Cancer Distribution Among Asian, Native Hawaiian, and Pacific Islander Subgroups - United States, 2015-2019.

Non-Hispanic Asian (Asian) and non-Hispanic Native Hawaiian and Pacific Islander (NHPI) persons represent growing segments of the U.S. population (1). Epidemiologic cancer studies often aggregate Asian and NHPI persons (2,3); however, because Asian and NHPI persons are culturally, geographically, and linguistically diverse (2,4), subgroup analyses might provide insights into the distribution of health outcomes. To examine the frequency and percentage of new cancer cases among 25 Asian and NHPI subgroups, CDC analyzed the most current 2015-2019 U.S. Cancer Statistics data.* The distribution of new cancer cases among Asian and NHPI subgroups differed by sex, age, cancer type, and stage at diagnosis (for screening-detected cancers). The percentage of cases diagnosed among females ranged from 47.1% to 68.2% and among persons aged <40 years, ranged from 3.1% to 20.2%. Among the 25 subgroups, the most common cancer type varied. For example, although breast cancer was the most common in 18 subgroups, lung cancer was the most common cancer among Chamoru, Micronesian race not otherwise specified (NOS), and Vietnamese persons; colorectal cancer was the most common cancer among Cambodian, Hmong, Laotian, and Papua New Guinean persons. The frequency of late-stage cancer diagnoses among all subgroups ranged from 25.7% to 40.3% (breast), 38.1% to 61.1% (cervical), 52.4% to 64.7% (colorectal), and 70.0% to 78.5% (lung). Subgroup data illustrate health disparities among Asian and NHPI persons, which might be reduced through the design and implementation of culturally and linguistically responsive cancer prevention and control programs, including programs that address social determinants of health.

Updated estimate of the annual direct medical cost of screening and treatment for human papillomavirus associated disease in the United States.

The annual direct medical cost attributable to human papillomavirus (HPV) in the United States over the period 2004-2007 was estimated at $9.36 billion in 2012 (updated to 2020 dollars). The purpose of this report was to update that estimate to account for the impact of HPV vaccination on HPV-attributable disease, reductions in the frequency of cervical cancer screening, and new data on the cost per case of treating HPV-attributable cancers. Based primarily on data from the literature, we estimated the annual direct medical cost burden as the sum of the costs of cervical cancer screening and follow-up and the cost of treating HPV-attributable cancers, anogenital warts, and recurrent respiratory papillomatosis (RRP). We estimated the total direct medical cost of HPV to be $9.01 billion annually over the period 2014-2018 (2020 U.S. dollars). Of this total cost, 55.0% was for routine cervical cancer screening and follow-up, 43.8% was for treatment of HPV-attributable cancer, and less than 2% was for treating anogenital warts and RRP. Although our updated estimate of the direct medical cost of HPV is slightly lower than the previous estimate, it would have been substantially lower had we not incorporated more recent, higher cancer treatment costs.

Prevalence of Out-Of-Pocket Payments for Mammography Screening Among Recently Screened Women.

Background: Because cost may be a barrier to receiving mammography screening, cost sharing for "in-network" screening mammograms was eliminated in many insurance plans with implementation of the Affordable Care Act. We examined prevalence of out-of-pocket payments for screening mammography after elimination in many plans. Materials and Methods: Using 2015 National Health Interview Survey data, we examined whether women aged 50-74 years who had screening mammography within the previous year (n = 3,278) reported paying any cost for mammograms. Logistic regression models stratified by age (50-64 and 65-74 years) examined out-of-pocket payment by demographics and insurance (ages 50-64 years: private, Medicaid, other, and uninsured; ages 65-74 years: private ± Medicare, Medicare+Medicaid, Medicare Advantage, Medicare only, and other). Results: Of women aged 50-64 years, 23.5% reported payment, including 39.1% of uninsured women. Compared with that of privately insured women, payment was less likely for women with Medicaid (adjusted OR 0.17 [95% CI 0.07-0.41]) or other insurance (0.49 [0.25-0.96]) and more likely for uninsured women (1.99 [0.99-4.02]) (p < 0.001 across groups). For women aged 65-74 years, 11.9% reported payment, including 22.5% of Medicare-only beneficiaries. Compared with private ± Medicare beneficiaries, payment was less likely for Medicare+Medicaid beneficiaries (adjusted OR 0.21 [95% CI 0.06-0.73]) and more likely for Medicare-only beneficiaries (1.83 [1.01-3.32]) (p = 0.005 across groups). Conclusions: Although most women reported no payment for their most recent screening mammogram in 2015, some payment was reported by >20% of women aged 50-64 years or aged 65-74 years with Medicare only, and by almost 40% of uninsured women aged 50-64 years. Efforts are needed to understand why many women in some groups report paying out of pocket for mammograms and whether this impacts screening use.

