Development of Neighborhood Trajectories Employing Historic Redlining and the Area Deprivation Index.

The role of historic residential redlining on health inequities is intertwined with policy changes made before and after the 1930s that influence current neighborhood characteristics and shape ongoing structural racism in the United States (U.S.). We developed Neighborhood Trajectories which combine historic redlining data and the current neighborhood socioeconomic characteristics as a novel approach to studying structural racism. Home Owners' Loan Corporation (HOLC) neighborhoods for the entire U.S. were used to map the HOLC grades to the 2020 U.S. Census block group polygons based on the percentage of HOLC areas in each block group. Each block group was also assigned an Area Deprivation Index (ADI) from the Neighborhood Atlas®. To evaluate changes in neighborhoods from historic HOLC grades to present degree of deprivation, we aggregated block groups into "Neighborhood Trajectories" using historic HOLC grades and current ADI. The Neighborhood Trajectories are "Advantage Stable"; "Advantage Reduced"; "Disadvantage Reduced"; and "Disadvantage Stable." Neighborhood Trajectories were established for 13.3% (32,152) of the block groups in the U.S., encompassing 38,005,799 people. Overall, the Disadvantage-Reduced trajectory had the largest population (16,307,217 people). However, the largest percentage of non-Hispanic/Latino Black residents (34%) fell in the Advantage-Reduced trajectory, while the largest percentage of Non-Hispanic/Latino White residents (60%) fell in the Advantage-Stable trajectory. The development of the Neighborhood Trajectories affords a more nuanced mechanism to investigate dynamic processes from historic policy, socioeconomic development, and ongoing marginalization. This adaptable methodology may enable investigation of ongoing sociopolitical processes including gentrification of neighborhoods (Disadvantage-Reduced trajectory) and "White flight" (Advantage Reduced trajectory).

Reporting on Race and Racial Disparities in Breast Cancer: The Neglect of Racism as a Driver of Inequitable Care.

OBJECTIVE: This study reviews the surgical literature on racial disparities in breast cancer mortality, specifically evaluating the inclusion, justification, and discussion of race and ethnicity as a driver of disparities. SUMMARY OF BACKGROUND DATA: The volume of research on racial disparities has increased over the past 2 decades, but we hypothesize that there is considerable variation in how race is contextualized, defined, and captured in the disparities literature, leading to its questionable validity and relevance as a covariate. Recent guidelines for reporting have been suggested, but not yet applied. METHODS: A rubric was developed to evaluate the reporting of race and/or ethnicity. A systematic review (2010-2020) was performed to identify studies reporting on racial disparities in breast cancer surgery and mortality. We then evaluated these original articles based on key domains of race and/or ethnicity: justification for inclusion, formal definition, methodology used for classification, and type of racism contributing to disparity. RESULTS: Of the 52 studies assessed, none provided a formal definition for race and/or ethnicity. A justification for the inclusion of race and/or ethnicity was provided in 71% of the studies. Although 81% of studies discussed at least 1 potential driver of observed racial disparities, only 1 study explicitly named racism as a driver of racial disparities. CONCLUSIONS: Significant improvement in the reporting on racial disparities in breast cancer surgical literature is warranted. A more rigorous framework should be applied by both researchers and publishers in reporting on race, racial health disparities, and racism.

Rural Disparities in Lung Cancer-directed Surgery: A Medicare Cohort Study.

