Disparities in utilization of preventive health services among Asian young adults in the United States.

Despite the favorable health impacts of preventive services use, young adults remain at a higher risk of not using these services compared with older adults. This study seeks to identify barriers to receiving recommended preventive services among Asian young adults compared to other racial/ethnic young adults. Using 2016-2018 National Health Interview Survey data, this study examined barriers to recommended preventive services among non-Hispanic (NH) Asian young adults aged 18-39 years compared with other racial/ethnic groups in the United States (Total = 25,430; NH Asians = 6.3%). General prevention included fasting blood sugar, cholesterol, blood pressure, and Human Immunodeficiency Virus checkups. We documented information on vaccinations for influenza, pneumonia, tetanus, hepatitis A/B, and female-specific preventive care measures. NH Asian young adults reported blood pressure checkups less often than NH Whites (72.88% vs. 79.92%, p < 0.001). NH Asian young adults were also less likely to report HIV testing than all other racial/ethnic groups (p < 0.001). After controlling for covariates, NH Whites (odds ratio [OR] = 2.00, 95% confidence interval [CI] = 1.60, 2.50), NH Blacks (OR = 1.55, 95% CI = 1.18, 2.02), and other races (OR = 2.40, 95% CI = 1.60, 3.58) were more likely to receive any preventive services than NH Asians. Among those receiving any preventive services, there were no differences between NH Asians and all other racial/ethnic groups in whether they reported receiving relatively more preventive services. Our findings demonstrate that the rates of certain recommended preventive services use were lower among NH Asian young adults. Targeted public health strategies are needed to increase the use of preventive healthcare for racial/ethnic minority young adults.

Cost-effectiveness analysis of neoadjuvant immune checkpoint inhibition vs. cisplatin-based chemotherapy in muscle invasive bladder cancer.

BACKGROUND: Multiple single-arm clinical trials showed promising pathologic complete response rates with neoadjuvant immune checkpoint inhibitors (ICIs) in muscle-invasive bladder cancer. We conducted a cost-effectiveness analysis comparing neoadjuvant ICIs with cisplatin-based chemotherapy (CBC). METHODS: We applied a decision analytic simulation model with a health care payer perspective to compare neoadjuvant ICIs vs. CBC. For the primary analysis we compared pembrolizumab with ddMVAC. We performed a secondary analysis with gemcitabine/cisplatin as CBC and exploratory analyses with atezolizumab or nivolumab/ipilimumab as ICI. We input pathologic complete response rates from trials or meta-analysis and costs from average sales price. Outcomes of interest included costs, 2-year recurrence-free survival (RFS), and incremental cost-effectiveness ratio (ICER) of cost per 2-year RFS. A threshold analysis estimated a price reduction for ICI to be cost-effective and one-way and probabilistic sensitivity analyses were performed. RESULTS: The incremental cost of pembrolizumab compared with ddMVAC was $8,041 resulting in an incremental improvement of 1.5% in 2-year RFS for an ICER of $522,143 per 2-year RFS. A 21% reduction in cost of pembrolizumab would render it more cost-effective with an ICER of $100,000 per 2-year RFS. GC required an 89% pembrolizumab cost reduction to achieve an ICER of $100,000 per 2-year RFS. Atezolizumab appeared to be more cost-effective than ddMVAC. CONCLUSIONS: ICIs were not cost-effective as neoadjuvant therapies, except when atezolizumab was compared with ddMVAC. Randomized clinical trials, larger sample sizes and longer follow-up are required to better understand the value of ICIs as neoadjuvant treatments.

Comparing Costs of Radical Versus Partial Cystectomy for Patients Diagnosed With Localized Muscle-Invasive Bladder Cancer: Understanding the Value of Surgical Care.