Population-Based Assessment of HPV Genotype-Specific Cervical Cancer Survival: CDC Cancer Registry Sentinel Surveillance System.

Background: Human papillomavirus (HPV) genotype influences the development of invasive cervical cancer (ICC); however, there is uncertainty regarding the association of HPV genotype with survival among ICC patients. Methods: Follow-up data were collected from 693 previously selected and HPV-typed ICC cases that were part of the Centers for Disease Control and Prevention Cancer Registry Surveillance System. Cases were diagnosed between 1994 and 2005. The Kaplan-Meier method was used to estimate five-year all-cause survival. A multivariable Cox proportional hazards model was used to estimate the effect of HPV genotype on survival after adjusting for demographic, tumor, and treatment characteristics. Results: Five-year all-cause survival rates varied by HPV status (HPV 16: 66.9%, HPV 18: 65.7%, HPV 31/33/45/52/58: 70.8%, other oncogenic HPV genotypes: 79.0%, nononcogenic HPV: 69.3%, HPV-negative: 54.0%). Following multivariable adjustment, no statistically significant survival differences were found for ICC patients with HPV 16-positive tumors compared with women with tumors positive for HPV 18, other oncogenic HPV types, or HPV-negative tumors. Women with detectable HPV 31/33/33/45/52/58 had a statistically significant 40% reduced hazard of death at five years (95% confidence interval [CI] = 0.38 to 0.95), and women who tested positive for nononcogenic HPV genotypes had a statistically significant 57% reduced hazard of death at five years (95% CI = 0.19 to 0.96) compared with women with HPV 16 tumors. Few statistically significant differences in HPV positivity, tumor characteristics, treatment, or survival were found by race/ethnicity. Conclusions: HPV genotype statistically significantly influenced five-year survival rates among women with ICC; however, screening and HPV vaccination remain the most important factors to improve patient prognosis and prevent future cases.

Mammography Use Among Medicare Beneficiaries After Elimination of Cost Sharing.

BACKGROUND: We examined mammography use before and after Medicare eliminated cost sharing for screening mammography in January 2011. METHODS: Using National Health Interview Survey data, we examined changes in mammography use between 2010 and 2013 among Medicare beneficiaries aged 65-74 years. Logistic regression and predictive margins were used to examine changes in use after adjusting for covariates. RESULTS: In 2013, 74.7% of women reported a mammogram within 2 years, a 3.5 percentage point increase (95% confidence interval, -0.3, 7.2) compared with 2010. Increases occurred among women aged 65-69 years, unmarried women, and women with usual sources of care and 2-5 physician visits in the prior year. After adjustment, mammography use increased in 2013 versus 2010 (74.8% vs. 71.3%, P=0.039). Interactions between year and income, insurance, race, or ethnicity were not significant. CONCLUSIONS: There was a modest increase in mammography use from 2010 to 2013 among Medicare beneficiaries aged 65-74 years, possibly consistent with an effect of eliminating Medicare cost sharing during this time. Findings suggest that eliminating cost sharing might increase use of recommended screening services.

US assessment of HPV types in cancers: implications for current and 9-valent HPV vaccines.

