Racialized inequities in live birth after cancer: A population-based study of 63,000 female adolescents and young adults with cancer.

INTRODUCTION: Fertility after cancer is a top concern for adolescents and young adults with cancer (AYAs) (15-39 years old at diagnosis). The authors characterized live births after cancer by race and ethnicity ("race/ethnicity") in a population-based sample of female AYAs. METHODS: This study used Texas Cancer Registry data linked to birth certificates (1995-2016) to estimate cumulative incidence of live birth, based on first live birth after cancer, and compared differences by race/ethnicity. Proportional subdistribution hazards models were used to estimate associations between race/ethnicity and live birth, adjusted for diagnosis age, cancer type, stage, year, and prior live birth, overall and for each cancer type. RESULTS: Among 65,804 AYAs, 10-year cumulative incidence of live birth was lower among non-Hispanic Black AYAs than other racial/ethnic groups: 10.2% (95% confidence interval [CI], 9.4-10.9) compared to 15.9% (95% CI, 14.1-17.9) among Asian or Pacific Islander, 14.7% (95% CI, 14.2-15.3) among Hispanic, and 15.2% (95% CI, 14.8-15.6) among non-Hispanic White AYAs (p < .01). In the adjusted overall model, Black AYAs were less likely to have a live birth after cancer than all other groups. In adjusted models for each cancer type, live birth was significantly less likely for Black AYAs with gynecologic cancers or lymphomas (compared to White AYAs) or thyroid cancers (compared to Hispanic AYAs). CONCLUSION: Black AYAs are less likely than AYAs of other races/ethnicities to have a live birth after cancer, in contrast to patterns of live birth in the general population. Research and action to promote childbearing equity after cancer are imperative.

Trusting information on cancer varies by source of information and political viewpoint.

PURPOSE: This study investigated how trusting information on cancer varies by the source of information and political viewpoint. METHODS: This study used cross-sectional survey data from the 2020 Health Information National Trends Survey (HINTS). The study comprised a sample of 2949 adults 18 years and older. The outcome variable was measured by assessing respondents' trust in cancer-related information from various sources, including religious organizations and leaders, government health agencies, charitable organizations, family or friends, and doctors. Political viewpoint was measured as liberal, moderate, and conservative. Multivariate linear probability models were estimated and adjusted for individual-level characteristics. RESULTS: Multivariate analysis found that conservatives (73%, 95% CI = 68-78%) were significantly less likely to trust information on cancer from government health agencies compared to liberals (84%, 95% CI = 80-88%). There was no statistically significant difference in trusting government health agencies between liberals and moderates (80%, 95% CI = 76-84%). Both moderates (27%, 95% CI = 21-34%) and conservatives (34%, 95% CI = 29-39%) were more likely to trust information on cancer from religious organizations and leaders compared to liberals (19%, 95% CI = 13-24%). The relationship between political viewpoint and trust of doctors, family or friends, and charitable organizations were not statistically significant. CONCLUSION: Compared to liberals, conservatives are more likely to trust information on cancer from religious organizations and leaders and less likely to trust government health agencies when adjusting for other covariates. This finding emphasizes the role of political viewpoint in shaping individuals' perceptions of information sources and cancer-related information.

Dietary intake of individuals receiving Supplemental Nutrition Assistance Program and food pantry assistance in North Texas.