OBJECTIVE: To compare costs associated with radical versus partial cystectomy. Prior studies noted substantial costs associated with radical cystectomy, however, they lack surgical comparison to partial cystectomy. METHODS: A total of 2305 patients aged 66-85 years diagnosed with clinical stage T2-4a muscle-invasive bladder cancer from January 1, 2002 to December 31, 2011 were included. Total Medicare costs within 1 year of diagnosis following radical versus partial cystectomy were compared using inverse probability of treatment-weighted propensity score models. Cox regression and competing risks analysis were used to determine overall and cancer-specific survival, respectively. RESULTS: Median total costs were not significantly different for radical than partial cystectomy in 90 days ($73,907 vs $65,721; median difference $16,796, 95% CI $10,038-$23,558), 180 days ($113,288 vs $82,840; median difference $36,369, 95% CI $25,744-$47,392), and 365 days ($143,831 vs $107,359; median difference $34,628, 95% CI $17,819-$53,558), respectively. Hospitalization, surgery, pathology/laboratory, pharmacy, and skilled nursing facility costs contributed largely to costs associated with either treatment. Patients who underwent partial cystectomy had similar overall survival but had worse cancer-specific survival (Hazard Ratio 1.45, 95% Confidence Interval, 1.34-1.58, P < .001) than patients who underwent radical cystectomy. CONCLUSION: While treatments for bladder cancer are associated with substantial costs, we showed radical cystectomy had comparable total costs when compared to partial cystectomy among patients with muscle-invasive bladder cancer. However, partial cystectomy resulted in worse cancer-specific survival further supporting radical cystectomy as a high-value surgical procedure for muscle-invasive bladder cancer.

An examination between census tract unhealthy food availability and colorectal cancer incidence.

BACKGROUND: Unhealthy food environments may be associated with higher risks of developing diet-related cancers, such as, colorectal cancer. We conducted an ecological analysis to evaluate the relationship between the local food environment and colorectal cancer incidence overall and separately for males and females. METHODS: Data from the Texas Cancer Registry was utilized to geocode individuals aged 40 years and older diagnosed with colorectal cancer from 2005 to 2015 to their residential 2010 census tract. Total number of establishments classified as Limited Service Restaurants for each census tract was retrieved from the 2005 Business Patterns Survey by using a crosswalk to map zip codes to census tract. Census tract unhealthy food availability was calculated by dividing the estimated number of Limited Service Restaurant establishments in each census tract by the census tract population and divided into quartiles. Generalized estimating equations were used to assess the association between unhealthy food availability quartiles and colorectal cancer incidence. RESULTS: Adjusting for the census tract level sociodemographic characteristics, the incidence of colorectal cancer was slightly higher in unhealthy food availability quartile 2 (Incidence Rate Ratio (IRR) = 1.03, 95 % CI: 1.00-1.05), but not quartile 3 (IRR = 1.02, 95 % CI: 1.00-1.05), and quartile 4 (highest availability, IRR = 1.02, 95 % CI: 0.99-1.05) compared to census tracts with lowest unhealthy food availability. CONCLUSION: Colorectal cancer incidence was not strongly associated with census tracts with higher unhealthy food availability. Future observational studies should be conducted to examine the influence of the built environment on colorectal cancer risk.

Comparison of the long-term impact and clinical outcomes of fewer doses and standard doses of human papillomavirus vaccine in the United States: A database study.

