Racial and socioeconomic disparities in survival among women with advanced-stage ovarian cancer who received systemic therapy.

PURPOSE: The purpose of this study was to assess the association between race/ethnicity and all-cause mortality among women with advanced-stage ovarian cancer who received systemic therapy. METHODS: We analyzed data from the National Cancer Database on women diagnosed with advanced-stage ovarian cancer from 2004 to 2015 who received systemic therapy. Race/ethnicity was categorized as Non-Hispanic (NH) White, NH-Black, Hispanic, NH-Asian/Pacific Islander, and Other. Income and education were combined to form a composite measure of socioeconomic status (SES) and categorized into low-, mid-, and high-SES. Multivariable Cox proportional hazards models were used to assess whether race/ethnicity was associated with the risk of death after adjusting for sociodemographic, clinical, and treatment factors. Additionally, subgroup analyses were conducted by SES, age, and surgery receipt. RESULTS: The study population comprised 53,367 women (52.4% ages ≥ 65 years, 82% NH-White, 8.7% NH-Black, 5.7% Hispanic, and 2.7% NH-Asian/Pacific Islander) in the analysis. After adjusting for covariates, the NH-Black race was associated with a higher risk of death versus NH-White race (aHR: 1.12; 95% CI: 1.07,1.18), while Hispanic ethnicity was associated with a lower risk of death compared to NH-White women (aHR: 0.87; 95% CI: 0.80, 0.95). Furthermore, NH-Black women versus NH-White women had an increased risk of mortality among those with low-SES characteristics (aHR:1.12; 95% CI:1.03-1.22) and mid-SES groups (aHR: 1.13; 95% CI:1.05-1.21). CONCLUSIONS: Among women with advanced-stage ovarian cancer who received systemic therapy, NH-Black women experienced poorer survival compared to NH-White women. Future studies should be directed to identify drivers of ovarian cancer disparities, particularly racial differences in treatment response and surveillance.

Diversity and transparency in gynecologic oncology clinical trials.

PURPOSE: Clinical trials advance the standard of care for patients. Patients enrolled in trials should represent the population who would benefit from the intervention in clinical practice. The aim of this study was to assess whether clinical trials enrolling patients with gynecologic cancers report racial and ethnic participant composition and to examine the level of diversity in clinical trials. METHODS: Using ClinicalTrials.gov, we identified clinical trials enrolling patients with ovarian, uterine/endometrial, cervical, vaginal, and vulvar cancers from 1988 to 2019. Race and ethnicity data were extracted from participant demographics. Descriptive statistics on race, ethnicity, cancer type, location, study status, and sponsor type were calculated. Among trials which reported race and/or ethnicity, sub-analyses were performed on composition of race and ethnicity by funding source, location, and completed study status. RESULTS: A total of 1,882 trials met inclusion criteria; only 179 trials (9.5%) reported race information. Of these, the racial distribution of enrollees was 66.9% White, 8.6% Asian, 8.5% Black/African American, 0.4% Indian/Alaskan Native, 0.1% Native Hawaiian/Pacific Islander, 1.0% more than one race, and 14.5% unknown. Only 100 (5.3%) trials reported ethnicity. Except for trials enrolling patients with cervical cancer which enrolled 65.2% White and 62.1% Non-Hispanic/Latino/a patients, enrollees in trials for other gynecologic cancers were over 80% White and 88% Non-Hispanic/Latino/a. Industry funded trials enrolled higher proportions of White (68.4%) participants than non-industry funded trials (57.5%). Domestic trials report race (11.5%) and ethnicity (7.6%) at higher rates than international trials (6.9% and 2.3%, respectively). Reporting of race (1.7% vs. 13.9%) and ethnicity (1.7% vs. 11.1%) has increased over time for patients enrolled in 2000 vs. 2018. CONCLUSION: Less than 10% of trials enrolling patients with gynecologic malignancies report racial/ethnic participant composition on ClinicalTrials.gov. Accurate reporting of participant race/ethnicity is imperative to ensuring minority representation in clinical trials.

Shiftwork, long working hours and markers of inflammation in a national US population-based sample of employed black and white men and women aged ≥45 years.