OBJECTIVE: Food pantries and the Supplemental Nutrition Assistance Program (SNAP) are widely available resources for individuals facing food insecurity, yet the dietary quality of individuals using both programmes is not well characterised. We describe the dietary intake of individuals in North Texas who use both food pantries and SNAP to identify nutritional gaps and opportunities to improve food assistance programmes. DESIGN: We analysed baseline data from a randomised controlled trial examining food security and dietary intake. At baseline, we administered the validated, 26-item Dietary Screener Questionnaire (DSQ). We calculated descriptive statistics for dietary intake variables and compared with the 2020-2025 Dietary Guidelines for Americans recommended intake values. SETTING: Two large food pantries in Dallas County, TX. PARTICIPANTS: Eligible participants were English or Spanish speaking adults receiving SNAP benefits who had used the food pantry within the last 4 months. RESULTS: We analysed baseline DSQ data from 320 participants (mean age 47 years; 90% female; 45% Black or African American; 37% Hispanic or Latino). Despite receiving SNAP benefits and food pantry assistance, most participants did not meet the minimum recommended intake values for fruits (88.4%), vegetables (97.4%), fibre (90·7%), whole grains (99·7%), dairy products (98·4%) and Ca (83·4%). Furthermore, 73·2% of participants exceeded the maximum recommended intake for added sugar. Still, the gap between median daily intake and recommended daily intake could be partially bridged with food obtained through current food assistance programmes. CONCLUSIONS: Multilevel, coordinated approaches within both SNAP and food pantry networks are needed to improve diet quality in individuals receiving food assistance.

A pilot randomized controlled trial comparing nutritious meal kits and no-prep meals to improve food security and diet quality among food pantry clients.

BACKGROUND: Food pantry clients have high rates of food insecurity and greater risk for and prevalence of diet-related diseases. Many clients face time, resource, and physical constraints that limit their ability to prepare healthy meals using foods typically provided by pantries. We compared two novel approaches to alleviate those barriers and encourage healthier eating: meal kits, which bundle ingredients with a recipe on how to prepare a healthy meal, and nutritious no-prep meals, which can be eaten after thawing or microwaving. METHODS: Participants were adult pantry clients from a large food pantry in the Southern sector of Dallas, Texas. We conducted a repeated measures between-subjects study with 70 clients randomized to receive 14-days of meal kits (n = 35) or no-prep meals (n = 35). Participants completed questionnaires at baseline and two-week follow-up on demographics, hedonic liking of study meals, perceived dietary quality, and food security. Two-way repeated measures analysis of variance was used to examine group and time effects, and group by time interactions. We also describe feasibility and satisfaction outcomes to inform future implementation. RESULTS: Sixty-six participants completed the study (94%). Participants were predominantly Hispanic or Latino(a) (63%) and African American or Black (31%) women (90%). There was a significant interaction on hedonic liking of study meals (ηp²=0.16, F(1,64) = 11.78, p < .001), such that participants that received meal kits had greater improvements in hedonic liking over time than participants in the no-prep group. We observed significant improvements in perceived dietary quality (ηp²=0.36, F(1,64) = 36.38, p < .001) and food security (ηp²=0.36, F(1,64) = 36.38, p < .001) across both groups over time, but no between group differences or significant interactions indicating one intervention was more effective than the other. Program satisfaction was high across both groups, but higher among the meal kit group (ηp²=0.09, F(1,64) = 6.28, p = .015). CONCLUSIONS: Results suggest nutritious meal kits and no-prep meals may be desirable nutrition intervention strategies for pantry clients and have potential to increase food security and perceived dietary quality in the short-term. Our findings are limited by a small sample and short follow-up. Future studies should continue to test both interventions, and include longer follow-up, objective measures of dietary quality, and relevant clinical outcomes. TRIAL REGISTRATION: This trial was registered on 25/10/2022 on ClinicalTrials.gov, identifier: NCT05593510.

Associations between perceived racial discrimination, racial residential segregation, and cancer screening adherence among low-income African Americans: a multilevel, cross-sectional analysis.