BACKGROUND: This study sought to determine the prevaccine type-specific prevalence of human papillomavirus (HPV)-associated cancers in the United States to evaluate the potential impact of the HPV types in the current and newly approved 9-valent HPV vaccines. METHODS: The Centers for Disease Control and Prevention partnered with seven US population-based cancer registries to obtain archival tissue for cancers diagnosed from 1993 to 2005. HPV testing was performed on 2670 case patients that were fairly representative of all participating cancer registry cases by age and sex. Demographic and clinical data were evaluated by anatomic site and HPV status. Current US cancer registry data and the detection of HPV types were used to estimate the number of cancers potentially preventable through vaccination. RESULTS: HPV DNA was detected in 90.6% of cervical, 91.1% of anal, 75.0% of vaginal, 70.1% of oropharyngeal, 68.8% of vulvar, 63.3% of penile, 32.0% of oral cavity, and 20.9% of laryngeal cancers, as well as in 98.8% of cervical cancer in situ (CCIS). A vaccine targeting HPV 16/18 potentially prevents the majority of invasive cervical (66.2%), anal (79.4%), oropharyngeal (60.2%), and vaginal (55.1%) cancers, as well as many penile (47.9%), vulvar (48.6%) cancers: 24 858 cases annually. The 9-valent vaccine also targeting HPV 31/33/45/52/58 may prevent an additional 4.2% to 18.3% of cancers: 3944 cases annually. For most cancers, younger age at diagnosis was associated with higher HPV 16/18 prevalence. With the exception of oropharyngeal cancers and CCIS, HPV 16/18 prevalence was similar across racial/ethnic groups. CONCLUSIONS: In the United States, current vaccines will reduce most HPV-associated cancers; a smaller additional reduction would be contributed by the new 9-valent vaccine.

Health insurance and other factors associated with mammography surveillance among breast cancer survivors: results from a national survey.

BACKGROUND: Whether disparities in mammography surveillance among breast cancer survivors exist by health insurance type is unclear. OBJECTIVES: To determine the association of surveillance mammography with insurance and other factors among breast cancer survivors. DESIGN/PARTICIPANTS/MEASURES: We examined mammography within the prior year among 1511 breast cancer survivors aged 30 or older and ≥1 year after diagnosis from the 2000, 2003, 2005, and 2008 National Health Interview Surveys. Insurance included private (health maintenance organization/independent practice association, other, unspecified), Medicare+private, public only (Medicare+Medicaid, other Medicare, other public), and uninsured. Multivariable logistic regression was used to determine factors associated with mammography, including age, race/ethnicity, education, time since diagnosis, health status, insurance, income to poverty threshold ratios, having a usual provider, and survey year. Results are presented as predictive margins. For insurance, pairwise comparisons were used to compare Medicare+private versus other groups. RESULTS: Overall 75% reported a mammogram. Mammography reporting was lower for uninsured survivors and those with only public insurance versus Medicare+private or private (50% and 68% vs. 76% and 80%, respectively; P=0.001). In each insurance group, 20% to 50% reported not receiving a mammogram. After adjustment, use remained lower for women with only public insurance versus Medicare+private (71% vs. 78%, P=0.029). Age of at least 75 years, greater time since diagnosis, and no usual provider were associated with not reporting a mammogram. CONCLUSIONS: One in 4 breast cancer survivors did not report guideline-concordant mammography surveillance. Women with only public insurance were less likely than those with Medicare+private coverage to report a mammogram. Efforts to understand barriers and promote mammography among survivors are needed.

Racial and ethnic differences in mammography use among U.S. women younger than age 40.

OBJECTIVE: Evidence-based recommendations for routine breast cancer screening suggest that women begin mammography at age 40, although some women receive a mammogram before that age. Little is known about mammography use among younger women, especially with respect to race and ethnicity. METHODS: We used data from the 2005 National Health Interview Survey to examine racial/ethnic differences in mammography use among U.S. women ages 30-39. We examined descriptive characteristics of women who reported ever having a mammogram, and used logistic regression to estimate associations between race/ethnicity and mammography use among women at average risk for breast cancer. RESULTS: Our sample comprised 3,098 women (18% Hispanic, 13% non-Hispanic [NH] black, 69% NH white), of whom 29% reported having ever had a mammogram. NH black women were more likely than NH white women to report ever having a mammogram and receiving multiple mammograms before age 40 among women of average risk. Patterns of mammography use for Hispanic women compared to NH white women varied. CONCLUSION: Findings suggest differential utilization of mammograms by race/ethnicity among women outside current recommendations and of average risk. Future studies should examine the role of practice patterns and patient-provider communication.

Examining the association between socioeconomic status and potential human papillomavirus-associated cancers.