OBJECTIVES: Work schedule demands contribute to circadian disruption and may influence health via an inflammatory response. We examined the impact of shiftwork and long work hours on inflammation in a national US sample. METHODS: Participants included 12 487 employed black and white men and women aged ≥45 years enrolled in the REasons for Geographic and Racial Differences in Stroke Study who completed an occupational questionnaire (2011-2013) and clinical examination (2013-2016). Cross-sectional associations between shiftwork and work hours with log-transformed high-sensitivity C reactive protein (CRP) and white blood cell (WBC) count were examined by multiple linear regression analysis, overall and by race-sex subgroups. RESULTS: Overall, rotating shift workers had higher log-CRP concentration compared with day workers (ß=0.09, 95% CI:0.02 to 0.16) and findings for WBC were null. Black women had the highest geometric mean CRP (2.82 mg/L), while white men had the highest WBC (6.35×109/L). White men who worked afternoons had higher log-CRP compared with those who worked days (ß=0.20, 95% CI: 0.08 to 0.33). Black men engaged in shiftwork <10 years working ≥55 hours/week had higher log-CRP and log-WBC compared with those working days <55 hours/week (ß=0.33, 95% CI: 0.02 to 0.64 and ß=0.10, 95% CI: 0.003 to 0.19). Among shift workers, non-retired white women working forward and backward shift rotations had higher log-CRP compared with those working forward only (ß=0.49, 95% CI: 0.02 to 0.96). CONCLUSIONS: Shift workers had higher inflammatory markers compared with day workers and race-sex disparities should be examined further. These findings highlight a potential biological pathway linking work schedule demands and chronic disease.

Association of area-level socioeconomic status and non-small cell lung cancer stage by race/ethnicity and health care-level factors: Analysis of the National Cancer Database.

BACKGROUND: This study examined whether the association of socioeconomic status (SES) and non-small cell lung cancer (NSCLC) stage varied by race/ethnicity and health care access measures. METHODS: This study used data from the 2004-2016 National Cancer Database for patients aged 18-89 years who had been diagnosed with Stage 0-IV NSCLC. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated for the associations of area-level SES with an advanced stage at diagnosis via multilevel, multivariable logistic regression. The stage at diagnosis was dichotomized into early (0-II) and advanced (III-IV) stages, and area-level SES was categorized on the basis of the patient's zip code level: (1) the proportion of adults aged ≥25 years without a high school degree and (2) the median household income. The models were stratified by race/ethnicity (non-Hispanic [NH] White, NH Black, Hispanic, Asian, American Indian/Alaskan Native, and Native Hawaiian/Pacific Islander), insurance status (none, government, and private), and health care facility type (community, comprehensive community, academic/research, and integrated network). RESULTS: The study population included 1,329,972 patients. Although only 17% of the NH White patients were in the lowest income quartile, 50% of the NH Black patients were in this group. Lower area-level education and income were associated with higher odds of an advanced-stage diagnosis (aOR for education, 1.12; 95% CI, 1.10-1.13; aOR for income, 1.13; 95% CI, 1.11-1.14). These associations persisted among NH White, NH Black, Hispanic, and Asian patients; among those with government and private insurance (but not the uninsured); and among those treated at each facility type. CONCLUSIONS: Area-level income and education are strongly associated with an advanced NSCLC diagnosis regardless of the facility type and among those with government and private insurance.

Healthcare Access Dimensions and Guideline-Concordant Ovarian Cancer Treatment: SEER-Medicare Analysis of the ORCHiD Study.

BACKGROUND: Racial disparities exist in receipt of guideline-concordant treatment of ovarian cancer (OC). However, few studies have evaluated how various dimensions of healthcare access (HCA) contribute to these disparities. METHODS: We analyzed data from non-Hispanic (NH)-Black, Hispanic, and NH-White patients with OC diagnosed in 2008 to 2015 from the SEER-Medicare database and defined HCA dimensions as affordability, availability, and accessibility, measured as aggregate scores created with factor analysis. Receipt of guideline-concordant OC surgery and chemotherapy was defined based on the NCCN Guidelines for Ovarian Cancer. Multivariable-adjusted modified Poisson regression models were used to assess the relative risk (RR) for guideline-concordant treatment in relation to HCA. RESULTS: The study cohort included 5,632 patients: 6% NH-Black, 6% Hispanic, and 88% NH-White. Only 23.8% of NH-White patients received guideline-concordant surgery and the full cycles of chemotherapy versus 14.2% of NH-Black patients. Higher affordability (RR, 1.05; 95% CI, 1.01-1.08) and availability (RR, 1.06; 95% CI, 1.02-1.10) were associated with receipt of guideline-concordant surgery, whereas higher affordability was associated with initiation of systemic therapy (hazard ratio, 1.09; 95% CI, 1.05-1.13). After adjusting for all 3 HCA scores and demographic and clinical characteristics, NH-Black patients remained less likely than NH-White patients to initiate systemic therapy (hazard ratio, 0.86; 95% CI, 0.75-0.99). CONCLUSIONS: Multiple HCA dimensions predict receipt of guideline-concordant treatment but do not fully explain racial disparities among patients with OC. Acceptability and accommodation are 2 additional HCA dimensions which may be critical to addressing these disparities.

Demographic, presentation, and treatment factors and racial disparities in ovarian cancer hospitalization outcomes.