BACKGROUND: Human papillomavirus (HPV)-related disease remains a significant source of morbidity and mortality, and this underscores the need to increase HPV vaccination to reduce the burden of the disease. The objective of this study was to examine the association between the number of HPV vaccine doses and the risk of histologically confirmed preinvasive cervical disease and high-grade cytology. METHODS: This retrospective matched cohort study used administrative data from Optum's Clinformatics DataMart Database to identify females aged 9 to 26 years who received 1 or more quadrivalent HPV vaccine doses between January 2006 and June 2015. Cases and controls were matched on region, age, sexually transmitted disease history, and pregnancy. All had a Papanicolaou test ≥1 year after the date of the matched case's final dose. Cox proportional hazards models were used to examine the association between the number of HPV vaccine doses and the incidence of preinvasive cervical disease and high-grade cytology. The Kaplan-Meier method was used to estimate the cumulative incidence rate at the 5-year follow-up. RESULTS: The study included 133,082 females (66,541 vaccinated and 66,541 unvaccinated) stratified by the number of HPV vaccine doses and the vaccine initiation age. Among those aged 15 to 19 years, the hazard ratio (HR) for high-grade cytology for the 3-dose group was 0.84 (95% confidence interval [CI], 0.73-0.97), whereas the HRs for histologically confirmed preinvasive cervical disease for 1, 2, and 3 doses were 0.64 (95% CI, 0.47-0.88), 0.72 (95% CI, 0.54-0.95), and 0.66 (95% CI, 0.55-0.80), respectively. CONCLUSIONS: The receipt of 1, 2, or 3 doses of an HPV vaccine by females aged 15 to 19 years was associated with a lower incidence of preinvasive cervical disease in comparison with unvaccinated females, and this supports the use of any HPV vaccination in reducing the burden of the disease.

Health Care Expenditures and Utilization Among Older Mexican Adults.

Objectives: Examine differences in health care utilization and out-of-pocket (OOP) expenditures among older Mexican adults in 2001 and 2012, and identify individual characteristics associated with utilization and expenditures in both years. Method: Data from the 2001 and 2012 cross-sections of the Mexican Health and Aging Study were utilized. Outcomes included nights spent in the hospital, medical/outpatient procedures, and OOP expenditures with these services. Covariates included demographics and comorbidities. Two-part regression models were used to identify covariates associated with utilization and expenditures in each year. Results: The proportion of those who spent at least one night in the hospital or had at least one medical/outpatient visit was higher in 2012 than in 2001, while the proportion of individuals with OOP expenditures decreased between the years. Those with more comorbidities had the highest OOP expenditures in both years. Discussion: Although the population paying for health care services OOP was lower in 2012, there is persistent inequality in expenditures across population groups.

School-based human papillomavirus vaccination program for increasing vaccine uptake in an underserved area in Texas.

OBJECTIVE: Compare the effectiveness of community-based HPV-related education and onsite school-based vaccination versus community-based education only for increasing HPV vaccine uptake in a rural, medically underserved area. METHODS: Our cohort included 2307 Rio Grande City Consolidated Independent School District (RGCISD) middle school students from 3 schools enrolled in August 2016 and followed until April 2018. Using a quasi-experimental design, this study implemented an onsite school-based vaccination program and physician-led education on HPV and HPV vaccines for parents/guardians, school nurses/staff, and pediatric/family providers in the surrounding community (15-mile radius of RGCCISD) at 1 middle school ("intervention school"), and education-only for the remaining 2 schools ("comparison schools"). The Centers for Disease Control and Prevention's HPV-related educational materials supplemented the education. HPV vaccine status was obtained from school immunization records and the project's contracted vaccine vendor. HPV vaccine initiation and completion rates were compared pre and post intervention and between the intervention and comparison schools. Logistic regression was used to compare the odds of newly initiating/completing vaccination between the intervention and comparison schools. RESULTS: At baseline, the intervention school had lower HPV vaccine initiation and completion rates than the comparison schools (20.00% and 8.70% vs 28.97% and 14.56%). Post intervention, the intervention school had higher initiation and completion rates than the comparison schools (53.67% and 28.36% vs 41.56% and 20.53%). Students from the intervention school were over 3.6-times more likely to newly initiate/complete the HPV vaccinations than students from the comparison schools. CONCLUSION: The school with on-site vaccination events and community-based education had a higher adolescent HPV vaccination rate compared to schools that received community-based education only.

Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients With Localized Muscle-Invasive Bladder Cancer.