OBJECTIVE: The primary objective of this study was to determine the influence of rural residence on access to and outcomes of lung cancer-directed surgery for Medicare beneficiaries. SUMMARY OF BACKGROUND DATA: Lung cancer is the leading cause of cancerrelated death in the United States and rural patients have 20% higher mortality. Drivers of rural disparities along the continuum of lung cancercare delivery are poorly understood. METHODS: Medicare claims (2015-2018) were used to identify 126,352 older adults with an incident diagnosis of nonmetastatic lung cancer. Rural Urban Commuting Area codes were used to define metropolitan, micropolitan, small town, and rural site of residence. Multivariable logistic regression models evaluated influence of place of residence on 1) receipt of cancer-directed surgery, 2) time from diagnosis to surgery, and 3) postoperative outcomes. RESULTS: Metropolitan beneficiaries had higher rate of cancer-directed surgery (22.1%) than micropolitan (18.7%), small town (17.5%), and isolated rural (17.8%) (P < 0.001). Compared to patients from metropolitan areas, there were longer times from diagnosis to surgery for patients living in micropolitan, small, and rural communities. Multivariable models found nonmetropolitan residence to be associated with lower odds of receiving cancer-directed surgery and MIS. Nonmetropolitan residence was associated with higher odds of having postoperative emergency department visits. CONCLUSIONS: Residence in nonmetropolitan areas is associated with lower probability of cancer-directed surgery, increased time to surgery, decreased use of MIS, and increased postoperative ED visits. Attention to timely access to surgery and coordination of postoperative care for nonmetropolitan patients could improve care delivery.

Residential Redlining, Neighborhood Trajectory, and Equity of Breast and Colorectal Cancer Care.

OBJECTIVE: This study aimed to determine the influence of structural racism, vis-à-vis neighborhood socioeconomic trajectory, on colorectal and breast cancer diagnosis and treatment. SUMMARY BACKGROUND DATA: Inequities in cancer care are well documented in the United States but less is understood about how historical policies like residential redlining and evolving neighborhood characteristics influence current gaps in care. METHODS: This retrospective cohort study included adult patients diagnosed with colorectal or breast cancer between 2010 and 2015 in 7 Indiana cities with available historic redlining data. Current neighborhood socioeconomic status was determined by the Area Deprivation Index (ADI). Based on historic redlining maps and current ADI, we created four "Neighborhood Trajectory" categories: Advantage Stable, Advantage Reduced, Disadvantage Stable, Disadvantage Reduced. Modified Poisson regression models estimated the relative risks (RR) of Neighborhood Trajectory on cancer stage at diagnosis and receipt of cancer-directed surgery (CDS). RESULTS: A final cohort derivation identified 4,862 cancer patients with colorectal or breast cancer. Compared to Advantage Stable neighborhoods, Disadvantage Stable neighborhood was associated with late-stage diagnosis for both colorectal and breast cancer (RR=1.30 [95% CI=1.05 - 1.59]; RR=1.41 [1.09 - 1.83], respectively). Black patients had lower likelihood of receiving CDS in Disadvantage Reduced neighborhoods (RR=0.92 [0.86 - 0.99]) than White patients. CONCLUSIONS: Disadvantage Stable neighborhoods were associated with late-stage diagnosis for breast and colorectal cancer. Disadvantage Reduced (gentrified) neighborhoods were associated with racial-inequity in CDS. Improved neighborhood socioeconomic conditions may improve timely diagnosis but could contribute to racial inequities in surgical treatment.

Reasons for Long-term Opioid Prescriptions After Guideline-directed Opioid Prescribing and Excess Opioid Pill Disposal.

