Changes in health-related quality of life in older women after diagnosis with gynecologic cancer.

PURPOSE: The impact of gynecologic cancer on health-related quality of life (HRQOL) is not fully understood. To our knowledge, this is the first longitudinal study to measure HRQOL changes from before to after gynecologic cancer diagnosis in older women. METHODS: Data were obtained from the Surveillance, Epidemiology, and End Results - Medicare Health Outcomes Survey database. Women aged 65 and older who were diagnosed with cervical, ovarian, or uterine cancer between baseline and follow-up surveys (n = 248; mean time from diagnosis = 12.54 ± 7.11 months) were propensity-matched to cancer-free controls (n = 1240). Logistic regression was used to assess risk of functional impairments and depressive symptoms at follow-up. Changes in HRQOL, as measured by the Medical Outcomes Study Short Form-36 and Veterans RAND 12-Item Survey, were estimated with mixed effects linear models. RESULTS: Women who were within 12 months of diagnosis and women diagnosed with regional/distant disease had significantly greater odds than controls of impairment at follow-up. HRQOL declines were greatest in those with advanced disease, with the most notable changes from baseline to follow-up observed for role limitations due to emotional problems (-8.60 vs. -3.42 in controls), general health (-7.76 vs 0.10), and physical functioning (-7.70 vs. -1.67). There were significant decreases in physical functioning and role limitations due to emotional problems for all cancer patients regardless of time since diagnosis. CONCLUSIONS: Gynecologic cancer has significant impacts on physical and mental aspects of HRQOL in older women. Interventions are needed to reduce pain, provide support, and prepare patients for changes in functioning and health.

Pre-diagnosis health-related quality of life and survival in older women with endometrial cancer.

PURPOSE: Health-related quality of life (HRQOL) is an important prognostic factor in cancer patients. To date, no other studies have assessed the association between HRQOL measured before diagnosis and survival in older women with endometrial cancer. METHODS: The Surveillance, Epidemiology, and End Results - Medicare Health Outcomes Survey linked database was used to identify 995 women who were at least 65 years old and completed a survey before diagnosis with endometrial cancer. We obtained scores for 10 HRQOL scales, as measured by Medical Outcomes Study Short Form-36 and Veterans RAND 12-Item Survey, and data on activities of daily living (ADLs) impairments and depressive symptoms. Fine and Gray competing risks regression and Cox proportional hazards were used to estimate the association of HRQOL with endometrial cancer-specific and overall survival, respectively. RESULTS: Women who died had worse pre-diagnosis HRQOL than women who were still alive at the end of the study period. For every five-point increase in HRQOL score, overall survival improved by 5-9%. The strongest associations were observed for vitality (HR = 0.91, 95% CI 0.86, 0.97, p = 0.0021) and physical functioning (HR = 0.92, 95% CI 0.87, 0.97, p = 0.0010). ADL impairments were generally not predictive of survival, though depressive symptoms were significantly associated with increased hazard of death from all causes (HR = 1.34, 95% CI 1.00, 1.79, p = 0.0466). CONCLUSION: HRQOL measured before diagnosis with endometrial cancer has prognostic value. Having measures of HRQOL available at diagnosis may facilitate timely supportive care to improve survival.

Racial/ethnic differences in survival among gastric cancer patients in california.

BACKGROUND: Gastric cancer is an important cause of death among racial/ethnic minorities in the U.S. The objective of this study was to investigate racial disparities in survival among gastric cancer patients within demographic and disease subgroups. METHODS: Patients diagnosed with invasive epithelial gastric cancer between 2006 and 2015 were identified from the California Cancer Registry. Cox proportional hazards regression was used to identify factors associated with survival among non-Hispanic whites (NHWs, n = 7,475), non-Hispanic blacks (NHBs, n = 1,246), Hispanics (n = 6,274), and Asians/Pacific Islanders (APIs, n = 4,204). Survival was compared across race/ethnicity within subgroups of demographic and disease factors. Five-year relative survival was also calculated within subgroups. RESULTS: There were notable differences in patient characteristics by race/ethnicity, but predictors of survival were similar for each group. Overall, APIs (HR = 0.83, 95% CI: 0.79, 0.88, p < 0.0001) and Hispanics (HR = 0.94, 95% CI: 0.90, 0.99, p = 0.0104) had better survival than NHWs, but NHBs and NHWs did not have different prognosis (HR = 1.06, 95% CI: 0.98, 1.15, p = 0.2237). The survival advantage of APIs persisted in nearly every demographic and disease subgroup, but Hispanics and NHBs had similar survival as NHWs in most groups. Race was not a significant predictor of survival among those with public or no insurance and patients with cardia tumors. CONCLUSIONS: There are some differences in survival by race/ethnicity, but race/ethnicity alone cannot explain disparate outcomes in gastric cancer. Future studies, particularly ones that investigate the role of population-specific etiological factors and molecular tumor profiles, are needed to further understand factors associated with survival.

