES: The SARS-COVID-19 pandemic significantly limited healthcare access. We sought to evaluate whether California's lockdown in March 2020 affected staging and time to treatment of pancreatic ductal adenocarcinoma (PDAC). We hypothesized that patients diagnosed after the lockdown would have longer time to treatment and higher stage at presentation. METHODS: We retrospectively identified and categorized 1294 patients presenting to five University of California healthcare systems with a new diagnosis of PDAC into "pre-lockdown" and "post-lockdown" groups based on timing of pathologic diagnosis. RESULTS: In the 12 months pre-lockdown, 835 patients were diagnosed with PDAC, and 459 patients in the 6 months post-lockdown. Demographics, staging, and treatment type were similar between eras. There was a decreased male:female ratio post- versus pre-lockdown (0.97 vs. 1.25; p = 0.03). Time from symptom onset to first treatment was significantly increased among females post-lockdown (p = 0.001). However, overall time from diagnosis to first treatment was shorter in the post-lockdown era (median 23 vs. 26 days, p < 0.001). CONCLUSIONS: The COVID-19 lockdown did not significantly delay initial presentation, diagnosis, or treatment of newly diagnosed PDAC patients. Time from diagnosis to first treatment was shorter post-lockdown. Reduced healthcare utilization for minor complaints and increased telehealth utilization may have contributed.

Insights, beliefs, and myths surrounding tuberculosis among pulmonary patients with delayed healthcare access in a high-burden TB state in Nigeria - a qualitative inquiry.

Introduction: Nigeria grapples with a substantial burden of tuberculosis (TB), particularly in Oyo State, designated as a high-burden State for TB. Effectively addressing this persistent health challenge necessitates more than just medical interventions; it requires a profound understanding of the diverse insights, beliefs, and myths held by TB patients. Methods: This qualitative study explores the perspectives of pulmonary TB patients with delayed healthcare access in Oyo State, Nigeria, focusing on their beliefs, and conceptions. In-depth interviews were conducted with 25 TB patients and 20 healthcare providers. Results: Thematic analysis of patients' responses revealed a complex interplay between cultural, spiritual, and biomedical insights. These challenges questioned the germ theory, associating TB with witchcraft and spiritual attacks. Beliefs in hereditary transmission, links between tobacco use and health outcomes, and uncertainties about infection nature underscored disparities influenced by socio-economic factors. Insights into transmission ideas, preventive measures, and treatment beliefs highlighted a blend of culturally influenced and scientifically supported strategies. Healthcare providers' insights emphasized the necessity for targeted health education. Discussion: These findings contribute to a nuanced understanding of TB perceptions, emphasizing the importance of culturally sensitive interventions to enhance awareness and promote timely and accurate health-seeking behaviors.

Solutions for Addressing the Dermatologist Shortage in Rural Canada: A Review of the Literature.

In Canada, there is a maldistribution of dermatologists, with as many as 5.6 dermatologists per 100,000 population in urban areas and as low as 0.6 per 100,000 in rural areas. Considering trends of dermatologists to work in group practices in urban areas, and the low number of rural dermatologists, one solution may be to incentivize dermatologists to practice rurally. Several solutions using the following themes are discussed: dermatology program-specific incentives, dermatology practice-specific incentives, and other indirect incentives. The low number of dermatologists in rural areas in Canada is concerning and has negative consequences for access to care for patients in rural areas, ultimately resulting in worse patient outcomes. Future research is needed to evaluate the impact of these initiatives and assess future access to dermatological care.

Expanding eligibility and improving quality of cervical cancer screening in Estonia: The 2021 reforms.

Estonia has one of the highest death rates from cervical cancer in the European Union despite having had a population-based screening programme for over 15 years. In 2021, this high disease burden, alongside a new national cancer prevention plan, prompted a series of cervical cancer screening programme reforms to address low screening uptake and evidence of variable screening test quality. The reforms had three main elements: expansion of eligibility to all women aged 30-65 regardless of insurance status; increasing test provision by enabling family physicians to take screening samples and introducing self-sampling; and improving testing procedures, replacing cytology with HPV testing as the primary screening test. Although the impact of these changes is yet to be seen, early signs suggest increased programme participation. However, at 51 %, further action to address barriers to uptake will likely be necessary. If Estonia is to avoid another period of policy dormancy, as happened between 2006 and 2021, greater clarity on screening programme accountability is required. The establishment of the National Cancer Screening Group may enable this. The first test will be the delivery of an end-to-end evaluation of the reformed programme, with an emphasis on equity of access. The next step will be to develop and deliver solutions that respond to these needs.