BACKGROUND: This study examines whether racial disparities in hospitalization outcomes persist between African-American and White women with ovarian cancer after matching on demographic, presentation, and treatment factors. METHODS: Using data from the Nationwide Inpatient Sample database, 5,164 African-American ovarian cancer patients were sequentially matched with White patients on demographic (e.g., age, income), presentation (e.g., stage, comorbidities), and treatment (e.g., surgery, radiation) factors. Racial differences in-hospital length of stay, post-operative complications, and in-hospital mortality were evaluated using conditional logistic regression models. RESULTS: White ovarian cancer patients had relatively higher odds of post-operative complications when matched on demographics (OR 1.35, 95% CI 1.05, 1.74), and presentation (OR 1.28, 95% CI 1.00, 1.65) but not when additionally matched on treatment (OR 1.03, 95% CI 0.78, 1.35). African-American patients had longer in-hospital length of stay (6.96 ± 7.21 days) compared with White patients when matched on demographics (6.37 ± 7.07 days), presentation (6.48 ± 7.16 days), and treatment (6.53 ± 7.59 days). Compared with African-American patients, White patients experienced lower odds of in-hospital mortality when matched on demographics (OR 0.78, 95% CI 0.66, 0.92), but this disparity was no longer significant when additionally matched on presentation (OR 0.88, 95% CI 0.75, 1.04) and treatment (OR 0.95, 95% CI 0.81, 1.12). CONCLUSION: Racial disparities in ovarian cancer hospitalization outcomes persisted after adjusting for demographic and presentation factors; however these differences were eliminated after additionally accounting for treatment factors. More studies are needed to determine the factors driving racial differences in ovarian cancer treatment in otherwise similar patient populations.

Meta-analysis of the association between dietary inflammatory index (DII) and cancer outcomes.

Proinflammatory dietary patterns have been associated with increased cancer risk and mortality. We present a systematic review and meta-analysis of the current published literature on a dietary inflammatory index (DII) score and its association with cancer risk and mortality outcomes. Published articles from online databases (PubMed, Scopus, and Embase) examining the association between DII and any cancer risk, incidence, or mortality between 1980 and November 2016 were selected for review. Results of studies meeting inclusion criteria were summarized and meta-analyzed using STATA to generate summary measures of association across studies. Sixty-three published articles were identified from the search, and following title, abstract and full-text review, twenty-four studies met inclusion criteria. All articles calculated DII scores based on study-specific food-frequency questionnaires using methodology from the same article. Of the 24 included studies, 13 were case-control, 6 were prospective cohort, 1 was a retrospective cohort, 3 were RCTs, and 1 did not specify study design. The most common cancers examined were colorectal, breast, lung, and prostate. Individuals in the highest versus lowest DII categories had 25% increased risk of overall cancer incidence (RR: 1.25, 95% CI: 1.16-1.35), 75% higher odds of cancer (OR: 1.75, 95% CI: 1.43-2.16) and 67% increased risk of cancer mortality (RR: 1.67, 95% CI: 1.13-2.48). Upon stratification for cancer type, positive associations remained (RRbreast : RR: 1.12, 95% CI: 1.03-1.22) (RRcolorectal : 1.33, 95% CI: 1.22-1.46) (RRlung : 1.30, 95% CI: 1.13-1.50). There were consistent and significant positive associations between higher DII and cancer incidence and mortality across cancer types, study populations, and study design.

Screening, prevalence, and risk factors for cervical lesions among HIV positive and HIV negative women in Swaziland.

BACKGROUND: Cervical Cancer (CC) is the number one cancer among women in sub-Saharan Africa. Although CC is preventable, most women in developing countries do not have access to screening. METHODS: This cross-sectional study was conducted to determine the prevalence and risk factors for cervical lesions using visual inspection with acetic acid (VIA) among 112 HIV positive and 161 negative women aged 18-69 years. RESULTS: The presence of cervical lesions was greater among HIV positive (22.9%) than HIV negative women (5.7%; p < 0.0001). In logistic models, the risk of cervical lesions among HIV positive women was 5.24 times higher when adjusted by age (OR 5.24, CI 2.31-11.88), and 4.06 times higher in a full model (OR 4.06, CI 1.61-10.25), than among HIV negative women. In the age-adjusted model women who had ≥2 lifetime sexual partners were 3 times more likely (OR 3.00, CI 1.02-8.85) to have cervical lesions compared to women with one lifetime partner and the odds of cervical lesions among women with a history of STIs were 2.16 greater (OR 2.16, CI 1.04-4.50) than among women with no previous STI. In the fully adjusted model women who had a previous cervical exam were 2.5 times more likely (OR 2.53, CI 1.06-6.05) to have cervical lesions than women who had not. CONCLUSIONS: The high prevalence of HIV infection and the strong association between HIV and cervical lesions highlight the need for substantial scale-up of cervical screening to decrease the rate of CC in Swaziland.

Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mm Hg, 1990-2015.