Socioeconomic gradients in cancer incidence by race and ethnicity in California, 2008-2012: the influence of tobacco use or screening detectable cancers.

PURPOSE: There are clearly documented inequalities in cancer incidence by socioeconomic position, but it is unclear whether this is due primarily to differences in tobacco exposure and screening practices or to other factors. METHODS: Our study included 741,373 incident cases of invasive cancer from 2008 to 2012 in California. We calculated age-standardized incidence rates across twelve categories of census tract poverty as a measure of socioeconomic position (SEP) for (1) all cancer sites combined, (2) sites not strongly related to tobacco use, (3) sites not related to screening, and (4) sites not related to tobacco use or screening. RESULTS: There was higher cancer incidence among those living in areas with higher levels of poverty for sites not strongly related to tobacco use or screening, among Whites, Blacks, and Asians, but not among Latinos. Among Whites there was no relationship with census tract poverty at lower levels of poverty-the relationship with cancer incidence was primarily among those in higher poverty. For Blacks and Asians, there is a more linear relationship with cancer incidence across levels of poverty. CONCLUSIONS: SEP gradients in cancer incidence remain after exclusion of cancer sites strongly related to tobacco use and screening. Our findings demonstrate a need for research on other environmental and social causes of cancer where exposures are differentially distributed by SEP.

Understanding care and outcomes in adolescents and young adult with Cancer: A review of the AYA HOPE study.

Historically, adolescents and young adults (AYA) diagnosed with cancer have been an understudied population, and their unique care experiences, needs, and outcomes were not well understood. Thus, 10 years ago, the National Cancer Institute supported the fielding of the Adolescent and Young Adult Health Outcomes and Patient Experiences (AYA HOPE) study to address this gap. We recruited individuals diagnosed at ages 15 to 39 with germ cell, Hodgkin and non-Hodgkin lymphoma, acute lymphoblastic leukemia, and sarcoma from Surveillance, Epidemiology, and End Results cancer registries into the first multicenter population-based study of medical care, physical, and mental health outcomes for AYAs with cancer in the United States. This review of the 17 published manuscripts showed low awareness of clinical trials and substantial impact of cancer on financial burden, education and work, relationships and family planning, and physical and mental health. It highlights the feasibility of a longitudinal population-based study and key lessons learned for research on AYAs with cancer in and beyond the United States.

Increased clinical trial enrollment among adolescent and young adult cancer patients between 2006 and 2012-2013 in the United States.

BACKGROUND: Stagnant outcomes for adolescents and young adults (AYAs) 15-39 years of age with cancer are partly attributed to poor enrollment onto clinical trials. Initiatives have focused on increasing accrual, but changes at the population-level are unknown. We examined patterns of clinical trial participation over time in AYA patients with cancer. PROCEDURE: We utilized medical record data from AYAs in two population-based National Cancer Institute Patterns of Care Studies identified through the Surveillance, Epidemiology and End Results Program. Among 3135 AYAs diagnosed with non-Hodgkin lymphoma (NHL), Hodgkin lymphoma, acute lymphoblastic leukemia (ALL), and sarcoma, we used multivariate logistic regression to evaluate patient and provider characteristics associated with clinical trial enrollment. Interaction terms evaluated variation in clinical trial enrollment across patient and provider characteristics by year of diagnosis. RESULTS: From 2006 to 2012-2013, clinical trial participation increased from 14.8% to 17.9% (P < 0.01). Adjusting for patient and provider characteristics, we found lower clinical trial enrollment among those who were older at diagnosis, diagnosed with NHL vs ALL, treated by adult hematologist/oncologists only (vs pediatric hematologist/oncologists), and of non-Hispanic Black race/ethnicity (vs non-Hispanic White) (P < 0.05 for all). Interaction analyses indicate improved clinical trial enrollment from 2006 to 2012-2013 among young adults 25-29 years of age and the uninsured. CONCLUSIONS: Although disparities in enrollment onto clinical trials remain for AYAs with cancer, our study identified increasing overall clinical trial participation over time. Further, we identify promising trends in enrollment uptake among AYAs 25-29 years of age and the uninsured.