OBJECTIVES: The aim of this study was to determine the frequency and reasons for long-term opioid prescriptions (rxs) after surgery in the setting of guideline-directed prescribing and a high rate of excess opioid disposal. BACKGROUND: Although previous studies have demonstrated that 5% to 10% of opioid-naïve patients prescribed opioids after surgery will receive long-term (3-12 months after surgery) opioid rxs, little is known about the reasons why long-term opioids are prescribed. METHODS: We studied 221 opioid-naïve surgical patients enrolled in a previously reported prospective clinical trial which used a patient-centric guideline for discharge opioid prescribing and achieved a high rate of excess opioid disposal. Patients were treated on a wide variety of services; 88% of individuals underwent cancer-related surgery. Long-term opioid rxs were identified using a Prescription Drug Monitoring Program search and reasons for rxs and opioid adverse events were ascertained by medical record review. We used a consensus definition for persistent opioid use: opioid rx 3 to 12 months after surgery and >60day supply. RESULTS: 15.3% (34/221) filled an opioid rx 3 to 12 months after surgery, with 5.4% and 12.2% filling an rx 3 to 6 and 6 to 12 months after surgery, respectively. The median opioid rx days supply per patient was 7, interquartile range 5 to 27, range 1 to 447 days. The reasons for long-term opioid rxs were: 51% new painful medical condition, 40% new surgery, 6% related to the index operation; only 1 patient on 1 occasion was given an opioid rx for a nonspecific reason. Five patients (2.3%) developed persistent opioid use, 2 due to pain from recurrent cancer, 2 for new medical conditions, and 1 for a chronic abscess. CONCLUSIONS: In a group of prospectively studied opioid-naïve surgical patients discharged with guideline-directed opioid rxs and who achieved high rates of excess opioid disposal, no patients became persistent opioid users solely as a result of the opioid rx given after their index surgery. Long-term opioid use did occur for other, well-defined, medical or surgical reasons.

The Use of Area-Level Socioeconomic Indices in Evaluating Cancer Care Delivery: A Scoping Review.

BACKGROUND: Multiple composite indices of small-area socioeconomic characteristics have been used to examine how neighborhood characteristics influence cancer care, but there is little consensus regarding how to use them. This scoping review aimed to summarize the use of these indices in cancer literature and their association with outcomes. METHODS: A search was conducted to identify studies from 2015 to 2021 that investigated cancer incidence, disease stage at diagnosis, and mortality using area-based indices of deprivation as an independent variable. Studies were screened and assessed for eligibility. Data were extracted regarding the geospatial and statistical use of these indices. RESULTS: All the inclusion criteria were met by 45 studies. The area level of analysis was at the census tract level in 19 studies (42.3%), the county level in 15 studies (33.3%), the block group level in 6 studies (13.3%), and the ZIP code level in 5 studies (11.1%). Altogether, 18 unique indices were used, with 4 indices used most frequently. Of the studies that used their indices ordinally, 3 defined high and low deprivation dichotomously, 10 used tertiles, 13 used quartiles, and 15 used quintiles. Of the 45 studies, 34 (76%) showed a significant association between area deprivation and cancer-related outcomes. CONCLUSIONS: Neighborhood deprivation indices are most commonly used at the census tract level and ordinally as quintiles. Despite variance in methods, there is a strong indication that deprived areas are at adverse odds with cancer-related outcomes. Further study investigating deprivation in the context of cancer can inform drivers of inequity and identify potential targets for care delivery and policy interventions.

Geographic variation in the rate and route of hysterectomy for benign disease in the USA: A retrospective cross-sectional study.

OBJECTIVES: To describe population rate of hysterectomy for benign disease in the USA, including geographic variation across states and Hospital Service Areas (HSAs; areas defined by common patient flows to healthcare facilities). DESIGN: Cross-sectional study. SETTING: Four US states including 322 HSAs. POPULATION: A total of 316 052 cases of hysterectomy from 2012 to 2016. METHODS: We compiled annual hysterectomy cases, merged female populations, and adjusted for reported rates of previous hysterectomy. We assessed small-area variation and created multi-level Poisson regression models. MAIN OUTCOME MEASURES: Prior-hysterectomy-adjusted population rates of hysterectomy for benign disease. RESULTS: The annual population rate of hysterectomy for benign disease was 49 per 10 000 hysterectomy-eligible residents, declining slightly over time, mostly among reproductive-age populations. Rates peaked among residents ages 40-49 years, and declined with increasing age, apart from an increase with universal coverage at age 65 years. We found large differences in age-standardised population rates of hysterectomy across states (range 42.2-69.0), and HSAs (range: overall 12.9-106.3; 25th-75th percentile 44.0-64.9). Among the non-elderly population, those with government-sponsored insurance had greater variation than those with private insurance (coefficient of variation 0.61 versus 0.32). Proportions of minimally invasive procedures were similar across states (71.0-74.8%) but varied greatly across HSAs (27-96%). In regression models, HSA population characteristics explained 31.8% of observed variation in annual rates. Higher local proportions of government-sponsored insurance and non-White race were associated with lower population rates. CONCLUSIONS: We found substantial variation in rate and route of hysterectomy for benign disease in the USA. Local population characteristics explained less than one-third of observed variation.