Importance: Elevated systolic blood (SBP) pressure is a leading global health risk. Quantifying the levels of SBP is important to guide prevention policies and interventions. Objective: To estimate the association between SBP of at least 110 to 115 mm Hg and SBP of 140 mm Hg or higher and the burden of different causes of death and disability by age and sex for 195 countries and territories, 1990-2015. Design: A comparative risk assessment of health loss related to SBP. Estimated distribution of SBP was based on 844 studies from 154 countries (published 1980-2015) of 8.69 million participants. Spatiotemporal Gaussian process regression was used to generate estimates of mean SBP and adjusted variance for each age, sex, country, and year. Diseases with sufficient evidence for a causal relationship with high SBP (eg, ischemic heart disease, ischemic stroke, and hemorrhagic stroke) were included in the primary analysis. Main Outcomes and Measures: Mean SBP level, cause-specific deaths, and health burden related to SBP (≥110-115 mm Hg and also ≥140 mm Hg) by age, sex, country, and year. Results: Between 1990-2015, the rate of SBP of at least 110 to 115 mm Hg increased from 73 119 (95% uncertainty interval [UI], 67 949-78 241) to 81 373 (95% UI, 76 814-85 770) per 100 000, and SBP of 140 mm Hg or higher increased from 17 307 (95% UI, 17 117-17 492) to 20 526 (95% UI, 20 283-20 746) per 100 000. The estimated annual death rate per 100 000 associated with SBP of at least 110 to 115 mm Hg increased from 135.6 (95% UI, 122.4-148.1) to 145.2 (95% UI 130.3-159.9) and the rate for SBP of 140 mm Hg or higher increased from 97.9 (95% UI, 87.5-108.1) to 106.3 (95% UI, 94.6-118.1). For loss of DALYs associated with systolic blood pressure of 140 mm Hg or higher, the loss increased from 95.9 million (95% uncertainty interval [UI], 87.0-104.9 million) to 143.0 million (95% UI, 130.2-157.0 million) [corrected], and for SBP of 140 mm Hg or higher, the loss increased from 5.2 million (95% UI, 4.6-5.7 million) to 7.8 million (95% UI, 7.0-8.7 million). The largest numbers of SBP-related deaths were caused by ischemic heart disease (4.9 million [95% UI, 4.0-5.7 million]; 54.5%), hemorrhagic stroke (2.0 million [95% UI, 1.6-2.3 million]; 58.3%), and ischemic stroke (1.5 million [95% UI, 1.2-1.8 million]; 50.0%). In 2015, China, India, Russia, Indonesia, and the United States accounted for more than half of the global DALYs related to SBP of at least 110 to 115 mm Hg. Conclusions and Relevance: In international surveys, although there is uncertainty in some estimates, the rate of elevated SBP (≥110-115 and ≥140 mm Hg) increased substantially between 1990 and 2015, and DALYs and deaths associated with elevated SBP also increased. Projections based on this sample suggest that in 2015, an estimated 3.5 billion adults had SBP of at least 110 to 115 mm Hg and 874 million adults had SBP of 140 mm Hg or higher.

Life-course socio-economic status and adult BMI in Ghana; analysis of the WHO study on global ageing and adult health (SAGE).

BACKGROUND: Obesity rates have continued to increase over time globally, resulting in an increase in the burden of obesity-associated chronic diseases. There is a paucity of research on the association between obesity and generational changes in socio-economic status (SES) in developing countries like Ghana, and therefore a critical need to better understand within-country differences in obesity and its association with SES over the life-course. METHODS: Data from a nationally representative sample of adult women in Ghana was used to examine the association between life-course SES and adult body mass index (BMI). Life-course SES was defined based on changes in the employment and education status of both parents and the study participant. Survey weighted multivariable linear regression models were used to examine the association between individual and life-course SES in relation to BMI. RESULTS: Participants with higher SES over their life course, that is, both the participant and her father had at least a primary education (both > = primary vs. both < primary: BMI 27.2 vs. 24.1), and both were employed (both employed vs. both unemployed: BMI 26.5 vs. 24.4) had higher BMI compared with participants with lower SES over their life course. CONCLUSION: Higher individual and life-course SES is associated with higher BMI among women in Ghana, although maternal employment was associated with lower BMI.

Residential environment and breast cancer incidence and mortality: a systematic review and meta-analysis.

BACKGROUND: Factors beyond the individual level such as those characterizing the residential environment may be important to breast cancer outcomes. We provide a systematic review and results of meta-analysis of the published empirical literature on the associations between breast cancer risk and mortality and features of the residential environment. METHODS: Using PRISMA guidelines, we searched four electronic databases and manually searched the references of selected articles for studies that were published before June 2013. We selected English language articles that presented data on adult breast cancer incidence or mortality in relation to at least one area-based residential (ABR) independent variable. RESULTS: We reviewed 31 eligible studies, and observed variations in ABR construct definition and measurement, study design, and analytic approach. The most common ABR measures were indicators of socioeconomic status (SES) (e.g., income, education, summary measures of several SES indicators or composite SES). We observed positive associations between breast cancer incidence and urbanization (Pooled RR for urban vs. rural: 1.09. 95% CI: 1.01, 1.19), ABR income (Pooled RR for highest vs. lowest ABR income: 1.17, 95% CI: 1.15, 1.19) and ABR composite SES (Pooled RR for highest vs. lowest ABR composite SES: 1.25, 95% CI: 1.08, 1.44). We did not observe consistent associations between any ABR measures and breast cancer mortality. CONCLUSIONS: The findings suggest modest positive associations between urbanization and residential area socioeconomic environment and breast cancer incidence. Further studies should address conceptual and methodological gaps in the current publications to enable inference regarding the influence of the residential environment on breast cancer.