Nine-year prostate cancer survival differences between aggressive versus conservative therapy in men with advanced and metastatic prostate cancer.

BACKGROUND: To the authors' knowledge, the survival benefit of local therapy in the setting of advanced prostate cancer remains unknown. The authors investigated whether prostate-directed treatment with either surgery or radiotherapy versus conservative treatment in the setting of locally advanced or metastatic disease was associated with improved survival within a cohort of men from the Centers for Disease Control and Prevention's (CDC) Breast and Prostate Cancer Data Quality and Patterns of Care Study (CDC POC-BP). METHODS: Men diagnosed with locally advanced (cT3-T4 or N+ and M0) or metastatic prostate cancer were identified. The authors compared survival by treatment type, categorized as conservative (androgen deprivation therapy only) versus aggressive (radical prostatectomy or any type of radiotherapy). Nine-year overall survival and prostate cancer-specific survival were estimated using the Kaplan-Meier method. The Cox proportional hazards model was used to determine factors independently associated with 9-year prostate cancer-specific survival. RESULTS: For men with advanced, nonmetastatic prostate cancer, conservative treatment alone was associated with a 4 times higher likelihood of prostate cancer mortality compared with men treated with surgery (hazard ratio, 4.18; 95% confidence interval, 1.44-12.14). In contrast, no difference was found between conservative versus aggressive treatment after adjusting for covariates for men with metastatic disease. The 9-year prostate cancer-specific survival rate was 27% for those receiving aggressive treatment versus 24% for men undergoing conservative treatment. CONCLUSIONS: The authors did not observe a survival advantage with local therapy in addition to standard androgen deprivation therapy for men with metastatic prostate cancer. However, the results of the current study did affirm advantages in the setting of locally advanced disease. Aggressive local therapy in the setting of metastatic disease needs to be studied carefully before clinical adoption. Cancer 2018;124:1921-8. © 2018 American Cancer Society.

Obesity and mortality after locoregional breast cancer diagnosis.

PURPOSE: Higher mortality after a breast cancer diagnosis has been observed among women who are obese. We investigated the relationships between body mass index (BMI) and all-cause or breast cancer-specific mortality after a diagnosis of locoregional breast cancer. METHODS: Women diagnosed in 2004 with AJCC Stage I, II, or III breast cancer (n = 5394) were identified from a population-based National Program of Cancer Registries (NPCR) patterns of care study (POC-BP) drawing from registries in seven U.S. states. Differences in overall and breast cancer-specific mortality were investigated using Cox proportional hazards regression models adjusting for demographic and clinical covariates, including age- and stage-based subgroup analyses. RESULTS: In women 70 or older, higher BMI was associated with lower overall mortality (HR for a 5 kg/m2 difference in BMI = 0.85, 95% CI 0.75-0.95). There was no significant association between BMI and overall mortality for women under 70. BMI was not associated with breast cancer death in the full sample, but among women with Stage I disease; those in the highest BMI category had significantly higher breast cancer mortality (HR for BMI ≥ 35 kg/m2 vs. 18.5-24.9 kg/m2 = 4.74, 95% CI 1.78-12.59). CONCLUSIONS: Contrary to our hypothesis, greater BMI was not associated with higher overall mortality. Among older women, BMI was inversely related to overall mortality, with a null association among younger women. Higher BMI was associated with breast cancer mortality among women with Stage I disease, but not among women with more advanced disease.

Underutilization of brachytherapy and disparities in survival for patients with cervical cancer in California.