Influence of Race, Insurance, Rurality, and Socioeconomic Status on Equity of Lung and Colorectal Cancer Care.

BACKGROUND: This study evaluated the influence that social determinants of health had on stage at diagnosis and receipt of cancer-directed surgery for patients with lung and colorectal cancer in the North Carolina Central Cancer Registry (2010-2015). METHODS: This study examined non-Hispanic uninsured or privately-insured patients 18 to 64 years of age. Multivariable logistic regression models, including two-way interaction terms, assessed the influence of race, insurance status, rurality, and Social Deprivation Index on stage at diagnosis and receipt of surgery. RESULTS: 6574 lung cancer patients and 5355 colorectal cancer patients were included. Among the lung cancer patients, the uninsured patients had higher odds of having stage IV disease (odds ratio [OR] = 1.46; 95 % confidence interval [CI] = 1.22-1.76) and lower odds of receiving surgery (OR = 0.48; 95 % CI = 0.34-0.69) than the privately-insured patients. Among the colorectal cancer patients, uninsured status was associated with higher odds of stage IV disease (OR = 1.53; 95 % CI = 1.17-2.00) than privately-insured status. A significant insurance status and rurality interaction (p = 0.03) was found in the colorectal model for receipt of surgery. In the privately-insured group, non-Hispanic Black and rural patients had lower odds of receiving colorectal surgery (OR = 0.69; 95 % CI = 0.50-0.94 and OR = 0.68; 95 % CI = 0.52-0.89; respectively) than their non-Hispanic White and urban counterparts. CONCLUSIONS: After controlling for confounding and evaluation of interactions between patient-, community-, and geographic-level factors, uninsured status remained the strongest driver of patients' presentation with late-stage lung and colorectal cancer. As policy and care delivery transformation targets uninsured and vulnerable populations, explicit recognition, and measurement of intersectionality should be considered.

Rural-Urban Differences in Breast Cancer Surgical Delays in Medicare Beneficiaries.

BACKGROUND: Delays between breast cancer diagnosis and surgery are associated with worsened survival. Delays are more common in urban-residing patients, although factors specific to surgical delays among rural and urban patients are not well understood. METHODS: We used a 100% sample of fee-for-service Medicare claims during 2007-2014 to identify 238,491 women diagnosed with early-stage breast cancer undergoing initial surgery and assessed whether they experienced biopsy-to-surgery intervals > 90 days. We employed multilevel regression to identify associations between delays and patient, regional, and surgeon characteristics, both in combined analyses and stratified by rurality of patient residence. RESULTS: Delays were more prevalent among urban patients (2.5%) than rural patients (1.9%). Rural patients with medium- or high-volume surgeons had lower odds of delay than patients with low-volume surgeons (odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.58-0.88; OR = 0.74, 95% CI = 0.61-0.90). Rural patients whose surgeon operated at ≥ 3 hospitals were more likely to experience delays (OR = 1.29, 95% CI = 1.01-1.64, Ref: 1 hospital). Patient driving times ≥ 1 h were associated with delays among urban patients only. Age, black race, Hispanic ethnicity, multimorbidity, and academic/specialty hospital status were associated with delays. CONCLUSIONS: Sociodemographic, geographic, surgeon, and facility factors have distinct associations with > 90-day delays to initial breast cancer surgery. Interventions to improve timeliness of breast cancer surgery may have disparate impacts on vulnerable populations by rural-urban status.