Health care access dimensions and cervical cancer screening in South Africa: analysis of the world health survey.

BACKGROUND: Cervical cancer is the most commonly diagnosed cancer and the leading cause of cancer mortality among women in sub-Saharan Africa. Recent recommendations for cervical cancer primary prevention highlight HPV vaccination, and secondary prevention through screening. However, few studies have examined the different dimensions of health care access, and how these may influence screening behavior, especially in the context of clinical preventive services. METHODS: Using the 2003 South Africa World Health Survey, we determined the prevalence of cervical cancer screening with pelvic examinations and/or pap smears among women ages 18 years and older. We also examined the association between multiple dimensions of health care access and screening focusing on the affordability, availability, accessibility, accommodation and acceptability components. RESULTS: About 1 in 4 (25.3%, n = 65) of the women who attended a health care facility in the past year got screened for cervical cancer. Screened women had a significantly higher number of health care providers available compared with unscreened women (mean 125 vs.12, p-value <0.001), and were more likely to have seen a medical doctor compared with nurses/midwives (73.1% vs. 45.9%, p-value = 0.003). In multivariable analysis, every unit increase in the number of health care providers available increased the likelihood of screening by 1% (OR = 1.01, 95% CI: 1.00, 1.01). In addition, seeing a nurse/midwife compared to a medical doctor reduced the likelihood of screening by 87% (OR = 0.13, 95% CI: 0.04, 0.42). CONCLUSIONS: Our findings suggest that cost issues (affordability component) and other patient level factors (captured in the acceptability, accessibility and accommodation components) were less important predictors of screening compared with availability of physicians in this population. Meeting cervical cancer screening and HPV vaccination goals will require significant investments in the health care workforce, improving health care worker density in poor and rural areas, and improved training of the existing workforce.

A Couch Mounted Smartphone-based Motion Monitoring System for Radiation Therapy.

PURPOSE: Surface-guided radiation-therapy (SGRT) systems are being adopted into clinical practice for patient setup and motion monitoring. However, commercial systems remain cost prohibitive to resource-limited clinics around the world. Our aim is to develop and validate a smartphone-based application using LiDAR cameras (such as on recent Apple iOS devices) for facilitating SGRT in low-resource centers. The proposed SGRT application was tested at multiple institutions and validated using phantoms and volunteers against various commercial systems to demonstrate feasibility. METHODS AND MATERIALS: An iOS application was developed in Xcode and written in Swift using the Augmented-Reality (AR) Kit and implemented on an Apple iPhone 13 Pro with a built-in LiDAR camera. The application contains multiple features: 1) visualization of both the camera and depth video feeds (at a ∼60Hz sample-frequency), 2) region-of-interest (ROI) selection over the patient's anatomy where motion is measured, 3) chart displaying the average motion over time in the ROI, and 4) saving/exporting the motion traces and surface map over the ROI for further analysis. The iOS application was tested to evaluate depth measurement accuracy for: 1) different angled surfaces, 2) different field-of-views over different distances, and 3) similarity to a commercially available SGRT systems (Vision RT AlignRT and Varian IDENTIFY) with motion phantoms and healthy volunteers across 3 institutions. Measurements were analyzed using linear-regressions and Bland-Altman analysis. RESULTS: Compared with the clinical system measurements (reference), the iOS application showed excellent agreement for depth (r = 1.000, P < .0001; bias = -0.07±0.24 cm) and angle (r = 1.000, P < .0001; bias = 0.02±0.69°) measurements. For free-breathing traces, the iOS application was significantly correlated to phantom motion (institute 1: r = 0.99, P < .0001; bias =-0.003±0.03 cm; institute 2: r = 0.98, P < .0001; bias = -0.001±0.10 cm; institute 3: r = 0.97, P < .0001; bias = 0.04±0.06 cm) and healthy volunteer motion (institute 1: r = 0.98, P < .0001; bias = -0.008±0.06 cm; institute 2: r = 0.99, P < .0001; bias = -0.007±0.12 cm; institute 3: r = 0.99, P < .0001; bias = -0.001±0.04 cm). CONCLUSIONS: The proposed approach using a smartphone-based application provides a low-cost platform that could improve access to surface-guided radiation therapy accounting for motion.

Characterizing Cancer Burden in the American Indian Population in North Carolina.