PURPOSE: The treatment for locally advanced cervical cancer is external beam radiation (EBRT), concurrent chemotherapy, and brachytherapy (BT). We investigated demographic and socioeconomic factors that influence trends in BT utilization and disparities in survival. METHODS: Using the California Cancer Registry, cervical cancer patients FIGO IB2-IVA from 2004 to 2014 were identified. We collected tumor, demographic and socioeconomic (SES) factors. We used multivariable logistic regression analysis to determine predictors of use of BT. Using Cox proportional hazards, we examined the impact of BT vs EBRT boost on cause specific (CSS) and overall survival (OS). RESULTS: We identified 4783 patients with FIGO stage 11% IB2; 32% II, 54% III, 3% IVA. Nearly half (45%) of patients were treated with BT, 18% were treated with a EBRT boost, and 37% had no boost. Stage II and III were more likely to be treated with BT (p = 0.002 and p = 0.0168) vs Stage IB2. As patients aged, the use of BT decreased. Using multivariate analysis, BT impacted CCS (HR 1.16, p = 0.0330) and OS (HR 1.14, p = 0.0333). Worse CSS was observed for black patients (p = 0.0002), low SES (p = 0.0263), stage III and IVA (p < 0.0001. Black patients, low and middle SES had worse OS, (p = 0.0003). CONCLUSIONS: The utilization of BT in locally advanced cervical cancer was low at 45%, with a decrease in CSS and OS. Black patients and those in low SES had worse CSS. As we strive for outcome improvement in cervical cancer, we need to target increasing access and disparities for quality and value.

Contribution of clinical and socioeconomic factors to differences in breast cancer subtype and mortality between Hispanic and non-Hispanic white women.

PURPOSE: To assess tumor subtype distribution and the relative contribution of clinical and sociodemographic factors on breast cancer survival between Hispanic and non-Hispanic whites (NHWs). METHODS: We analyzed data from the California Cancer Registry, which included 29,626 Hispanic and 99,862 NHW female invasive breast cancer cases diagnosed from 2004 to 2014. Logistic regression was used to assess ethnic differences in tumor subtype, and Cox proportional hazard modeling to assess differences in breast cancer survival. RESULTS: Hispanics compared to NHWs had higher odds of having triple-negative (OR = 1.29; 95% CI 1.23-1.35) and HER2-overexpressing tumors (OR = 1.19; 95% CI 1.14-1.25 [HR-] and OR = 1.39; 95% CI 1.31-1.48 [HR+]). In adjusted models, Hispanic women had a higher risk of breast cancer mortality than NHW women (mortality rate ratio [MRR] = 1.24; 95% CI 1.19-1.28). Clinical factors accounted for most of the mortality difference (MRR = 1.05; 95% CI 1.01-1.09); however, neighborhood socioeconomic status (SES) and health insurance together accounted for all of the mortality difference (MRR = 1.01; 95% CI 0.97-1.05). CONCLUSIONS: Addressing SES disparities, including increasing access to health care, may be critical to overcoming poorer breast cancer outcomes in Hispanics.

Evolving patterns of care in the management of stage I non-seminomatous germ cell tumors: data from the California Cancer Registry.

PURPOSE: To assess the shifting population-level practice patterns across a 20-year time span in the management of stage I non-seminomatous germ cell tumors (NSGCT). METHODS: Using the California Cancer Registry, we reviewed all patients with stage I NSGCT between 1988 and 2010. We determined their primary treatment and their overall rates across the years. Other analyzed variables included patient age, T stage, socioeconomic status, race, and year of diagnosis. Predictors of treatment were assessed using logistic regression analysis. Predictors of overall and CSS were assessed using Cox proportional hazards models. RESULTS: Three thousand nine hundred and sixty-one patients with stage I NSGCT were identified. The most common treatment was surveillance (48 %), followed by RPLND (26 %) and chemotherapy (24 %). Rates of surveillance increased from 35 % in 1988 to 61 % in 2010; rates of RPLND decreased from 44 % in 1988 to 10 % in 2010. These were significant changes in treatment strategies (p < 0.01). Significant predictors of undergoing surveillance included diagnosis after 2006 (OR 1.52, CI 1.25-1.84) and age at diagnosis >60 years old (OR 1.63, CI 1.19-5.82). With a median follow-up of 96 months, 5-year overall survival rate was 95 %. CONCLUSIONS: Treatment patterns in the management of stage I NSGCT have shifted in the past two decades with an increased utilization of surveillance and concurrent decrease in use of RPLND. Surveillance is now the dominant strategy, potentially reflecting changes in perception of the oncologic safety and morbidity profile of such an approach.

Trends in early-stage hepatocellular carcinoma, California 1988-2010.