OBJECTIVES: African Americans suffer disproportionately from cancer compared to their White counterparts. Racism may be an important determinant, but the literature on its association with cancer screening is limited. We examine associations between racism and cancer screening among a sample of African Americans. DESIGN: Guided by the Public Health Critical Race Praxis and the Behavioral Model of Health Services Use, we conducted a multilevel, cross-sectional study using cancer risk assessment data collected from 405 callers to the 2-1-1 Texas helpline. We merged these data with contextual data from the U.S. Census Bureau. We assessed perceived racial discrimination using the Experiences of Discrimination Scale and racial residential segregation using the Location Quotient for Racial Residential Segregation. We used multilevel regression models to test hypothesized associations between each indicator of racism and four cancer screening adherence outcomes (Pap test, mammography, colorectal cancer screening [CRCS], and any cancer screening). RESULTS: Participants were 18-83 years old (mean = 45 years). Most (81%) were non-adherent to at least one recommended screening. Approximately 42% reported experiencing discrimination and 73% lived in a segregated neighborhood. Discrimination was non-significantly related to lower odds of mammography (aOR = 0.68; 95%CI: 0.38-1.22), CRCS (aOR = 0.79; 95%CI: 0.41-1.52), and any cancer screening adherence (aOR = 0.88; 95%CI: 0.59-1.32). Segregation was related to greater odds of mammography (non-significant; aOR = 1.43; 95%CI: 0.76-2.68) and CRCS (significant; aOR = 2.80; 95%CI: 1.21-6.46) but not associated with any cancer screening. Neither indicator of racism was associated with Pap test screening adherence. CONCLUSIONS: Racism has a nuanced association with cancer screening among low-income, medically underserved African Americans. Specifically, discrimination appears to be associated with lower odds of screening, while segregation may be associated with higher odds of screening in certain situations. Future research is needed to better explicate relations between indicators of racism and cancer screening among African Americans.

Provider- and Facility-Level Variation in Precancerous Cervical Biopsy Diagnoses.

OBJECTIVES: Reproducibility of cervical biopsy diagnoses is low and may vary based on where the diagnostic test is performed and by whom. Our objective was to measure multilevel variation in diagnoses across colposcopists, pathologists, and laboratory facilities. METHODS: We cross-sectionally examined variation in cervical biopsy diagnoses within the 5 sites of the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR I) consortium within levels defined by colposcopists, pathologists, and laboratory facilities. Patients aged 18 to 65 years with a colposcopy with biopsy performed were included, with diagnoses categorized as normal, cervical intraepithelial neoplasia grade 1 (CIN1), grade 2 (CIN2), and grade 3 (CIN3). Using Markov Chain Monte-Carlo methods, we fit mixed-effects logistic regression models for biopsy diagnoses and presented median odds ratios (MORs), which reflect the variability within each level. Median odds ratios can be interpreted as the average increased odds a patient would have for a given outcome (e.g., CIN2 or CIN3 vs normal or CIN1) when switching to a provider with higher odds of diagnosing that outcome. The MOR is always 1 or greater, and a value of 1 indicates no variation in outcome for that level, with higher values indicating greater variation. RESULTS: A total of 130,110 patients were included who received care across 82 laboratory facilities, 2,620 colposcopists, and 489 pathologists. Substantial variation in biopsy diagnoses was found at each level, with the most occurring between laboratory facilities, followed by pathologists and colposcopists. Substantial variation in biopsy diagnoses of CIN2 or CIN3 (vs normal or CIN1) was present between laboratory facilities (MOR: 1.26; 95% credible interval = 1.19-1.36). CONCLUSIONS: Improving consistency in cervical biopsy diagnoses is needed to reduce underdiagnosis, overdiagnosis, and unnecessary treatment resulting from variation in cervical biopsy diagnoses.

Potential Impact of Revised NCI Eligibility Criteria Guidance: Prior Malignancy Exclusion in Breast Cancer Clinical Trials.

BACKGROUND: Many individuals with cancer have survived a prior cancer and for this reason may have been excluded from clinical trials. Recent NCI guidance recommends including these individuals, especially when the risk of the prior malignancy interfering with either safety or efficacy endpoints is very low. Using breast cancer as an example, we determined the potential effect this policy change may have on clinical trial accrual. PATIENTS AND METHODS: We reviewed protocols of NCI-sponsored breast cancer clinical trials activated in 1991 through 2016. We quantified prevalence of prior cancer-related exclusion criteria and assessed the association with trial characteristics using Fisher's exact tests. Using SEER data, we estimated the prevalence and timing of prior primary (nonbreast) cancer diagnoses among patients with breast cancer. RESULTS: Among 87 clinical trials (total target enrollment, 137,253 patients), 77% excluded individuals with prior cancer, most commonly (79%) within the preceding 5 years. Among trials with radiographic response or toxicity endpoints, 69% excluded prior cancer. In SEER data, the prevalence of a prior (nonbreast) cancer diagnosis ranged from 5.7% to 7.7%, depending on breast cancer stage, of which 39% occurred within 5 years of the incident breast cancer. For trials excluding prior cancer, the estimated proportion of patients excluded for this reason ranged from 1.3% to 5.8%, with the estimated number of excluded patients ranging from 1 to 288. CONCLUSIONS: More than three-fourths of NCI-sponsored breast cancer clinical trials exclude patients with prior cancer, including almost 70% of trials with response or toxicity endpoints. Given that >5% of patients with breast cancer have a history of prior cancer, in large phase III trials this practice may exclude hundreds of patients. Following recent NCI eligibility guidance, the inclusion of patients with prior cancer on breast cancer trials may have a meaningful impact on accrual.

