Assessing Structural Racism Measures on Health Outcomes of Asian Americans, Native Hawaiians, and Pacific Islanders: A Scoping Review.

BACKGROUND: Limited literature exists on structural racism measures on health outcomes for Asian Americans, Native Hawaiians, and Pacific Islanders (AAs and NH/PIs). AAs and NH/PIs make up approximately 6.2% of the U.S. population and consist of diverse ethnic subgroups with distinct languages, cultures, religions, socioeconomic statuses, and historical backgrounds. The lack of disaggregated data collection and contextualized measures hinders our understanding of how structural racism affects health outcomes in these populations. METHODS: We conducted a scoping review to assess the extent to which measures of structural racism are used in research with AAs and NH/PIs. Databases, including CINAHL, EBSCO, PsychINFO, PubMed, Scopus, and Social Science Citation Index, were searched for peer-reviewed articles on the measures of and empirical impacts of structural racism on AA and NH/PI health. We identified 23 full-text articles from a pool of 11,660 screened articles. Four articles were included in the final analysis. RESULTS: Among the selected studies, two studies identified an association between racial segregation and mental and behavioral health outcomes within AAs and NH/PIs. The other two studies found redlining on chronic health outcomes in these communities. These studies uncovered associations between government systems and policies and AA and NH/PI health outcomes. DISCUSSION: Existing measures may not adequately capture the complex relationships between structural racism and health outcomes in AAs and NH/PIs. Future research should contextualize and operationalize the multifaceted manifestations of structural racism unique to AAs and NH/PIs to achieve health equity.

Paying for PrEP: A qualitative study of cost factors that impact pre-exposure prophylaxis uptake in the US.

BACKGROUND: Concerns about the actual and perceived costs of pre-exposure prophylaxis (PrEP) continue to be a major barrier to uptake among gay, bisexual and men who have sex with men (GBMSM) in the United States. METHODS: We conducted semi-structured interviews with 25 GBMSM who presented for routine health care at a STD clinic in the northeastern United States. The cohort included GBMSM who were or were not currently taking PrEP and represented varied health care coverage and financial resources. We used a structured coding scheme to analyze transcripts and identify themes relevant to cost factors. RESULTS: Participants shared their perspectives about PrEP and their experiences with accessing and paying for PrEP. Our findings suggest that health care coverage or financial assistance were essential to PrEP access but were not easily accessible to all people and did not always cover all costs. Therefore, paying for PrEP had to be balanced with other life expenses. Participants had multiple sources for information about PrEP cost and assistance from clinic and pharmacy staff helped reduce burden and resolve difficulties. CONCLUSION: Addressing gaps in health care coverage, providing financial support, and improving the enrollment process in a financial assistance program may improve PrEP uptake.

Financial toxicity in ovarian cancer.

Ovarian cancer is the most costly and deadly of the gynecologic malignancies. Financial toxicity from out-of-pocket costs for direct care and medications as well as indirect costs from lost income is a growing challenge in oncology. The aim of this review is to focus on recent financial toxicity literature in the gynecologic oncology sphere and highlight specific issues and challenges regarding financial toxicity in ovarian cancer. Treatment options for ovarian cancer lead to variable costs for patients, and there are risk factors for high financial toxicity unique to gynecologic oncology patients. Identification and prompt intervention for those most at risk can help alleviate financial distress from ovarian cancer care.

Disparities in the management and outcome of cervical cancer in the United States according to health insurance status.

INTRODUCTION: Our study sought to characterize the presentation, local management and outcomes of invasive cervical cancer with regard to patient insurance status. METHODS: We queried the NCI-SEER database for invasive cervical cancer cases in patients aged 18-64 from 2007 to 2011. We analyzed clinical and socioeconomic data with regard insurance status (insured, Medicaid, or uninsured). We tested for associations between patient insurance status and treatment with definitive surgery for FIGO IA2-IB1 patients, and treatment with suboptimal radiation therapy (RT) for FIGO IB2-IVA patients (other than combination external beam and brachytherapy). We evaluated overall and cause specific survival according to insurance status. RESULTS: 11,714 cases were analyzed: 60% insured, 31% Medicaid, and 9% uninsured. FIGO III/IV stage at presentation was more frequent with Medicaid (40%) and uninsured (42%) compared to insured patients (28%) (p<0.001). For FIGO IA2-IB1 patients, receipt of definitive surgery was inversely associated with uninsured status (OR [95%CI]=0.65 [0.47-0.90], p<0.001) in univariable analysis; however the relationship lost significance after multivariable adjustment. For FIGO IB2-IVA patients, the use of suboptimal RT was associated with uninsured status (OR [95%CI]=1.33 [1.07-1.65], p=0.011) in adjusted analyses. Among all patients, overall mortality was increased with Medicaid (HR [95%CI]=1.16 [1.05-1.28], p=0.003) and uninsured status (HR [95%CI]=1.17 [1.01-1.34], p=0.031) in multivariable analysis. Cancer specific mortality survival trended towards significance in multivariable analyses for both Medicaid (HR [95%CI]=1.11 [1.00-1.24] and uninsured status (HR [95%CI]=1.14 [0.98-1.33]). CONCLUSIONS: Disparities in cervical cancer treatment with regard to insurance status are apparent in a recent cohort of American patients. Later stage at presentation and differences in management partially account for the inferior prognostic outcomes associated with Medicaid and uninsured status.