PURPOSE: California Cancer Registry data were used to explore the impact of hepatocellular carcinoma (HCC) surveillance on patient outcomes. The purpose of this analysis was to determine the trend in diagnosis of early-stage HCC in California from 1988 to 2010. METHODS: Patients 20+ years old, diagnosed with early HCC during 1988-2010 in California, were included. Stratified proportions of early HCC were evaluated to estimate any trends and significant disparities. The primary endpoint was the average annual percent change (AAPC) of the proportion of early-stage HCC; 2- and 5-year survival trends were calculated for age, sex, race, SES, and stage. RESULTS: A total of 13,855 patients were diagnosed with early HCC. The proportion of patients diagnosed early increased from 19.2 to 49.2 % between 1988 and 2010, at an AAPC of 4.3 %. The proportion of cases diagnosed with early HCC increased in all demographic groups. Both the 2- and 5-year cause-specific survival analyses showed that survival among HCC patients has been increasing since 1988. CONCLUSION: The proportion of HCC cases diagnosed early, and the 2- and 5-year survival trends of all HCC patients have increased in California since 1988. It is not entirely clear whether better diagnostic imaging or better surveillance has led to these findings and whether earlier diagnosis has led to improved patient survival. This increase in survival among patients with HCC may be correlated with the innovation of new treatments and most importantly that patients are being diagnosed earlier to receive such treatments.

Underutilization of gene expression profiling for early-stage breast cancer in California.

PURPOSE: To describe the utilization of gene expression profiling (GEP) among California breast cancer patients, identify predictors of use of GEP, and evaluate how utilization of GEP influenced treatment of early-stage breast cancer. METHODS: All women diagnosed with hormone-receptor-positive, node-negative breast cancer reported to the California Cancer Registry between January 2008 and December 2010 were linked to Oncotype DX (ODX) assay results. RESULTS: Overall, 26.7 % of 23,789 eligible patients underwent the assay during the study period. Women age 65 or older were much less likely than women under age 50 to be tested (15.1 vs. 41.4 %, p < 0.001). Black women were slightly less likely and Asian women were slightly more likely than non-Hispanic white women to undergo GEP with the ODX assay (22.2 and 28.9 vs. 26.9 %, respectively, p < 0.001). Patients residing in low SES census tracts had the lowest use of the test (8.9 %), with the proportion increasing with higher SES category. Women with Medicaid health insurance were less likely than other women to be tested (17.7 vs. 27.5 %, p < 0.001). Receipt of adjuvant chemotherapy (ACT) was associated with the ODX recurrence score, although only 63 % of patients whose recurrence scores indicated a high benefit received ACT. Of patients not tested, 15 % received ACT. CONCLUSIONS: Nearly three-fourths of eligible breast cancer patients in California during the 3-year period 2008 through 2010 did not undergo GEP. As a result, it is likely that many women unnecessarily received ACT and suffered associated morbidity. In addition, some high-risk women who would have benefited most from ACT were not identified.

Fertility preservation knowledge, counseling, and actions among adolescent and young adult patients with cancer: A population-based study.

BACKGROUND: The fertility of adolescent and young adult (AYA) patients with cancer can be threatened by treatments, but to the authors' knowledge little is known regarding the extent to which providers discuss this with patients or recommend fertility preservation, or the patient and physician characteristics associated with these interactions. METHODS: Questionnaires from 459 AYA patients with cancer who were diagnosed between 2007 and 2008 and recruited through 7 US population-based cancer registries were analyzed using sex-specific multivariable models. The authors assessed characteristics associated with not discussing therapy effects on fertility or fertility preservation options, and not making fertility preservation arrangements. RESULTS: Males without a medical oncologist were more likely not to be told that therapy might affect fertility than those with a medical oncologist (male odds ratio [OR], 2.28; 95% confidence interval [95% CI], 1.03-5.00). Individuals without insurance (male OR, 2.91 [95% CI, 1.41-5.91] and female OR, 5.46 [95% CI, 1.59-18.72]); those raising children aged <18 years; and, among males only, those who received treatment posing no or a low fertility risk (OR, 3.39; 95% CI, 1.60-7.16) were more likely not to discuss fertility preservation with providers. Finally, among males, those without a college degree (OR, 1.98; 95% CI, 1.00-3.97), lacking private insurance (OR, 2.97; 95% CI, 1.16-7.63), and raising children aged <18 years (OR, 3.53; 95% CI, 1.63-7.65) were more likely to not make fertility preservation arrangements; too few females had made fertility preservation arrangements for similar analyses to be performed. CONCLUSIONS: Discussion and action surrounding fertility preservation for AYA patients with cancer are associated with medical factors, patient socioeconomic data, and child-rearing status. These results highlight the need for insurance coverage for fertility preservation and increased awareness of fertility preservation options.