Importance: Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. Objective: To compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs. Design, Setting, and Participants: This population-based cohort study used the US Surveillance, Epidemiology, and End Results-Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018. Main Outcomes and Measures: Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment-weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias. Results: Of 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83 754 vs $68 692; median difference, $11 805; 95% CI, $7745-$15 864), 180 days ($187 162 vs $109 078; median difference, $62 370; 95% CI, $55 581-$69 160), and 365 days ($289 142 vs $148 757; median difference, $109 027; 95% CI, $98 692-$119 363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment-weighted adjusted analyses, patients undergoing trimodal therapy had $136 935 (95% CI, $122 131-$152 115) higher mean costs compared with radical cystectomy 1 year after diagnosis. Conclusions and Relevance: Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.

High-Cost Hospitalizations Among Elderly Patients With Cancer.

PURPOSE: Health care costs are driven by a small proportion of patients, and it is important to identify their characteristics to effectively manage their health care needs. We examined characteristics associated with high-cost inpatient visits of elderly patients with cancer using a national sample. METHODS: We identified 574,367 inpatient visits of individuals age 65 years or older with a cancer diagnosis using the 2014 National Inpatient Sample data, an all-payer sample of inpatient stays in the United States. High-cost visits were defined as those with a total cost at or above the 90th percentile. The remaining visits were defined as the lower-cost group. We examined patients' clinical characteristics and hospital characteristics for both groups. Logistic regression was used to identify characteristics associated with being in the high-cost group. RESULTS: The median visit cost in the high-cost group was $38,194 (interquartile range, $31,405 to $51,802), which was nearly five times the cost of the lower-cost group (median, $8,257; interquartile range, $5,032 to $13,335). Hematologic malignancies were the most common cancer in the high-cost group. Those in the high-cost group were more likely to have metastatic cancer. Compared with patients with no comorbidities, those with five or more comorbidities were four times more likely to be in the high-cost group (odds ratio, 4.08; 95% CI, 3.74 to 4.46). Patients with a greater number of procedures were also more likely to be in the high-cost group (odds ratio, 1.57; 95% CI, 1.52 to 1.61). CONCLUSION: High-cost cancer visits were five times more expensive than the remaining visits. Identification of high-cost visits and the associated factors may help provide tailored strategies to effectively manage costly inpatient admissions.

Human Papillomavirus Vaccine Interventions in the U.S.: A Systematic Review and Meta-analysis.

CONTEXT: Despite current recommendations, human papillomavirus vaccine uptake remains low. A systematic review and meta-analysis assessed the effectiveness of interventions targeting human papillomavirus vaccine initiation and completion among children, adolescents, and young adults aged 9-26 years. EVIDENCE ACQUISITION: Three electronic databases (CINAHL, OVID, and Web of Science) were searched for articles published in English peer-reviewed journals between January 2006 and January 2017 of U.S. studies that evaluated intervention strategies and reported post-intervention human papillomavirus vaccine initiation or completion rates among individuals aged 9-26 years. Study characteristics and outcomes were extracted. Data were collected in 2016 and analyzed in 2017. EVIDENCE SYNTHESIS: Reviewers screened 983 unique titles and abstracts, read 241 full-text articles, and extracted data from 30 articles meeting the inclusion criteria (12 behavioral, ten environmental, four informational, and four combination strategies). Published EQUATOR (Enhancing the Quality and Transparency of Health Research) guidelines were used to assess study quality. Random effects meta-analyses were conducted. The meta-analyses included 17 RCTs and quasi-experiments involving 68,623 children, adolescents, and young adults. The pooled relative incidence estimates were 1.84 (95% CI=1.36, 2.48) for human papillomavirus vaccine initiation and 1.50 (95% CI=1.23, 1.83) for completion. Behavioral and informational interventions doubled human papillomavirus vaccine initiation (relative incidence estimate=2.04, 95% CI=1.36, 3.06 and relative incidence estimate=1.92, 95% CI=1.27, 2.91, respectively). Behavioral interventions increased completion by 68% (relative incidence estimate=1.68, 95% CI=1.25, 2.27). CONCLUSIONS: Evidence supports behavioral interventions for increasing human papillomavirus vaccine initiation and completion. Future studies are needed to assess the effectiveness of interventions in reaching diverse populations and reducing missed opportunities for human papillomavirus vaccination.