Experiences of increased food insecurity, economic and psychological distress during the COVID-19 pandemic among Supplemental Nutrition Assistance Program-enrolled food pantry clients.

OBJECTIVE: The COVID-19 pandemic initially doubled the rates of food insecurity across the USA and tripled rates among households with children. Despite the association among food insecurity, chronic disease and psychological distress, narratives depicting the experiences of already food insecure populations are notably underrepresented in the literature. The current study assessed the impact of COVID-19 on clients of a food pantry who were also enrolled in the Supplemental Nutrition Assistance Program (SNAP). DESIGN: A qualitative study probing the effects of the pandemic on daily living, food needs, food buying and food insecurity. Interview transcripts were analysed using a combined deductive and inductive approach. SETTING: Interviews were conducted via telephone between May and June of 2020. PARTICIPANTS: Equal numbers of English- and Spanish-speaking clients (n 40 total). RESULTS: Three main findings emerged: (1) the pandemic increased economic distress, such as from job loss or increased utility bills due to sustained home occupancy and (2) the pandemic increased food needs, food prices and food shortages. In combination with economic stressors, this led to greater food insecurity; (3) increased economic stress and food insecurity contributed to increased psychological stress, such as from fear of infection, isolation and children being confined at home. CONCLUSIONS: Despite federal legislation and state and local programmes to alleviate food insecurity, COVID-19 exacerbated economic hardship, food insecurity and psychological distress among urban SNAP and food pantry clients. Additional research is needed to identify the most effective policies and programmes to ameliorate the short- and long-term health and economic inequities exacerbated by the pandemic.

Residence in a Latinx enclave and end-induction minimal residual disease positivity among children with acute lymphoblastic leukemia.

Racial and ethnic inequities in survival persist for children with acute lymphoblastic leukemia (ALL). In the US, there are strong associations between SES, race/ethnicity, and place of residence. This is evidenced by ethnic enclaves: neighborhoods with high concentrations of ethnic residents, immigrants, and language isolation. The Latinx enclave index (LEI) can be used to investigate how residence in a Latinx enclave is associated with health outcomes. We studied the association between LEI score and minimal residual disease (MRD) in 142 pediatric ALL patients treated at Texas Children's Hospital. LEI score was associated with end-induction MRD positivity (OR per unit increase 1.63, CI 1.12-2.46). There was also a significant trend toward increased odds of MRD positivity among children living in areas with the highest enclave index scores. MRD positivity at end of induction is associated with higher incidence of relapse and lower overall survival among children with ALL; future studies are needed to elucidate the exact causes of these findings and to improve ALL outcomes among children residing within Latinx enclaves.Supplemental data for this article is available online at https://doi.org/10.1080/08880018.2022.2047850.

Survival of women diagnosed with breast cancer and who have survived a previous cancer.