Influence of Race, Insurance, and Rurality on Equity of Breast Cancer Care.

BACKGROUND: Considerable gaps in knowledge remain regarding the intersectionality between race, insurance status, rurality, and community-level socioeconomic status that contribute in concert to disparities in breast cancer care delivery. METHODS: Women age 18-64 y old with either private, Medicaid, or no insurance coverage and a diagnosis of breast cancer from the North Carolina Central Cancer Registry (2010-2015) were identified and reviewed. Logistic regression models examined the impact of race, insurance status, rurality, and the Social Deprivation Index (SDI) on advanced stage disease at diagnosis (III, IV) and receipt of cancer directed surgery (CDS). Models tested two-way interactions between race, insurance status, rurality, and SDI. RESULTS: Of the study population (n = 23,529), 14.6% were diagnosed with advanced stage disease (III, IV), and 97.1% of women with non-metastatic breast cancer (n = 22,438) received cancer directed surgery (CDS). Twenty percent of women were non-Hispanic Black (NHB), 3.0% Hispanic, 10.9% Medicaid insured, 5.9% uninsured, 20.0% of women resided in rural areas, and 20.0% resided in communities of the highest quartile SDI. NHB race, Medicaid or uninsured status, and residence in rural or socially deprived areas were associated with advanced stage breast cancer at diagnosis. NHB and Medicaid or uninsured women were significantly less likely to receive CDS. There were no statistically significant interactions found influencing stage at diagnosis or receipt of cancer directed surgery. CONCLUSIONS: In a heterogeneous population across the state of North Carolina, non-Hispanic Black race, Medicaid or uninsured status, and residence in rural or high social deprivation communities are independently associated with advanced stage breast cancer at diagnosis, while non-Hispanic Black race and Medicaid or uninsured status are associated with lower odds to receive cancer directed surgery.

Surgical Diseases are Common and Complicated for Criminal Justice Involved Populations.

BACKGROUND: At any given time, almost 2 million individuals are in prisons or jails in the United States. Incarceration status has been associated with disproportionate rates of cancer and infectious diseases. However, little is known about the burden emergency general surgery (EGS) in criminal justice involved (CJI) populations. MATERIALS AND METHODS: The California Office of Statewide Health Planning and Development (OSHPD) database was used to evaluate all hospital admissions with common EGS diagnoses in CJI persons from 2012-2014. The population of CJI individuals in California was determined using United States Bureau of Justice Statistics data. Primary outcomes were rates of admission and procedures for five common EGS diagnoses, while the secondary outcome was probability of complex presentation. RESULTS: A total of 4,345 admissions for CJI patients with EGS diagnoses were identified. The largest percentage of EGS admissions were with peptic ulcer disease (41.0%), followed by gallbladder disease (27.5%), small bowel obstruction (14.0%), appendicitis (13.8%), and diverticulitis (10.5%). CJI patients had variable probabilities of receipt of surgery depending on condition, ranging from 6.2% to 90.7%. 5.6% to 21.0% of admissions presented with complicated disease, the highest being with peptic ulcer disease and appendicitis. CONCLUSION: Admissions with EGS diagnoses were common and comparable to previously published rates of disease in general population. CJI individuals had high rates of complicated presentation, but low rates of surgical intervention. More granular evaluation of the burden and management of these common, morbid, and costly surgical diagnoses is essential for ensuring timely and quality care delivery for this vulnerable population.

A case of YAP1 and NUTM1 rearranged porocarcinoma with corresponding immunohistochemical expression: Review of recent advances in poroma and porocarcinoma pathogenesis with potential diagnostic utility.