BACKGROUND: This study examined the association between county-level measures of socioeconomic status (SES) and the incidence rate of human papillomavirus(HPV)-associated cancers, including cervical, vulvar, vaginal, anal, penile, and oral cavity and oropharyngeal cancers. METHODS: The authors collected data from cancer registries for site-specific invasive cancer diagnoses between 1998 and 2003, inclusive, among adults aged >20 years at the time of diagnosis. County-level variables that included education, income, and poverty status were used as factors for socioeconomic status. Measures of rural-urban status, the percentage of the population that currently smoked, and the percentage of women who reported having ever had a Papanicolaou (Pap) test were also studied. RESULTS: Lower education and higher poverty were found to be associated with increased penile, cervical, and vaginal invasive cancer incidence rates. Higher education was associated with increased incidence of vulvar cancer, male and female anal cancer, and male and female oral cavity and oropharyngeal cancers. Race was an independent predictor of the development of these potentially HPV-associated cancers. CONCLUSIONS: These findings illustrate the association between SES variables and the development of HPV-associated cancers. The findings also highlight the importance of considering SES factors when developing policies to increase access to medical care and reduce cancer disparities in the United States.

Estimating personal costs incurred by a woman participating in mammography screening in the National Breast and Cervical Cancer Early Detection Program.

BACKGROUND: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) covers the direct clinical costs of breast and cervical cancer screening and diagnostic follow-up for medically underserved, low-income women. Personal costs are not covered. In this report, the authors estimated personal costs per woman participating in NBCCEDP mammography screening by race/ethnicity and also estimated lifetime personal costs (ages 50-74 years). METHODS: A decision analysis model was constructed and parameterized by using empiric data from a retrospective cohort survey of mammography rescreening among women ages 50 years to 64 years who participated in the NBCCEDP. Data from 1870 women were collected from 1999 to 2000. The model simulated the flow of resources incurred by a woman participating in the NBCCEDP. The analysis was stratified by annual income into 2 scenarios: Scenario 1, <$10,000; and Scenario 2, from $10,000 to <$20,000. Sensitivity analyses were conducted to appraise uncertainty, and all costs were standardized to 2000 U.S. dollars. RESULTS: In Scenario 1, for all races/ethnicities, a woman incurred a 1-time cost of $17 and a discounted lifetime cost of $108 for 10 screens and $262 for 25 screens; in Scenario 2, these amounts were $31 and from $197 to $475, respectively. In both scenarios, a non-Hispanic white woman incurred the highest cost. The sensitivity analyses revealed that >70% of cost incurred was attributable to opportunity cost. CONCLUSIONS: Capturing and quantifying personal costs will help ascertain the total cost (ie, societal cost) of providing mammography screening to a medically underserved, low-income woman participating in a publicly funded cancer screening program and, thus, will help determine the true cost-effectiveness of such programs.

Total, free, and percent free prostate-specific antigen levels among U.S. men, 2001-04.

OBJECTIVE: Screening for prostate cancer using prostate-specific antigen (PSA) tests is common but remains controversial. Total PSA using thresholds of 4.0 and 2.5 ng/mL has been used for screening men. In addition, the percent free PSA (free PSA/total PSA x 100%) using thresholds of less than 25% and 15% have been proposed for use in screening for prostate cancer in conjunction with the total PSA. The distributions of total PSA, free PSA, and percent free PSA, which vary with age and race-ethnicity among American men, would help determine the burden of screening using different thresholds of PSA tests. METHODS: PSA tests were performed on serum samples from men age 40 years and older (n = 2,546) who participated in the 2001-04 National Health and Nutrition Examination Survey (NHANES). Total, free and percent free PSA were estimated for Mexican American, non-Hispanic white, and non-Hispanic black men. RESULTS: About 6.2%, (95% confidence interval, 95% CI: 5.2-7.2%), corresponding to an estimated 3.6 million (95% CI: 3.0-4.2 million) men 40 years of age and older, had a total PSA of greater than or equal to 4.0 ng/mL. Approximately 3.6% (95% CI: 1.8-6.2%) of Mexican American men, 6.2% (95% CI: 5.1-7.6%) of non-Hispanic white men, and 7.8% (95% CI: 5.2-11.1 ) of non-Hispanic black men had total PSA of 4.0 ng/mL or more. Approximately 13.1 (95% CI: 11.7-14.5%) of men 40 years of age and older had total PSA greater than or equal to 2.5 ng/mL. For men with total PSA less than 2.5 ng/mL, 23.1% (95% CI: 21.0-25.3%) had a percent free PSA between 15% and 25%, and 5.0% had free PSA (95% CI: 3.9-6.4%) less than or equal to 15%. CONCLUSIONS: The effect of lowering the total PSA thresholds increases the number of U.S. men who would be referred for screening for prostate cancer. Total and free PSA increased with age in Mexican American, non-Hispanic white, and non-Hispanic black men. Information about the distribution of total, free, and percent free PSA will help guide public health policy in screening for prostate cancer.