Disparities in Adolescent and Young Adult Sarcoma Survival: Analyses of the Texas Cancer Registry and the National SEER Data.

PURPOSE: Examine disparities in survival for adolescents and young adults (AYAs) diagnosed with bone and soft tissue sarcomas in Texas compared with national estimates. METHODS: AYAs with sarcomas diagnosed between 1995 and 2012 at ages 15-39 years were identified from the Texas Cancer Registry (TCR) and Surveillance, Epidemiology, and End Results (SEER) program. Patient demographic, treatment, and clinical characteristics were compared between TCR and SEER using chi-squared tests. Five-year survival was computed using the Kaplan-Meier method. Cox proportional hazards (CPH) models evaluated the factors associated with the risk of mortality between and within the two datasets. RESULTS: Sarcoma patients in TCR were more likely to be Hispanic, uninsured, diagnosed at late stage, and have lower rates of surgery as the first line of treatment than those in SEER. In Texas, 5-year survival was 68.7% versus 72.2% in SEER (p < 0.001). However, after including surgery in our fully adjusted CPH model, survival differences between the two datasets were no longer observed. In these models, males, and those living in nonmetropolitan areas were more likely to die than their counterparts in both datasets. In TCR, those who lived in the U.S. and Mexico border had higher mortality. In SEER, Hispanics and non-Hispanic blacks had higher mortality. CONCLUSION: The adjusted AYA sarcoma survival in Texas was similar to that of SEER, but patients in Texas were more likely to be uninsured and have lower surgery rates. Those living in the U.S. and Mexico border in Texas faced lower survival. These results are important for delineating effective care for this high-risk patient group.

Emergency Department Visits by Adolescent and Young Adult Cancer Patients Compared with Pediatric Cancer Patients in the United States.

PURPOSE: Limited information exists on emergency department (ED) visits for adolescent and young adult (AYA) patients with cancer. We examined the clinical reasons for ED visits, and outcomes, for AYAs with cancer compared to pediatric cancer patients. METHODS: The 2013 Nationwide Emergency Department Sample data were used to identify 53,274 AYA (ages 15-39) and 6952 pediatric (ages 0-14) cancer ED visits. We evaluated patient (i.e., demographic and diagnosis) and hospital characteristics, and the ED event outcome (admitted to the same hospital or treated/released). Clinical reasons for visits were identified as procedures, infections, or noninfectious toxicities. Variables were compared between groups using chi-squared tests. Logistic regressions identified characteristics associated with the outcome between and within groups. RESULTS: AYA cancer visits were more likely to be self-paid (15.8% vs. 1.9%, p < 0.001), and be from low-income households and nonmetro counties than pediatric visits. Toxicity was the most prevalent reason for AYA visits (46.0%) and infections for pediatrics (47.3%, p < 0.001). AYA cancer visits were less likely to be admitted (OR = 0.84, 95% CI = 0.71-0.98; p = 0.03) than pediatric cancer. Among AYAs, self-paid visits were less likely to be admitted compared with privately insured visits (OR = 0.58, 95% CI: 0.52-0.66, p < 0.001). Self-pay did not affect the outcome for pediatric visits. CONCLUSIONS: In the United States, compared with pediatric cancer patients, AYAs with cancer visit EDs more often for toxicity-related problems, and are more often self-paid and from poorer households. These distinctive features impacting health service use should be incorporated into care plans aimed at delineating effective care for these patients.

Follow-Up Care Provider Preferences of Adolescent and Young Adult Cancer Survivors.