PURPOSE: Many women diagnosed with breast cancer have survived previous cancer; yet little is known about the impact of previous cancer on overall and cancer-specific survival. METHODS: This population-based cohort study using SEER-Medicare data included women (age ≥ 66 years) diagnosed with breast cancer between 2005 and 2015. Separately by breast cancer stage, we estimated effect of previous cancer on overall survival using Cox regression and on cause-specific survival using competing risk regression; all survival analyses adjusted for covariates. RESULTS: Of 138,576 women diagnosed with breast cancer, 8% had a previous cancer of another organ site, most commonly colorectal or uterine cancer or melanoma. Many of these women (46.3%) were diagnosed within 5 years of breast cancer. For all breast cancer stages except IV wherein there was no difference, women with vs. without previous cancer had worse overall survival. This survival disadvantage was driven by deaths due to the previous cancer and other causes. In contrast, women with previous cancer generally had favorable breast-cancer-specific survival, although this varied by stage. Overall survival varied by previous cancer type, timing, and stage; previous lung cancer, cancer diagnosed within 1 year of incident breast cancer, and previous cancer at a distant stage were associated with the worst survival. In contrast, women with a previous melanoma had equivalent overall survival to women without previous cancer. CONCLUSION: We observed variable impact of previous cancer on overall and breast-cancer-specific survival depending on breast cancer stage at diagnosis and the type, timing, and stage of previous cancer.

Survival analysis among unresectable pancreatic adenocarcinoma patients undergoing endoscopic or percutaneous interventions.

BACKGROUND AND AIMS: Most patients with pancreatic cancer are diagnosed at a late stage and are not candidates for surgical resection. Many have jaundice requiring biliary drainage, which can be accomplished using ERCP or percutaneous transhepatic biliary drainage (PTBD). To date, no studies have evaluated the impact of ERCP or PTBD on survival among patients with unresectable pancreatic cancer. The aims of our study were to compare overall survival between patients with unresectable pancreatic cancer receiving ERCP with those receiving PTBD, to compare overall survival between patients who received a biliary intervention (ERCP or PTBD) versus those who received no biliary intervention, and to compare secondary outcomes, such as length of hospital stay and costs, between ERCP and PTBD. METHODS: We conducted a retrospective cohort study using the Surveillance, Epidemiology, and End Results-Medicare database. Patients with known pancreatic cancer were included if they had a pancreatic head mass and/or evidence of biliary obstruction. We used a time-varying Cox proportional hazards model to estimate overall survival of patients receiving ERCP versus PTBD and overall survival among patients who received a biliary intervention versus no biliary drainage. Secondary outcomes included length of hospital stay, costs, and admissions within 30 days. RESULTS: Of 14,808 patients with unresectable pancreatic cancer, 8898 patients (60.0%) underwent biliary drainage and 5910 patients (39.9%) received no biliary intervention. ERCP accounted for most biliary interventions (8271, 93.0%), whereas 623 patients (7.0%) underwent PTBD. In multivariable analysis, ERCP was associated with reduced mortality compared with PTBD (adjusted hazard ratio [aHR], .67; 95% confidence interval [CI], .60-.75). When ERCP or PTBD was compared with no biliary intervention, both procedures were associated with a survival benefit (aHR, .51 [95% CI, .49-.54] and .53 [95% CI, .48-.59], respectively). Compared with patients receiving PTBD, those who underwent ERCP had shorter mean length of hospital stay (7.0 ± 5.7 days vs 9.6 ± 6.6 days, respectively; P < .001) and lower hospital charges ($54,899.25 vs $75,246.00, P < .001) but no significant difference in hospitalization or 30-day readmissions. CONCLUSIONS: ERCP is associated with reduced mortality compared with PTBD in pancreatic cancer patients, highlighting the critical role of ERCP in the management of biliary obstruction from pancreatic cancer.

Nativity, ethnic enclave residence, and breast cancer survival among Latinas: Variations between California and Texas.