BACKGROUND: The American Indian (AI) population in North Carolina has limited access to the Indian Health Service. Consequently, cancer burden and disparities may differ from national estimates. We describe the AI cancer population and examine AI-White disparities in cancer incidence and mortality. METHODS: We identified cancer cases diagnosed among adult AI and White populations between 2014 and 2018 from the North Carolina Central Cancer Registry. We estimated incidence and mortality rate ratios (IRR and MRR) by race. In addition, between the AI and White populations, we estimated the ratio of relative frequency differences [RRF, with 95% confidence limits (CL)] of clinical and sociodemographic characteristics. Finally, we evaluated the geographic distribution of incident diagnoses among AI populations. RESULTS: Our analytic sample included 2,161 AI and 204,613 White individuals with cancer. Compared with the White population, the AI population was more likely to live in rural areas (48% vs. 25%; RRF, 1.89; 95% CL, 1.81-1.97) and to have Medicaid (18% vs. 7%; RRF, 2.49; 95% CL, 2.27-2.71). Among the AI population, the highest age-standardized incidence rates were female breast, followed by prostate and lung and bronchus. Liver cancer incidence was significantly higher among the AI population than White population (IRR, 1.27; 95% CL, 1.01-1.59). AI patients had higher mortality rates for prostate (MRR, 1.72; CL, 1.09-2.70), stomach (MRR, 1.82; 95% CL, 1.15-2.86), and liver (MRR, 1.70; 95% CL, 1.25-2.33) cancers compared with White patients. CONCLUSIONS: To reduce prostate, stomach, and liver cancer disparities among AI populations in North Carolina, multi-modal interventions targeting risk factors and increasing screening and treatment are needed. IMPACT: This study identifies cancer disparities that can inform targeted interventions to improve outcomes among AI populations in North Carolina.

Health Care Access Dimensions and Racial Disparities in End-of-Life Care Quality among Patients with Ovarian Cancer.

This study investigated the association between health care access (HCA) dimensions and racial disparities in end-of-life (EOL) care quality among non-Hispanic Black (NHB), non-Hispanic White (NHW), and Hispanic patients with ovarian cancer. This retrospective cohort study used the Surveillance, Epidemiology, and End Results-linked Medicare data for women diagnosed with ovarian cancer from 2008 to 2015, ages 65 years and older. Health care affordability, accessibility, and availability measures were assessed at the census tract or regional levels, and associations between these measures and quality of EOL care were examined using multivariable-adjusted regression models, as appropriate. The final sample included 4,646 women [mean age (SD), 77.5 (7.0) years]; 87.4% NHW, 6.9% NHB, and 5.7% Hispanic. In the multivariable-adjusted models, affordability was associated with a decreased risk of intensive care unit stay [adjusted relative risk (aRR) 0.90, 95% confidence interval (CI): 0.83-0.98] and in-hospital death (aRR 0.91, 95% CI: 0.84-0.98). After adjustment for HCA dimensions, NHB patients had lower-quality EOL care compared with NHW patients, defined as: increased risk of hospitalization in the last 30 days of life (aRR 1.16, 95% CI: 1.03-1.30), no hospice care (aRR 1.23, 95% CI: 1.04-1.44), in-hospital death (aRR 1.27, 95% CI: 1.03-1.57), and higher counts of poor-quality EOL care outcomes (count ratio:1.19, 95% CI: 1.04-1.36). HCA dimensions were strong predictors of EOL care quality; however, racial disparities persisted, suggesting that additional drivers of these disparities remain to be identified. SIGNIFICANCE: Among patients with ovarian cancer, Black patients had lower-quality EOL care, even after adjusting for three structural barriers to HCA, namely affordability, availability, and accessibility. This suggests an important need to investigate the roles of yet unexplored barriers to HCA such as accommodation and acceptability, as drivers of poor-quality EOL care among Black patients with ovarian cancer.

Predicting the Effect of Proton Beam Therapy Technology on Pulmonary Toxicities for Patients With Locally Advanced Lung Cancer Enrolled in the Proton Collaborative Group Prospective Clinical Trial.