The intersection of race and social determinants of health on clinical outcome of glioblastoma patients.

OBJECTIVE: Resection, chemotherapy, radiation therapy, and tumor treating fields significantly increase the overall survival (OS) of glioblastoma (GBM) patients. Yet, cost and healthcare disparities might limit access. Multiple studies have attributed more than 80% of the GBM disease burden to White patients. The aim of this study was to explore the intersections of race and social determinants of health (SDoH) with healthcare access and outcomes of GBM patients in a large metropolitan area. METHODS: In this retrospective single-center study, the tumor registry at the authors' institution (2011-2019) was queried to identify a GBM cohort according to the updated WHO criteria. Data were supplemented by electronic health records to include demographics, outcome, National Cancer Institute Comorbidity Index (NCI-CI), and the Agency for Healthcare Research and Quality (AHRQ) socioeconomic status (SES) index. RESULTS: A total of 276 unique patients met the study inclusion criteria; 46% of the cohort was female, and 45% was non-White. This racial proportion differs from previous reports indicating that 80% of patients with GBM are White. The proportion of non-White patients in this study was similar to that of the general US population and significantly lower than that of New York City (p < 0.05). Non-White patients predominantly composed the lowest AHRQ SES index quartile, while White patients constituted the highest quartile (p < 0.001). White patients were older at diagnosis compared with non-White patients (63 vs 58 years, p = 0.001). Older age (p = 0.03), higher NCI-CI (p = 0.0006), and lack of insurance (p = 0.03) reduced the odds of a home discharge. Private insurance (p = 0.005), younger age (p = 0.02), and the highest ("wealthiest") AHRQ SES index quartile (p = 0.02) predicted a lower hospital length of stay (LOS). Patients who underwent gross-total resection had greater OS than those who received a subtotal resection or biopsy, independent of race and SDoH (1.68 vs 1.4 years, p = 0.022). CONCLUSIONS: This study is the first to report on race and SDoH of a cohort using the latest WHO criteria for GBM classification. In contrast to previous literature, the study cohort exhibits a higher proportion of non-White patients with GBM, similar to the representation of non-White individuals in the general US population. This study corroborates the impact of SDoH and not race on LOS and discharge location. Initiatives to identify and address these barriers are crucial for enhancing the care of all GBM patients.

Virtual multi-institutional tumor board: a strategy for personalized diagnoses and management of rare CNS tumors.

PURPOSE: Multidisciplinary tumor boards (MTBs) integrate clinical, molecular, and radiological information and facilitate coordination of neuro-oncology care. During the COVID-19 pandemic, our MTB transitioned to a virtual and multi-institutional format. We hypothesized that this expansion would allow expert review of challenging neuro-oncology cases and contribute to the care of patients with limited access to specialized centers. METHODS: We retrospectively reviewed records from virtual MTBs held between 04/2020-03/2021. Data collected included measures of potential clinical impact, including referrals to observational or therapeutic studies, referrals for specialized neuropathology analysis, and whether molecular findings led to a change in diagnosis and/or guided management suggestions. RESULTS: During 25 meetings, 32 presenters discussed 44 cases. Approximately half (n = 20; 48%) involved a rare central nervous system (CNS) tumor. In 21% (n = 9) the diagnosis was changed or refined based on molecular profiling obtained at the NIH and in 36% (n = 15) molecular findings guided management. Clinical trial suggestions were offered to 31% (n = 13), enrollment in the observational NCI Natural History Study to 21% (n = 9), neuropathology review and molecular testing at the NIH to 17% (n = 7), and all received management suggestions. CONCLUSION: Virtual multi-institutional MTBs enable remote expert review of CNS tumors. We propose them as a strategy to facilitate expert opinions from specialized centers, especially for rare CNS tumors, helping mitigate geographic barriers to patient care and serving as a pre-screening tool for studies. Advanced molecular testing is key to obtaining a precise diagnosis, discovering potentially actionable targets, and guiding management.

Impact of the pandemic on surgical oncology in Piedmont, Italy: A retrospective observational study.