BACKGROUND: Among Latinas with breast cancer, residence in an ethnic enclave may be associated with survival. However, findings from prior studies are inconsistent. METHODS: The authors conducted parallel analyses of California and Texas cancer registry data for adult (aged ≥18 years) Latinas who were diagnosed with invasive breast cancer from 1996 to 2005, with follow-up through 2014. Existing indices applied to tract-level 2000 US Census data were used to measure Latinx enclaves and neighborhood socioeconomic status (nSES). Multivariable Cox proportional hazard models were fit for all-cause and breast cancer-specific survival adjusted for year of diagnosis, patient age, nativity (with multiple imputation), tumor stage, histology, grade, size, and clustering by census tract. RESULTS: Among 38,858 Latinas, the majority (61.3% in California and 70.5% in Texas) lived in enclaves. In fully adjusted models for both states, foreign-born women were found to be more likely to die of breast cancer and all causes when compared with US-born women. Living in enclaves and in neighborhoods with higher SES were found to be independently associated with improved survival from both causes. When combined into a 4-level variable, those in low nSES nonenclaves had worse survival for both causes compared with those living in low nSES enclaves and, in the all-cause but not breast cancer-specific models, those in high nSES neighborhoods, regardless of enclave status, had improved survival from all causes. CONCLUSIONS: Applying the same methods across 2 states eliminated previously published inconsistent associations between enclave residence and breast cancer survival. Future studies should identify specific protective effects of enclave residence to inform interventions.

Racial Disparities and Trends in Pancreatic Cancer Incidence and Mortality in the United States.

BACKGROUND & AIMS: Pancreatic cancer is one of the few cancers in the United States that is increasing in incidence. Little is known about racial disparities in incidence and mortality. We characterized racial disparities in pancreatic cancer incidence and mortality in different locations, time periods, age groups, and disease stages. METHODS: We obtained data on the incidence of pancreatic cancer from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results program of cancer registries from 2001 through 2015 on incidence, demographics, tumor characteristics, and population estimates for all 50 states and the District of Columbia. We obtained data on mortality from pancreatic cancer from the National Center for Health Statistics during the same time period. We plotted incidence rates by 10-year age group (30-39 years through 70-79 years and 80 years or older) separately for white and black patients. We calculated incidence and mortality rate ratios with 95% CIs for categories of age and race. To determine racial disparities, we calculated incidence rate ratios (IRR) for black vs white patients and mortality rate ratios by state. RESULTS: Disparities in pancreatic cancer incidence and mortality in black vs white patients decreased over 5-year time periods from 2001 through 2015. However, among all age groups, from 2001 through 2015, pancreatic cancer incidence and mortality were higher among blacks than whites (incidence, 24.7 vs 19.4 per 100,000; IRR, 1.28; 95% CI, 1.26-1.29; mortality, 23.3 vs 18.4 per 100,000; IRR, 1.27; 95% CI, 1.26-1.28). Black patients had a higher incidence of distant pancreatic cancer (IRR, 1.32; 95% CI, 1.31-1.34) and a lower incidence of local cancer. Incidence increased in whites and blacks of younger age groups and was most prominent among persons 30-39 years old. Incidence increased by 57% among younger whites (IRR, 1.70; 95% CI, 1.43-2.02) and by 44% among blacks (IRR, 1.47; 95% CI, 1.01-2.15) from 2001 through 2015. Mortality remained stable among blacks and slightly increased among whites during this time period. CONCLUSIONS: In the United States, there are racial disparities in pancreatic incidence and mortality that vary with location, patient age, and cancer stage. Further research is needed to identify factors associated with increasing incidence and persistence of racial disparities in pancreatic cancer.

Do mobile units contribute to spatial accessibility to mammography for uninsured women?

Limited spatial accessibility to mammography, and socioeconomic barriers (e.g., being uninsured), may contribute to rural disparities in breast cancer screening. Although mobile mammography may contribute to population-level access, few studies have investigated this relationship. We measured mammography access for uninsured women using the variable two-step floating catchment area (V2SFCA) method, which estimates access at the local level using estimated potential supply and demand. Specifically, we measured supply with mammography machine certifications in 2014 from FDA and brick-and-mortar and mobile facility data from the community-based Breast Screening and Patient Navigation (BSPAN) program. We measured potential demand using Census tract-level estimates of female residents aged 45-74 from 5-year 2012-2016 American Community Survey data. Using the sign test, we compared mammography access estimates based on 3 facility groupings: FDA-certified, program brick-and-mortar only, and brick-and-mortar plus mobile. Using all mammography facilities, accessibility was high in urban Dallas-Ft. Worth, low for the ring of adjacent counties, and high for rural counties outlying this ring. Brick-and-mortar-based estimates were lower for the outlying ring, and mobile-unit contribution to access was observed more in urban tracts. Weak mobile-unit contribution across the study area may indicate suboptimal dispatch of mobile units to locations. Geospatial methods could identify the optimal locations for mobile units, given existing brick-and-mortar facilities, to increase access for underserved areas.