Porocarcinoma is a rare malignant adnexal tumor with predilection for the lower extremities and the head and neck region of older adults. This entity may arise de novo or in association with a benign poroma. Porocarcinoma's non-specific clinical appearance, immunohistochemical profile, and divergent differentiation may occasionally be diagnostically challenging. Recently, highly recurrent YAP1 and NUTM1 gene rearrangements have been described in cases of poroma and porocarcinoma. In this report, we present a case of porocarcinoma with squamous differentiation in an 81-year-old woman which harbored rearrangement of the YAP1 and NUTM1 loci and was diffusely immunoreactive for NUTM1. We discuss the recent advancements in the pathogenesis of poromas and porocarcinomas with emphasis on the clinical utility of the NUTM1 antibody.

CD10 and p63 expression in a sarcomatoid undifferentiated melanoma: A cautionary (and molecularly annotated) tale.

Undifferentiated melanoma should be considered in the differential diagnosis of sarcomatoid cutaneous malignancies to ensure that patients receive the correct treatment. Dermatopathologists should recognize the pitfalls of relying too heavily on immunohistochemistry to establish this diagnosis and consider ancillary tests, including single-nucleotide polymorphism (SNP) copy number arrays and targeted next-generation sequencing (NGS), when a definitive diagnosis cannot be rendered on a primary or metastatic tumor. This technology can also help to exclude a collision of melanoma and sarcoma when both differentiated and undifferentiated components are juxtaposed. We describe an exceedingly rare, illustrative example of undifferentiated sarcomatoid melanoma presenting as a pedunculated nodule. The clinical context and presence of a small differentiated component helped to establish the diagnosis; however, the transition from differentiated to undifferentiated melanoma was accompanied by an abrupt loss of S100, Sox10, MITF, MelanA, and HMB45 with gain of CD10 and p63 staining. SNP copy number array and NGS revealed shared chromosomal copy number changes and overlapping mutations with additional aberrances detected exclusively in the sarcomatoid component, thereby excluding a collision tumor and confirming our putative impression of melanoma with progression to an undifferentiated sarcomatoid phenotype.

Impact of Expanded Insurance Coverage on Racial Disparities in Vascular Disease: Insights From Massachusetts.

OBJECTIVE: To evaluate the impact of health insurance expansion on racial disparities in severity of peripheral arterial disease. BACKGROUND: Lack of insurance and non-white race are associated with increased severity, increased amputation rates, and decreased revascularization rates in patients with peripheral artery disease (PAD). Little is known about how expanded insurance coverage affects disparities in presentation with and management of PAD. The 2006 Massachusetts health reform expanded coverage to 98% of residents and provided the framework for the Affordable Care Act. METHODS: We conducted a retrospective cohort study of nonelderly, white and non-white patients admitted with PAD in Massachusetts (MA) and 4 control states. Risk-adjusted difference-in-differences models were used to evaluate changes in probability of presenting with severe disease. Multivariable linear regression models were used to evaluate disparities in disease severity before and after the 2006 health insurance expansion. RESULTS: Before the 2006 MA insurance expansion, non-white patients in both MA and control states had a 12 to 13 percentage-point higher probability of presenting with severe disease (P < 0.001) than white patients. After the expansion, measured disparities in disease severity by patient race were no longer statistically significant in Massachusetts (+3.0 percentage-point difference, P = 0.385) whereas disparities persisted in control states (+10.0 percentage-point difference, P < 0.001). Overall, non-white patients in MA had an 11.2 percentage-point decreased probability of severe PAD (P = 0.042) relative to concurrent trends in control states. CONCLUSIONS: The 2006 Massachusetts insurance expansion was associated with a decreased probability of patients presenting with severe PAD and resolution of measured racial disparities in severe PAD in MA.

Treatment of Locally Advanced Pancreatic Ductal Adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDAC) is increasingly common and a leading cause of cancer-related mortality. Surgery remains the only possibility for cure. Upwards of 40% of patients present with locally advanced PDAC (LA-PDAC), where management strategies continue to evolve. In this review, we highlight current trends in neoadjuvant chemotherapy, surgical resection, and other multimodality approaches for patients with LA-PDAC. Despite promising early results, additional work is needed to more accurately and appropriately tailor treatment for patients with LA-PDAC.