BACKGROUND AND METHODS: This retrospective observational study analyzes how the COVID-19 pandemic affected surgical oncology healthcare in a large sample from Piedmont, Northern Italy. Patients admitted for regular hospitalization were included (n = 99 651). Data from 2020 were compared to the averages from 2016 to 2019, stratified by tumor site, year, month, and admission method, using interrupted time series analysis post-March 2020. RESULTS: In 2020, oncological surgeries decreased by 12.3% (n = 17 923) compared to the 2016-2019 average (n = 20 432), notably dropping post-March (incidence rate ratio = 0.858; p < 0.001). The greatest reduction was observed for breast (-19.2%), colon (-18.2%), bladder (-17.5%), kidney (-14.2%), and prostate (-14%) surgeries. There was a huge reduction in nonemergency admissions (-13.6%), especially for colon (-23.8%), breast (-19.4%), and bladder (-18.7%). The proportion of hospitalizations with emergency access increased (p < 0.001). CONCLUSIONS: The COVID-19 pandemic led to a significant decrease in cancer surgeries in Piedmont in 2020, with an increase in the proportion of admissions through emergency access. DISCUSSION: The research provides valuable insights for comparing data with other regions and evaluating the effectiveness of efforts to recover lost surgical procedures. These findings can be useful to policymakers in developing coordinated measures and more efficient access strategies to healthcare services in any future emergency situations.

Effect of core preventative screening on kidney stone surgical patterns.

PURPOSE: In the surgical treatment of kidney stones, decreased access to healthcare has been shown to exacerbate stone burden, often requiring more invasive and extensive procedures. The objective of this study is to evaluate the effects of preventative health screening on kidney stone surgical treatment patterns. METHODS: We performed a retrospective analysis of data from the Healthcare Cost and Utilization Project (HCUP) Florida state-wide dataset and the PLACES Local Data for Better Health dataset from the Centers of Disease Control and Prevention (CDC). ZIP Code Tabulation Areas (ZCTAs) identified from the PLACES data were merged with the HCUP dataset to create a single dataset of community-level stone outcomes and community health measures. We included adult patients 18 years or older who underwent at least one urologic stone procedure from 2016 to 2020. RESULTS: 128,038 patients from 885 communities were included in the study. Patients underwent an average of 1.42 surgeries (Median = 1.39, SD = 0.16). Increased core preventative screening was associated with increased surgical frequency (Estimate: 0.51, P < 0.001). The low core preventative screening group had a higher prevalence of PNL than SWL while the high core preventative screening group had a low PNL prevalence compared to SWL. CONCLUSION: Increased core preventative screenings are associated with less invasive kidney stone surgeries, suggesting that preventative screenings detect stones at an earlier stage.

Access to Laparoscopic Pediatric Surgery: Do Ethnic and Racial Disparities Exist?

INTRODUCTION: Disparate access to laparoscopic surgery may contribute to poorer health outcomes among racial and ethnic minorities, especially among children. We investigated whether racial and ethnic disparities in laparoscopic procedures existed among four common surgical operations in the pediatric population in the United States. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatrics, we conducted a retrospective review of pediatric patients, aged less than 18 y old, undergoing appendectomy, fundoplication, cholecystectomy, and colectomy from 2012 to 2021. To compare the surgical approach (laparoscopy or open), a propensity score matching algorithm was used to compare laparoscopic and open procedures between non-Hispanic Black with non-Hispanic White children and Hispanic with non-Hispanic White children. RESULTS: 143,205, 9,907, 4,581, and 26,064 children underwent appendectomy, fundoplication, colectomy, and cholecystectomy, respectively. After propensity score matching, non-Hispanic Black children undergoing appendectomy were found to be treated laparoscopically less than non-Hispanic White children (93.5% versus 94.4%, P = 0.007). With fundoplication, Hispanic children were more likely to be treated laparoscopically than White ones (86.7% versus 80.9%, P < 0.0001). There were no statistically significant differences between Black or Hispanic children and White children in rates of laparoscopy for other procedures. CONCLUSIONS: Though some racial and ethnic disparities exist with appendectomies and fundoplications, there is limited evidence to indicate that widespread inequities among common laparoscopic procedures exist in the pediatric population.

Reduced healthcare access contributes to delay of care in endometrial cancer.