PURPOSE: This study aimed to predict the probability of grade ≥2 pneumonitis or dyspnea within 12 months of receiving conventionally fractionated or mildly hypofractionated proton beam therapy for locally advanced lung cancer using machine learning. METHODS AND MATERIALS: Demographic and treatment characteristics were analyzed for 965 consecutive patients treated for lung cancer with conventionally fractionated or mildly hypofractionated (2.2-3 Gy/fraction) proton beam therapy across 12 institutions. Three machine learning models (gradient boosting, additive tree, and logistic regression with lasso regularization) were implemented to predict Common Terminology Criteria for Adverse Events version 4 grade ≥2 pulmonary toxicities using double 10-fold cross-validation for parameter hyper-tuning without leak of information. Balanced accuracy and area under the curve were calculated, and 95% confidence intervals were obtained using bootstrap sampling. RESULTS: The median age of the patients was 70 years (range, 20-97), and they had predominantly stage IIIA or IIIB disease. They received a median dose of 60 Gy in 2 Gy/fraction, and 46.4% received concurrent chemotherapy. In total, 250 (25.9%) had grade ≥2 pulmonary toxicity. The probability of pulmonary toxicity was 0.08 for patients treated with pencil beam scanning and 0.34 for those treated with other techniques (P = 8.97e-13). Use of abdominal compression and breath hold were highly significant predictors of less toxicity (P = 2.88e-08). Higher total radiation delivered dose (P = .0182) and higher average dose to the ipsilateral lung (P = .0035) increased the likelihood of pulmonary toxicities. The gradient boosting model performed the best of the models tested, and when demographic and dosimetric features were combined, the area under the curve and balanced accuracy were 0.75 ± 0.02 and 0.67 ± 0.02, respectively. After analyzing performance versus the number of data points used for training, we observed that accuracy was limited by the number of observations. CONCLUSIONS: In the largest analysis of prospectively enrolled patients with lung cancer assessing pulmonary toxicities from proton therapy to date, advanced machine learning methods revealed that pencil beam scanning, abdominal compression, and lower normal lung doses can lead to significantly lower probability of developing grade ≥2 pneumonitis or dyspnea.

Healthcare access dimensions and uterine cancer survival: a national cancer database study.

Objective: Disparities exist throughout diagnosis, treatment, and survival for Black patients with uterine cancer. There is limited data on how several healthcare access (HCA) dimensions contribute to these disparities in patients with advanced stage uterine cancer. Methods: Using the National Cancer Database (NCDB), we identified patients aged 40-89 years with Stage III-IV uterine cancer between 2004-2015 who received chemotherapy and/or radiotherapy. Race/ethnicity were classified as non-Hispanic (NH)-Black, Hispanic, and NH-White. Variables defined in the NCDB were used to assess HCA affordability, availability, and accessibility. Kaplan-Meier estimates, log-rank test, and multivariable Cox proportional hazards models were used to analyze overall survival. Results: Of 43,134 patients, 78.8% of the cohort identified as NH-White, 15.3% NH-Black, and 5.9% Hispanic. NH-Black patients were the most likely to have type II (75.6% vs. 53.9% and 55.4%) and stage IV (40.8% vs. 30.7% and 32.3%) disease compared to NH-White and Hispanic patients. NH-Black patients were more likely than NH-White and Hispanic patients to have government funded insurance (58.6% vs. 50.3% and 50.4%), live in low-income areas (46.4% vs. 14.2% and 29.9%), and receive only chemotherapy (53.5% vs. 43.1% and 46.2%). Having private insurance and receiving treatment at an academic facility were positive predictors of survival. NH-Black patients had worse survival than NH-White patients after adjusting for clinical characteristics and healthcare access dimensions (HR 1.29; 95% CI 1.24, 1.34). Conclusion: While HCA affordability and availability predicted survival in patients with advanced stage uterine cancer, additional factors contribute to racial disparities. Compared to NH-White patients, NH-Black patients had more aggressive disease, received only chemotherapy rather than combined therapy, and had worse survival regardless of cancer subtype. Additional dimensions of healthcare access must be explored to remedy uterine cancer disparities.

Association of educational attainment with cancer mortality in a national cohort study of black and white adults: A mediation analysis.

Background: Low educational attainment is associated with excess cancer mortality. However, the mechanisms driving this association remain unknown. Methods: Using data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, we evaluated the associations of participant and parental/caregiver education with cancer mortality using Cox proportional hazards models, adjusting for socio-demographic characteristics and health conditions. We used principal components analysis to generate indices of measures representing the social determinants of health (SDOH) and health behaviors. We used structural equation modeling to determine if the association between educational attainment and cancer mortality was mediated by these domains. Results: Among 30,177 REGARDS participants included in this analysis, 3798 (12.6%) had less than a high school degree. In fully adjusted models, those without a high school education experienced about 50% greater risk of death than high school graduates and higher (White participants HR: 1.47; 95% CI: 1.23, 1.76 and Black HR: 1.54; 95% CI: 1.33, 1.79). There was evidence of a modest mediation effect for the association between education and cancer mortality by the SDOH domain score (White total effect HR: 1.25; 95% CI: 1.18, 1.33, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.21; 95% CI: 1.14, 1.28 and Black total effect HR: 1.24; 95% CI: 1.18, 1.29, indirect effect HR: 1.04; 95% CI: 1.03, 1.05, direct effect HR: 1.19; 95% CI: 1.14, 1.24). There was no evidence of mediation by the health behaviors score. No significant associations were found for female caregiver/mother's or male caregiver/father's education (N = 13,209). Conclusions: In conclusion, participant education was strongly associated with cancer mortality, and this association was partially mediated by the SDOH domain score.