Screening initiation with FIT or colonoscopy: Post-hoc analysis of a pragmatic, randomized trial.

Screening with FIT or colonoscopy can reduce CRC mortality. In our pragmatic, randomized trial of screening outreach over three years, patients annually received mailed FITs or colonoscopy invitations. We examined screening initiation after each mailing and crossover from the invited to other modality. Eligible patients (50-64 years, ≥1 primary-care visit before randomization, and no history of CRC) received mailed FIT kits (n = 2400) or colonoscopy invitations (n = 2400) from March 2013 through July 2016. Among those invited for colonoscopy, we used multinomial logistic regression to identify factors associated with screening initiation with colonoscopy vs. FIT vs. no screening after the first mailing. Most patients were female (61.8%) and Hispanic (48.9%) or non-Hispanic black (24.0%). Among those invited for FIT, 56.6% (n = 1359) initiated with FIT, whereas 3.3% (n = 78) crossed over to colonoscopy; 151 (15.7%) and 61 (7.7%) initiated with FIT after second and third mailings. Among those invited for colonoscopy, 25.5% (n = 613) initiated with colonoscopy whereas 18.8% (n = 452) crossed over to FIT; 112 (8.4%) and 48 (4.2%) initiated with colonoscopy after second and third mailings. Three or more primary-care visits prior to randomization were associated with initiating with colonoscopy (OR 1.49, 95% CI 1.17-1.91) and crossing over to FIT (OR 1.63, 95% CI 1.19-2.23). Although nearly half of patients initiated screening after the first mailing, few non-responders in either outreach group initiated after a second or third mailing. More patients invited to colonoscopy crossed over to FIT than those assigned to FIT crossed over to colonoscopy.

Effect of hospital safety net designation on treatment use and survival in hepatocellular carcinoma.

BACKGROUND: Racial/ethnic minorities with hepatocellular carcinoma (HCC) have worse survival than non-Hispanic whites. Comparing patient outcomes across health care delivery systems can identify biological and care delivery mechanisms contributing to this disparity. We compared presentation, treatment, and survival of HCC patients treated at safety net hospitals (SNHs) and non-SNHs. METHODS: Patients diagnosed with HCC from 2001 to 2012 were identified in the Texas Cancer Registry. We compared hospital and patient characteristics across three hospital categories: non-SNHs, low-proportion SNHs (l-SNHs), and high-proportion SNHs (h-SNHs). Covariate-adjusted treatment use and overall survival were compared among the 3 hospital categories. RESULTS: Despite comprising only 23% of hospitals, h-SNHs cared for 42% of 17,489 HCC patients and disproportionately delivered care to racial/ethnic minorities and patients of low socioeconomic status compared with non-SNHs. Compared with non-SNHs, treatment use was similar at l-SNHs (45% vs 45%; adjusted odds ratio [OR], 0.97; 95% confidence interval [CI], 0.89-1.06) but significantly lower at h-SNHs (32% vs 45%; OR, 0.64; 95% CI, 0.57-0.73). Similarly, patients with localized HCC were less likely to undergo curative treatment at h-SNHs than non-SNHs (OR, 0.51; 95% CI, 0.40-0.66). Compared with non-SNHs, overall survival was similar at l-SNHs (hazard ratio [HR], 0.93; 95% CI, 0.89-0.98) but significantly worse at h-SNHs (HR, 1.30; 95% CI, 1.22-1.39). CONCLUSION: Patients at SNHs are less likely to undergo HCC treatment, even when diagnosed at an early stage, which likely contributes to worse survival. System-level differences in care delivery may partly explain racial/ethnic and socioeconomic disparities in HCC prognosis. Cancer 2018;124:743-51. © 2017 American Cancer Society.

Colorectal cancer incidence among Hispanics and non-Hispanic Whites in the United States.