Risk of cancer among firefighters in California, 1988-2007.

BACKGROUND: Most studies of firefighter cancer risks were conducted prior to 1990 and do not reflect risk from advances in building materials. METHODS: A case-control study using California Cancer Registry data (1988-2007) was conducted to evaluate the risk of cancer among firefighters, stratified by race. RESULTS: This study identified 3,996 male firefighters with cancer. Firefighters were found to have a significantly elevated risk for melanoma (odds ratio [OR] = 1.8; 95% confidence interval [CI] 1.4-2.1), multiple myeloma (OR 1.4; 95%CI 1.0-1.8), acute myeloid leukemia (OR 1.4; 95%CI 1.0-2.0), and cancers of the esophagus (OR 1.6; 95%CI 1.2-2.1), prostate (OR 1.5; 95%CI 1.3-1.7), brain (OR 1.5; 95%CI 1.2-2.0), and kidney (OR 1.3; 95%CI 1.0-1.6). CONCLUSIONS: In addition to observing cancer findings consistent with previous research, this study generated novel findings for firefighters with race/ethnicity other than white. It provides additional evidence to support the association between firefighting and several specific cancers.

The influence of diabetes severity on receipt of guideline-concordant treatment for breast cancer.

Diabetes severity may influence breast cancer treatment choices. We examined whether receipt of guideline-concordant breast cancer treatment varied with diabetes severity. Cancer registry data from seven states regarding 6,912 stage I-III breast cancers were supplemented by medical record abstraction and physician verification. We used logistic regression models to examine associations of diabetes severity with guideline-concordant locoregional treatment, adjuvant chemotherapy, and hormonal therapy adjusted for sociodemographics, comorbidity, and tumor characteristics. We defined guideline concordance using National Comprehensive Cancer Network guidelines, and diabetes and comorbidities using the Adult Comorbidity Evaluation-27 index. After adjustment, there was significant interaction of diabetes severity with age for locoregional treatment (p = 0.001), with many diabetic women under age 70 less frequently receiving guideline-concordant treatment than non-diabetic women. Among similarly aged women, guideline concordance was lower for women with mild diabetes in their late fifties through mid-sixties, and with moderate/severe diabetes in their late forties to early sixties. Among women in their mid-seventies to early eighties, moderate/severe diabetes was associated with increased guideline concordance. For adjuvant chemotherapy, moderate/severe diabetes was less frequently associated with guideline concordance than no diabetes [OR 0.58 (95 % CI 0.36-0.94)]. Diabetes was not associated with guideline-concordant hormonal treatment (p = 0.929). Some diabetic women were less likely to receive guideline-concordant treatment for stage I-III breast cancer than non-diabetic women. Diabetes severity was associated with lower guideline concordance for locoregional treatment among middle-aged women, and lower guideline concordance for adjuvant chemotherapy. Differences were not explained by comorbidity and may contribute to potentially worse breast cancer outcomes.

Breast cancer survival in the US and Europe: a CONCORD high-resolution study.

Breast cancer survival is reportedly higher in the US than in Europe. The first worldwide study (CONCORD) found wide international differences in age-standardized survival. The aim of this study is to explain these survival differences. Population-based data on stage at diagnosis, diagnostic procedures, treatment and follow-up were collected for about 20,000 women diagnosed with breast cancer aged 15-99 years during 1996-98 in 7 US states and 12 European countries. Age-standardized net survival and the excess hazard of death up to 5 years after diagnosis were estimated by jurisdiction (registry, country, European region), age and stage with flexible parametric models. Breast cancers were generally less advanced in the US than in Europe. Stage also varied less between US states than between European jurisdictions. Early, node-negative tumors were more frequent in the US (39%) than in Europe (32%), while locally advanced tumors were twice as frequent in Europe (8%), and metastatic tumors of similar frequency (5-6%). Net survival in Northern, Western and Southern Europe (81-84%) was similar to that in the US (84%), but lower in Eastern Europe (69%). For the first 3 years after diagnosis the mean excess hazard was higher in Eastern Europe than elsewhere: the difference was most marked for women aged 70-99 years, and mainly confined to women with locally advanced or metastatic tumors. Differences in breast cancer survival between Europe and the US in the late 1990s were mainly explained by lower survival in Eastern Europe, where low healthcare expenditure may have constrained the quality of treatment.