OBJECTIVE: We aimed to characterize delays to care in patients with endometrioid endometrial cancer and the role healthcare access plays in these delays. METHODS: A chart review was performed of patients with endometrioid endometrial cancer who presented with postmenopausal bleeding at a diverse, urban medical center between 2006 and 2018. The time from symptom onset to treatment was abstracted from the medical record. This interval was subdivided to assess for delay to presentation, delay to diagnosis, and delay to treatment. RESULTS: We identified 484 patients who met the inclusion criteria. The median time from symptom onset to treatment was 4 months with an interquartile range of 2 to 8 months. Most patients had stage I disease at diagnosis (88.6%). There was no significant difference in race/ethnicity or disease stage at time of diagnosis between different groups. Patients who had not seen a primary care physician or general obstetrician-gynecologist in the year before symptom onset were more likely to have significantly delayed care (27.7% vs 14.3%, p = 0.02) and extrauterine disease (20.2% vs 4.9%, p < 0.01) compared to those with established care. Black and Hispanic patients were more likely to experience significant delays from initial biopsy to diagnosis. CONCLUSIONS: Delays exist in the evaluation of endometrial cancer. This delay is most pronounced in patients without an established outpatient primary care provider or obstetrician-gynecologist.

A visiting otolaryngology team in northern Ontario - demographics, clinical presentation and barriers to access.

CONTEXT: Approximately 20% of Canadians reside in rural or remote communities where access to medical specialties such as otolaryngology remains challenging due to long wait times and distance to services. The purpose of this study was to characterize patient demographics, common clinical diagnoses, and barriers to accessing otolaryngology services, in a remote Northern Ontario setting. A secondary objective was to describe a care model that provides multi-subspecialty otolaryngology services to a remote community. ISSUE: A team of academic otolaryngologists provided annual (2020-2021) subspecialty services in otology, neurotology, rhinology, head and neck oncology, and pediatrics to a remote hospital with admitting, general anesthesia and surgical resources. Data regarding patient demographics, otolaryngology-related diagnosis, wait times and distance travelled were recorded. Data were obtained for 276 patients treated in the clinic. The median age was 47 years (range 0-85 years). The most common otolaryngological conditions were hearing loss (n=62) and nasal obstruction (n=34). Nearly 30% of patients traveled further than 150 km to access care, and 62% waited 3-6 months for a consultation. LESSONS LEARNED: This is the first study to characterize the demographics and range of otolaryngological disorders encountered in a remote Northern Ontario setting. The results have identified specific otolaryngology needs and barriers to access to care. The data can be used to guide healthcare providers and administrators on resource allocation to optimize the delivery of otolaryngology services.

Are we well prepared for public health emergencies? COVID-19 pandemic effect on cancer care in Saudi Arabia: A qualitative study.

BACKGROUND: COVID-19 pandemic has significantly disrupted healthcare systems worldwide, raising concerns about its impact on cancer patients' access to healthcare services. This study aims to explore the experiences of cancer patients and assess effect of restrictions, delays, and changes in healthcare delivery on their health. METHODS: A qualitative study was performed through individual interviews and focus group discussions (FGDs) with cancer patients and key informants (KI). Participants with different cancer types, treatment stages, and residency regions in Saudi Arabia were recruited. Thematic analysis identified four major themes: access to healthcare services; impact on appointments, diagnosis, and treatment; healthcare delivery; and cancer condition deterioration due to the pandemic. RESULTS: Cancer patients reported variable responses to the pandemic and its effects on their healthcare seeking behavior. Several patients faced challenges in accessing healthcare services and experienced difficulties in continuing their treatment, others encountered obstacles in seeking timely diagnosis and care. Lockdown measures and travel restrictions posed barriers, affecting patients' ability to reach treatment centers. Delays in appointments, diagnosis, and treatment were also reported. In contrast, some participants did not report any negative impact but received improved care and condition prioritization. Healthcare delivery underwent a shift towards virtual appointments, online access to lab results and medication's home delivery service. Despite these adaptations, a small group of participants experienced health deterioration due to delays in treatment and difficulties in reaching their treating physicians. CONCLUSION: COVID-19 pandemic has had a multifaceted impact on cancer patients. Some participants faced challenges such as care delays and disruptions in accessing healthcare services. Yet others reported positive experiences such as improved communication and utilization of new healthcare delivery modalities. These findings underscore the need for resilient and adaptable healthcare systems to safeguard the well-being of cancer patients in times of crises and public health emergencies.

Financial strain across 25 years and women's bladder health: a life course perspective.