PURPOSE: To explore the experiences and perspectives of adolescent and young adult (AYA) cancer survivors regarding patient-provider relationships and their preferences surrounding type of healthcare provider for follow-up care. METHODS: We recruited AYA cancer survivors who were diagnosed between the ages of 15 and 39 using the Utah Cancer Registry. Twenty-eight survivors participated in six focus groups held between March and May of 2015 in Salt Lake City and St. George, Utah. This analysis focuses on how survivors' preferences about type of healthcare provider may influence their transition into, and utilization of, follow-up care. RESULTS: On average, survivors were 6.3 (standard deviation = 1.7) years from their cancer diagnosis. A majority of survivors expressed a desire not to transition to a new provider and preferred continuing to see their oncologist for follow-up care. For these survivors, this was due to already having a close relationship with their oncologist and because they trusted their provider's knowledge about cancer and how to handle late effects. However, survivors placed emphasis on being comfortable with their healthcare provider, regardless of provider type. CONCLUSIONS: Our findings demonstrate the importance of formalizing provider transitions and roles after cancer therapy to improve patient comfort with new providers. By understanding the complexities of the transition from active cancer treatment to follow-up care for AYA survivors, these findings can inform programs undertaking post-care educational activities to ensure a seamless transition into survivorship care. Survivorship care plans can facilitate these transitions and improve patient confidence in follow-up care.

Conditional survival of pediatric, adolescent, and young adult soft tissue sarcoma and bone tumor patients.

BACKGROUND: Survival estimates for soft tissue sarcomas (STS) and malignant bone tumors (BT) diagnosed in pediatric, adolescent, and young adult patients are not easily available. We present survival estimates based on a patient having survived a defined period of time (conditional survival). Conditional survival estimates for the short-term were calculated for patients from diagnosis to the first five years after diagnosis and for patients surviving in the long-term (up to 20 years after diagnosis). METHODS: We identified 703 patients who were diagnosed with a STS or BT at age ≤25 years from January 1, 1986 to December 31, 2012 at a large pediatric oncology center in Salt Lake City, Utah, United States. We obtained cancer type, age at diagnosis, primary site, and demographic data from medical records, and vital status through the National Death Index. Cancer stage was available for a subset of the cohort through the Utah Cancer Registry. Cox proportional hazards models, adjusted for age and sex, calculated survival estimates for all analyses. RESULTS: Short-term survival improves over time for both sarcomas. Short-term survival for STS from diagnosis (Year 0) did not differ by sex, but short-term survival starting from 1-year post diagnosis was significantly worse for male patients (Survival probability 1-year post-diagnosis [SP1]:77% [95% CI:71-83]) than female patients (SP1:86% [81-92]). Survival for patients who were diagnosed at age ≤10 years (Survival probability at diagnosis [SP0]:85% [79-91]) compared to diagnosis at ages 16-25 years (SP0:67% [59-75]) was significantly better at all time-points from diagnosis to 5-years post-diagnosis. Survival for axial sites (SP0:69% [63-75]) compared to extremities (SP0:84% [79-90]) was significantly worse from diagnosis to 1-year post-diagnosis. Survival for axial BT (SP0: 64% [54-74] was significantly worse than BT in the extremities (SP0:73% [68-79]) from diagnosis to 3-years post diagnosis. Relapsed patients of both sarcoma types had significantly worse short-term survival than non-relapsed patients. Long-term survival for STS in this cohort is 65% at diagnosis, and improves to 86% 5-years post-diagnosis. BT survival improves from 51% at diagnosis to 78% at 5-years post-diagnosis. CONCLUSION: Conditional survival for short- and long-term STS and BT improve as time from diagnosis increases. Short-term survival was significantly affected by patients' sex, age at diagnosis, cancer site, and relapse status.

Modifiable health-related factors (smoking, physical activity and body mass index) and health care use and costs among adult cancer survivors.