Tissue microarray for routine analysis of breast biomarkers in the clinical laboratory.

Tissue microarray analysis (TMA) allows multiple analyses on multiple patients on sections from a single paraffin block. Although it is widely used in research and in quality assurance settings, there are few references to its use in clinical practice. This study evaluated TMA assessment of breast biomarkers using immunohistochemical analysis in a clinical histopathology laboratory. Performance parameters, interobserver variability, and concordance between TMA and whole section results were assessed. The arrays had few lost or noninformative cores. A loss of stain intensity occurred in the arrays compared with the whole sections with some but not all antibodies, highlighting the need to validate the staining protocol for each antibody used on TMA sections. With recommended guidelines for specimen selection and reporting, TMA was found to be an economical replacement for whole section analysis for breast biomarkers.

Verification of imatinib cost-effectiveness in advanced gastrointestinal stromal tumor in British Columbia (VINCE-BC study).

BACKGROUND: This cost-effectiveness analysis of imatinib in British Columbia Cancer Agency (BCCA) patients with advanced gastrointestinal stromal tumors (GIST) was performed to justify funding. PATIENTS AND METHODS: A pragmatic, retrospective review identified BCCA patients with advanced GIST who received imatinib or historical treatment during successive, pre-specified time periods. Primary outcome was the cost-effectiveness (CE) of imatinib based on median overall survival (MOS). Secondary outcomes were cost-effectiveness based on median progression-free survival (PFS) and comparison to literature efficacy. This study took the BCCA perspective. Sensitivity analyses varying effectiveness over the 95% confidence interval (CI), cost to its extremes, discounting level at 0, 3, and 5%, and substituting life expectancy for MOS were performed. RESULTS: Forty-six and 47 patients in the imatinib and historical groups respectively showed MOS with imatinib to be 66.7 months (95%CI 61.7- infinity) compared to 7.7 (95%CI 6.0-12.6) in the historical group. Median-PFS were 45.3 months (95%CI 24.4-infinity) and 5.6 (95%CI 3.5-8.5) respectively. Imatinib effectiveness was similar to literature reports. The annual incremental CE ratio for imatinib was $15,882 CDN per median life year gained and $23,603 CDN per median year of PFS. CONCLUSIONS: Imatinib for advanced GIST seems cost-effective in BC. RESULT: were robust across a range of sensitivity analyses.

Inequities in Access: How Utilization of Palliative Radiation Therapy in British Columbia Varies with Geography.

PURPOSE: Referral and utilization rates are important measures of the quality of service offered by hospitals and clinics, specifically in regard to access to appropriate care. This study measured referral rates and utilization rates for palliative radiation therapy (PRT) for the different health authorities in British Columbia (BC), Canada, to establish areas where there were variations in access. METHODS AND MATERIALS: Incident data was taken from the British Columbia Cancer registry between 1986 and 1999. Radiation therapy (RT) data were extracted between 1986 and 2005. The extra years were included to allow time for any disease progression that may have occurred. Referral rates were defined as the percentage of incident cases that had a consultation at the British Columbia Cancer Agency. The PRT utilization rate was defined as the percentage of incident cases receiving at least one course of palliative radiation therapy. Data were analysed for each of the 16 Health Service Delivery Areas in BC. RESULTS: Significant geographical variations in both referral rates and utilization rates were identified. Generally, both referral rates and utilization rates were lower in areas where there is limited or difficult access to a cancer centre. After building a cancer centre in the Interior region of BC, both referral and utilization rates increased. INTERPRETATION: Utilization of palliative radiation varies depending on where people live. Access to RT is lower in remote geographical areas, implying a barrier to essential health care services. This seems to be related to lower referral rates in those areas.