Epidemiologic features of borderline ovarian tumors in California: a population-based study.

PURPOSE: Borderline ovarian tumors (BOT) became no longer reportable in 2001, and few registries still collect information on these still poorly understood tumors. This study's objective was to describe epidemiologic features, trends, and survival of BOTs compared with those of low-grade (LG) and high-grade (HG) epithelial ovarian cancer (EOC) in the large and diverse population of California. METHODS: Data from the California Cancer Registry were used to examine demographic and tumor characteristics among women diagnosed with BOT (n = 9,786), LG-EOC (n = 3,656), and HG-EOC (n = 40,611) from 1988 to 2010. Annual percent changes in BOT and LG-EOC incidence rates were estimated using Joinpoint regression; 5-year relative survival was calculated for both BOTs and LG-EOCs by age, race/ethnicity, and histology. RESULTS: Age-adjusted incidence rates of BOT in 2009 were 3.1, 2.3, 2.2, and 1.4 per 100,000 among whites, Latinas, African Americans, and Asian/Pacific Islanders, respectively. Incidence rates for LG-EOC decreased by 2.2 % per year; rates for BOT increased by 7.3 % per year until 1993, remained unchanged until 2006, and seemed to decline thereafter. Compared with LG-EOCs, BOTs were diagnosed in higher frequency among Latinas, at younger age, and were more likely to affect only one ovary. Overall, 5-year relative survival for BOT was 98.9 %; among women diagnosed with stage IV BOT, survival was 77.1 %. CONCLUSIONS: In this study, differences between BOTs and LG-EOCs were marked but varied substantially by histologic subtype and were far less dramatic than differences between BOTs and HG-EOCs. Findings underscore the importance of understanding these enigmatic tumors.

Underutilization of intravesical chemotherapy and immunotherapy for high grade non-muscle invasive bladder cancer in California between 2006-2018: Effect of race, age and socioeconomic status on treatment disparities.

OBJECTIVE: Among patients diagnosed with non-muscle invasive bladder cancer (NMIBC), those with high risk disease have the greatest risk of recurrence and disease progression. The underutilization of intravesical immunotherapy with Bacillus Calmette-Guérin (BCG) has been a longstanding concern in clinical practice. This study aimed to determine the disparities present in receipt of adjuvant intravesical chemotherapy and immunotherapy in treatment of patients with high grade NMIBC following initial transurethral resection of a bladder tumor (TURBT). METHODS: The California Cancer Registry data was used to identify 19,237 patients diagnosed with high grade NMIBC who underwent TURBT. Treatment variables include re-TURBT, re-TURBT and intravesical chemotherapy (IVC) and/or BCG. Independent variables include age, sex, race/ethnicity, neighborhood socioeconomic status (nSES), primary insurance payer and marital status at diagnosis. Multiple logistic regression and multinomial regression models were used to examine variation in the treatments received following TURBT. RESULTS: The proportion of patients receiving TURBT followed by BCG was similar across all racial and ethnic groups (28%-32%). BCG therapy was higher in patients belonging to the highest nSES quintile (37% for highest vs. 23%-26% for the 2 lowest quintiles). In multiple variable analyses, receipt of any intravesical therapy (IVT) was influenced by nSES, age, marital status, race/ethnicity, and insurance type. Patients in the lowest nSES quintile had a 45% less likelihood of receiving IVT compared to the highest nSES group (OR [95%CI]: 0.55[0.49, 0.61]). Race/ethnicity differences in receipt of any adjuvant therapy were noted in the middle to lowest nSES quintile for Hispanic and Asian/Pacific Islander patients when compared to non-Hispanic White patients. When comparing variation in treatment by insurance type at diagnosis, those with Medicare or other insurance were 24% and 30% less likely to receive BCG after TURBT compared to those with private insurance, (OR [95%CI]: 0.76 [0.70, 0.82] and 0.70[0.62, 0.79]) respectively. CONCLUSION: In patients with a diagnosis of high risk NMIBC, disparities in utilization of BCG are seen based on SES, age, and insurance type.