OBJECTIVE: To examine the associations between modifiable health-related factors, such as smoking, low physical activity and higher body mass index (BMI), and annual health care visits and expenditures among adult cancer survivors in the United States. METHODS: Using data from the 2010-2014 Medical Expenditures Panel Survey, we identified 4920 cancer survivors (aged 18-64 years) and a matched comparison group. Our outcomes were number of annual health care visits [i.e., outpatient/office-based, hospital discharges and emergency department (ED) visits] and total health care expenditures. We examined health-related factors, demographics, insurance and health status (i.e., comorbidity and mental distress). Bivariate and multivariable analyses examined the associations between outcomes and health-related factors. RESULTS: Of survivors, approximately 21% were current smokers, 52% reported low physical activity and 35% were obese, vs. 19.6, 49.5 and 36.7%, respectively, of the comparison group. These factors were associated with greater comorbidity and mental distress in both groups. Current smokers among survivors were less likely to have outpatient visits [marginal effect on the number of visits (ME) = -3.44, 95% confidence interval (CI) -5.02 to -1.86, P < 0.001] but more likely to have ED visits (ME = 0.11, 95% CI 0.05-0.18, P = 0.001) than non-smokers. Physically active individuals in both groups had fewer ED visits, and lower total expenditures than those who reported low physical activity. CONCLUSION: Regular assessments of health-related factors should be incorporated in survivorship care to reduce the burden of cancer. Modification of survivors' health-related factors (e.g., low physical activity) may help improve their health outcomes and reduce financial burden.

Risk of hospitalization among survivors of childhood and adolescent acute lymphoblastic leukemia compared to siblings and a general population sample.

BACKGROUND: Acute Lymphoblastic Leukemia (ALL) has a high survival rate, but cancer-related late effects in the early post-treatment years need documentation. Hospitalizations are an indicator of the burden of late effects. We identify rates and risk factors for hospitalization from five to ten years after diagnosis for childhood and adolescent ALL survivors compared to siblings and a matched population sample. METHODS: 176 ALL survivors were diagnosed at ≤22 years between 1998 and 2008 and treated at an Intermountain Healthcare facility. The Utah Population Database identified siblings, an age- and sex-matched sample of the Utah population, and statewide inpatient hospital discharges. Sex- and birth year-adjusted Poisson models with Generalized Estimating Equations and robust standard errors calculated rates and rate ratios. Cox proportional hazards models identified demographic and clinical risk factors for hospitalizations among survivors. RESULTS: Hospitalization rates for survivors (Rate:3.76, 95% CI=2.22-6.36) were higher than siblings (Rate:2.69, 95% CI=1.01-7.18) and the population sample (Rate:1.87, 95% CI=1.13-3.09). Compared to siblings and population comparisons, rate ratios (RR) were significantly higher for survivors diagnosed between age 6 and 22 years (RR:2.87, 95% CI=1.03-7.97 vs siblings; RR:2.66, 95% CI=1.17-6.04 vs population comparisons). Rate ratios for diagnosis between 2004 and 2008 were significantly higher compared to the population sample (RR:4.29, 95% CI=1.49, 12.32), but not siblings (RR:2.73, 95% CI=0.54, 13.68). Survivors originally diagnosed with high-risk ALL did not have a significantly higher risk than siblings or population comparators. However, high-risk ALL survivors (Hazard ratio [HR]:3.36, 95% CI=1.33-8.45) and survivors diagnosed from 2004 to 2008 (HR:9.48, 95% CI=1.93-46.59) had the highest risk compared to their survivor counterparts. CONCLUSIONS: Five to ten years after diagnosis is a sensitive time period for hospitalizations in the ALL population. Survivors of childhood ALL require better long-term surveillance.

Cost-related medication nonadherence among adolescent and young adult cancer survivors.