Factor Analysis of Health Care Access With Ovarian Cancer Surgery and Gynecologic Oncologist Consultation.

Importance: Poor health care access (HCA) is associated with racial and ethnic disparities in ovarian cancer (OC) survival. Objective: To generate composite scores representing health care affordability, availability, and accessibility via factor analysis and to evaluate the association between each score and key indicators of guideline-adherent care. Design, Setting, and Participants: This retrospective cohort study used data from patients with OC diagnosed between 2008 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) Medicare database. The SEER Medicare database uses cancer registry data and linked Medicare claims from 12 US states. Included patients were Hispanic, non-Hispanic Black, and non-Hispanic White individuals aged 65 years or older diagnosed from 2008 to 2015 with first or second primary OC of any histologic type (International Classification of Diseases for Oncology, 3rd Edition [ICD-O-3] code C569). Data were analyzed from June 2020 to June 2022. Exposures: The SEER-Medicare data set was linked with publicly available data sets to obtain 35 variables representing health care affordability, availability, and accessibility. A composite score was created for each dimension using confirmatory factor analysis followed by a promax (oblique) rotation on multiple component variables. Main Outcomes and Measures: The main outcomes were consultation with a gynecologic oncologist for OC and receipt of OC-related surgery in the 2 months prior to or 6 months after diagnosis. Results: The cohort included 8987 patients, with a mean (SD) age of 76.8 (7.3) years and 612 Black patients (6.8%), 553 Hispanic patients (6.2%), and 7822 White patients (87.0%). Black patients (adjusted odds ratio [aOR], 0.75; 95% CI, 0.62-0.91) and Hispanic patients (aOR, 0.81; 95% CI, 0.67-0.99) were less likely to consult a gynecologic oncologist compared with White patients, and Black patients were less likely to receive surgery after adjusting for demographic and clinical characteristics (aOR, 0.76; 95% CI, 0.62-0.94). HCA availability and affordability were each associated with gynecologic oncologist consultation (availability: aOR, 1.16; 95% CI, 1.09-1.24; affordability: aOR, 1.13; 95% CI, 1.07-1.20), while affordability was associated with receipt of OC surgery (aOR, 1.08; 95% CI, 1.01-1.15). In models mutually adjusted for availability, affordability, and accessibility, Black patients remained less likely to consult a gynecologic oncologist (aOR, 0.80; 95% CI, 0.66-0.97) and receive surgery (aOR, 0.80; 95% CI, 0.65-0.99). Conclusions and Relevance: In this cohort study of Hispanic, non-Hispanic Black, and non-Hispanic White patients with OC, HCA affordability and availability were significantly associated with receiving surgery and consulting a gynecologic oncologist. However, these dimensions did not fully explain racial and ethnic disparities.

Tungsten Filled 3-Dimensional Printed Lung Blocks for Total Body Irradiation.

PURPOSE: Lung blocks for total-body irradiation are commonly used to reduce lung dose and prevent radiation pneumonitis. Currently, molten Cerrobend containing toxic materials, specifically lead and cadmium, is poured into molds to construct blocks. We propose a streamlined method to create 3-dimensional (3D)-printed lung block shells and fill them with tungsten ball bearings to remove lead and improve overall accuracy in the block manufacturing workflow. METHODS AND MATERIALS: 3D-printed lung block shells were automatically generated using an inhouse software, printed, and filled with 2 to 3 mm diameter tungsten ball bearings. Clinical Cerrobend blocks were compared with the physician drawn blocks as well as our proposed tungsten filled 3D-printed blocks. Physical and dosimetric comparisons were performed on a linac. Dose transmission through the Cerrobend and 3D-printed blocks were measured using point dosimetry (ion-chamber) and the on-board Electronic-Portal-Imaging-Device (EPID). Dose profiles from the EPID images were used to compute the full-width-half-maximum and to compare with the treatment-planning-system. Additionally, the coefficient-of-variation in the central 80% of full-width-half-maximum was computed and compared between Cerrobend and 3D-printed blocks. RESULTS: The geometric difference between treatment-planning-system and 3D-printed blocks was significantly lower than Cerrobend blocks (3D: -0.88 ± 2.21 mm, Cerrobend: -2.28 ± 2.40 mm, P = .0002). Dosimetrically, transmission measurements through the 3D-printed and Cerrobend blocks for both ion-chamber and EPID dosimetry were between 42% to 48%, compared with the open field. Additionally, coefficient-of-variation was significantly higher in 3D-printed blocks versus Cerrobend blocks (3D: 4.2% ± 0.6%, Cerrobend: 2.6% ± 0.7%, P < .0001). CONCLUSIONS: We designed and implemented a tungsten filled 3D-printed workflow for constructing total-body-irradiation lung blocks, which serves as an alternative to the traditional Cerrobend based workflow currently used in clinics. This workflow has the capacity of producing clinically useful lung blocks with minimal effort to facilitate the removal of toxic materials from the clinic.