Breast, cervical, and colorectal carcinoma screening in a demographically defined region of the southern U.S.

BACKGROUND: The "Southern Black Belt," a term used for > 100 years to describe a subregion of the southern U.S., includes counties with high concentrations of African Americans and high levels of poverty and unemployment, and relatively high rates of preventable cancers. METHODS: The authors analyzed data from a state-based telephone survey of adults age >or= 18 years to compare the cancer screening patterns of African-American and white men and women in nonmetropolitan counties of this region, and to compare those rates with those of persons in other southern counties and elsewhere in the U.S. The primary study groups were comprised of 2165-5888 women and 1198 men in this region interviewed through the Behavioral Risk Factor Surveillance System. The respondents lived in predominantly rural counties in 11 southern states with sizeable African-American populations (>or= 24.5% of county residents). The main outcome measures were recent use of the Papanicolau (Pap) test, mammography, test for fecal occult blood in the stool (FOBT), and flexible sigmoidoscopy or colonoscopy. RESULTS: Between 1998-2000, 66.3% (95% confidence interval [95% CI] +/- 2.7%) of 1817 African-American women in the region age >or= 40 years had received a mammogram within the past 2 years, compared with 69.3% (95% CI +/- 1.8%) of 3922 white women (P = 0.066). The proportion of African-American and white women who had received a Pap test within the past 3 years was similar (85.7% [95% CI +/- 1.9%] vs. 83.4% [95% CI +/- 1.5%]; P = 0.068]. In 1997 and 1999, 29.3% of African-American women in these counties reported ever receiving an FOBT, compared with 36.9% in non-Black Belt counties and 42.5% in the remainder of the U.S. Among white women, 37.7% in Black Belt counties, 44.0% in non-Black Belt counties, and 45.3% in the remainder of the U.S. ever received an FOBT. Overall, similar patterns were noted among both men and women with regard to ever-use of FOBT, flexible sigmoidoscopy, or colonoscopy. Screening rates appeared to vary less by race than by region. CONCLUSIONS: The results of the current study underscore the need for continued efforts to ensure that adults in the nonmetropolitan South receive educational messages, outreach, and provider recommendations concerning the importance of routine cancer screening.

Cost-effectiveness of targeting patients undergoing cardiac surgery for therapy with intravenous amiodarone to prevent atrial fibrillation.

OBJECTIVES: This study evaluated the cost-effectiveness of administering prophylactic intravenous (IV) amiodarone therapy to patients undergoing cardiac surgery according to their predicted risk of postoperative atrial fibrillation. BACKGROUND: Atrial fibrillation (AF) is a common complication of cardiovascular surgery that is associated with a significant increase in hospitalization costs. Intravenous amiodarone has been shown to decrease the incidence of postoperative AF. METHODS: All 8,709 patients who underwent coronary artery bypass grafting (CABG), 1,217 patients who underwent valve replacement and 624 patients who underwent CABG and valve replacement procedures (CABG + valve) from January 1, 1994, to June 30, 1999, at Emory University Hospitals were studied. Models predicting the risk of AF were developed using logistic regression; linear regression was used to estimate the influence of AF on hospitalization costs. Cost-effectiveness was evaluated for patient subsets identified according to their predicted risk of AF. RESULTS: Postoperative AF rates were 17.7% for CABG, 24.6% for valve and 33.8% for CABG + valve. Using 5,000 dollars as an acceptable cost per episode of atrial fibrillation averted, prophylactic IV amiodarone in CABG patients was not found to be cost-effective. Therapy would be recommended for roughly 5% of valve patients with a predicted risk of atrial fibrillation >45%, and roughly two thirds of CABG + valve patients who have a predicted risk of >30%. CONCLUSIONS: Cost-effectiveness of prophylactic IV amiodarone varies according to type of surgery and the predicted risk of atrial fibrillation. Older patients undergoing valve replacement, particularly those with a history of chronic obstructive pulmonary disease, and those undergoing concomitant CABG are likely to be the most appropriate candidates for IV amiodarone therapy in the perioperative period.