PURPOSE: Colorectal cancer (CRC) incidence has declined over the past two decades; however, these declines have not occurred equally in all populations. To better understand the impact of CRC among Hispanics, we examined incidence trends by age and Hispanic ethnicity. METHODS: Using data from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results Program, we estimated CRC incidence rates during the period 2001-2014, and across all 50 U.S. states. We estimated incidence rates in younger (age < 50 years) and older (age ≥ 50 years) adults by anatomic subsite and stage at diagnosis, separately for non-Hispanic Whites and Hispanic Whites. RESULTS: CRC incidence rates declined among older (age ≥ 50 years) Whites and Hispanics, but Whites experienced a greater decline (31% vs. 27% relative decline among Hispanics). In contrast to older adults, there were continued increases in CRC incidence from 2001 to 2014 among younger (age 20-49 years) adults. The largest relative increases in incidence occurred in Hispanics aged 20-29 years (90% vs. 50% relative increase among Whites). CONCLUSIONS: Opposing incidence trends in younger versus older Hispanics may reflect generational differences in CRC risk by birth cohort, as well as environmental exposures and lifestyle-related risk factors associated with immigration and acculturation.

Estimating lead-time bias in lung cancer diagnosis of patients with previous cancers.

Surprisingly, survival from a diagnosis of lung cancer has been found to be longer for those who experienced a previous cancer than for those with no previous cancer. A possible explanation is lead-time bias, which, by advancing the time of diagnosis, apparently extends survival among those with a previous cancer even when they enjoy no real clinical advantage. We propose a discrete parametric model to jointly describe survival in a no-previous-cancer group (where, by definition, lead-time bias cannot exist) and in a previous-cancer group (where lead-time bias is possible). We model the lead time with a negative binomial distribution and the post-lead-time survival with a linear spline on the logit hazard scale, which allows for survival to differ between groups even in the absence of bias; we denote our model Logit-Spline/Negative Binomial. We fit Logit-Spline/Negative Binomial to a propensity-score matched subset of the Surveillance, Epidemiology, and End Results-Medicare linked data set, conducting sensitivity analyses to assess the effects of key assumptions. With lung cancer-specific death as the end point, the estimated mean lead time is roughly 11 months for stage I&II patients; with overall survival, it is roughly 3.4 months in stage I&II. For patients with higher-stage lung cancers, the mean lead time is 1 month or less for both outcomes. Accounting for lead-time bias reduces the survival advantage of the previous-cancer group when one exists, but it does not nullify it in all cases.

Revisiting a longstanding clinical trial exclusion criterion: impact of prior cancer in early-stage lung cancer.

BACKGROUND: Early-stage lung cancer represents a key focus of numerous multicenter clinical trials, but common exclusion criteria such as a prior cancer diagnosis may limit enrollment. We examined the prevalence and prognostic impact of a prior cancer diagnosis among patients with early-stage lung cancer. METHODS: We identified patients>65 years of age with early-stage lung cancer diagnosed 1996-2009 in the Surveillance, Epidemiology, and End Results-Medicare linked database. Prior cancers were characterized by type, stage, and timing with respect to the lung cancer diagnosis. All-cause and lung cancer specific-survival rates were compared between patients with and without prior cancer using Cox regression analyses and propensity scores. RESULTS: Among 42,910 patients with early-stage lung cancer, one-fifth (21%) had a prior cancer. The most common prior cancers were prostate (21%), breast (18%), gastrointestinal (17%), and other genitourinary (15%). Most prior cancers were localized, and 61% were diagnosed within 5 years of the lung cancer diagnosis. There was no difference in all-cause survival between patients with and without prior cancer (hazard ratio [HR] 1.01; P=0.52). Lung cancer specific survival was improved among patients with prior cancer (HR 0.79; P<0.001). CONCLUSIONS: A prior cancer history may exclude a substantial proportion of patients with early-stage lung cancer from enrollment in clinical trials. Without adverse effect on clinical outcomes, inclusion of patients age >65 years with prior cancer in clinical trials should be considered to improve study accrual, completion rates, and generalizability.