BACKGROUND: A small number of cross-sectional studies have found that financial insecurity-a social determinant of health-is associated with lower urinary tract symptoms. OBJECTIVE: This study aimed to examine (1) whether women in the Coronary Artery Risk Development in Young Adult Study with higher levels of financial strain, assessed at 7 time points across 25 years beginning in 1985-1986, were more likely to report lower urinary tract symptoms and impact after the 2010-2011 financial strain assessment and (2) whether healthcare access and comorbidities mediated potential associations. STUDY DESIGN: This prospective cohort study recruited Black and White participants aged 18 to 30 years at baseline (1985-1986) from the populations of 4 US cities. The analytical sample was composed of women with complete data for analyses involving financial strain trajectories across 7 assessments (n=841) and mediation tests of data collected at 4 assessments (n=886). The outcome variable was previously developed through a cluster analysis of urinary incontinence severity, urinary incontinence impact, other lower urinary tract symptoms severity, and their impact in 2012-2013, which yielded 4 lower urinary tract symptoms and impact cluster categories: women with no symptom or very mild symptoms and no impact vs women with mild, moderate, or severe symptoms and impact. Financial strain was defined as finding it "very hard," "hard," or "somewhat hard" (vs "not very hard") to pay for the very basics, such as food, heating, and medical care. Using proportional odds logistic regression, cluster categories were regressed on the financial strain trajectory group, adjusting for age, race, education, and parity. For mediation analyses, separate financial strain variables (difficulty paying for the very basics, such as food and heating, and difficulty paying for medical care) were created by combining 1995-1996 and 2000-2001 values. Two healthcare access variables (difficulty receiving care and underutilization of care) and a single comorbidity index (smoking, physical inactivity, body mass index, hypertension, diabetes mellitus, and depressive symptoms) were created by combining 2005-2006 and 2010-2011 values. Regression analyses and structural equation modeling were used to test whether healthcare access and comorbidities mediated associations between financial strain and lower urinary tract symptoms and impact cluster categories. RESULTS: In comparison to women who were consistently not financially strained, women who were consistently strained (odds ratio, 2.10; 95% confidence interval, 1.13-3.91), shifted into being strained (odds ratio, 2.00; 95% confidence interval, 1.29-3.10), or experienced >1 shift in strain (odds ratio, 1.99; 95% confidence interval, 1.46-2.71) had roughly twice the odds of reporting greater lower urinary tract symptoms and impact. Underutilization of healthcare and comorbidities mediated the association between difficulty paying for medical care and lower urinary tract symptoms and impact. In the structural equation model, difficulty paying for medical care and underutilization of care were associated (ß=.31; P<.01), as was underutilization of care and greater lower urinary tract symptoms and impact (ß=.09; P<.01). Moreover, difficulty paying for medical care and the comorbidity index were associated (ß=.34; P<.01), as was the comorbidity index and greater lower urinary tract symptoms and impact (ß=.24; P<.01). Collectively, these mediation pathways eliminated a direct association between difficulty paying for medical care and lower urinary tract symptoms and impact. CONCLUSION: Underutilization of healthcare and comorbidities explained an association between financial strain (difficulty paying for medical care) and lower urinary tract symptoms and impact. Research is needed to confirm the findings and examine other mechanisms that may further explain the association. Accumulated evidence may inform future policies and practices.

Multilevel Determinants of Palliative Care Referral in Women With Advanced Ovarian Cancer: A Scoping Review.

CONTEXT: Receipt of palliative care (PC) has long been suggested in practice for patients with advanced cancer for improved quality of life, mood, and prolonged survival. However, PC referrals in women with ovarian cancer remain suboptimal. OBJECTIVE: To consolidate existing literature on the multiple factors associated with PC referrals in women with advanced ovarian cancer and to better understand the contextual factors of PC referrals and frame receipt of PC using a socioecological model. METHODS: A search of scientific databases was conducted, including PubMed, Embase, CINAHL Complete, and PsycINFO. Key search terms included "ovarian cancer" and "palliative care," and later refined to include advanced stages of the diagnosis. The reviewed articles included a focus on advanced ovarian cancer and reported demographic, medical/clinical, support, or system-level factors examined in the PC referral process. RESULTS: Thirteen articles focused on the factors directly associated with PC referrals. Factors were categorized into different socioecological levels: tumor-level, intrapersonal, interpersonal, and environmental. Factors included tumor characteristics, age, marital status, medical condition, performance status, psychosocial status, support system, provider, and infrastructure. The patient's medical condition was the major component considered in PC referral and care transition. CONCLUSION: Various factors in the socioecological framework suggest that the decision for PC referral could be multifactorial and influenced by factors beyond the medical condition and status. Future research should aim to understand the impact of various socioecological factors on PC referral and examine PC referral experiences from the patient's perspective.