BACKGROUND: This study investigated cost-related medication nonadherence among survivors of adolescent and young adult cancer and a comparison group in the United States. METHODS: A cross-sectional analysis of the 2013 to 2015 National Health Interview Survey was performed. N=953 patients who were diagnosed with cancer between the ages of 15 and 39 years were identified, and a comparison group was created using propensity scores. Cost-related medication nonadherence was determined by individuals' report of skipping medication, taking less medication, or delaying filling medication to save money in the previous year. Covariates included demographics, insurance status, financial factors (eg, out-of-pocket health care expenditures), and health-related factors (eg, comorbidity and mental distress). Chi-square tests were used to compare nonadherence between survivors and the comparison group. Logistic regressions identified covariates associated with nonadherence. RESULTS: Survivors were more likely to report nonadherence than the comparison group (23.8% vs 14.3%; P < .001). Survivors were also more likely to report that they could not afford medication, asked their physician for lower cost medication, and used alternative therapies in the previous year to save money. Uninsured survivors were more likely to report nonadherence than those privately insured (odds ratio [OR], 3.19; 95% confidence interval [CI], 1.67-6.09). Non-Hispanic black survivors, those who reported greater mental distress, and those with greater comorbidities reported nonadherence more often than their counterparts. Survivors reporting a usual source of care were at a lower risk of nonadherence than those without it (OR, 0.39; 95% CI, 0.18-0.82). CONCLUSIONS: Cost-related communication with survivors may be needed to increase medication adherence. Uninsured and sicker survivors should receive regular screening to improve adherence. Future work should evaluate adherence for specific drugs. Cancer 2017;123:2726-34. © 2017 American Cancer Society.

Association between Obesity and Serum 25(OH)D Concentrations in Older Mexican Adults.

BACKGROUND: Vitamin D is essential for maintaining bone mineralization and calcium homeostasis, and prevents falls and fractures in older adults. Mexico is undergoing an epidemiologic and demographic transition with increasing obesity rates. The study's aim was to determine the association of obesity with serum 25-hydroxyvitamin D [25(OH)D] concentrations in older Mexican adults. METHODS: Data from 1772 Mexicans, aged ≥50 years, enrolled in a sub-sample of the 3rd wave of the Mexican Health and Aging Study, were included. Serum 25(OH)D concentrations were used to define vitamin D status, and were categorized into tertiles. Body mass index measures were used to categorize older adults into under/normal weight, overweight, and obese groups. Multinomial logistic regression models were used to assess the relationship, adjusting for potential confounders. RESULTS: Approximately 40% and 37% of older Mexican adults were either overweight or obese, respectively. Compared to under/normal weight older Mexicans, obese adults were 1.78 times (95% Confidence Interval (CI) 1.27-2.48) and 1.94 times (95% CI 1.40-2.68) more associated with the first and second tertile concentrations of serum 25(OH)D, respectively. Overweight adults were 1.52 times (95% CI 1.12-2.06) more associated with the second tertile of serum 25(OH)D concentration than under/normal weight adults. CONCLUSION: Overweight/Obesity was found to be significantly associated with low concentrations of serum 25(OH) in older Mexican adults.

Barriers to follow-up care among survivors of adolescent and young adult cancer.

PURPOSE: Though the need for risk-based follow-up care for survivors of adolescent and young adult (AYA) cancer has been documented, survivors often report forgoing recommended care due to cost. We sought to understand whether additional barriers to follow-up care exist for AYA survivors. METHODS: We recruited survivors who were diagnosed with cancer between the ages of 15 and 39 using the Utah Cancer Registry (UCR). Overall, 28 survivors participated in 6 focus groups held between March and May 2015 in Salt Lake City and St. George, UT. Focus group discussions focused on the reasons survivors may or may not attend recommended medical visits after completing therapy. RESULTS: Survivors reported myriad barriers to follow-up medical visits, including lack of clear provider recommendation, fear of recurrent cancer diagnosis, wishing to move on with life, competing life responsibilities due to work and children, and not perceiving the need for a visit due to lack of symptoms. CONCLUSIONS: Though cost likely plays a major part in follow-up care adherence for survivors of AYA cancer, in our focus groups, participants indicated there were many other psychosocial and logistic barriers to care. Such factors play an important role in the day-to-day lives of survivors and are critical in medical decision-making. IMPLICATIONS FOR CANCER SURVIVORS: Several factors impede follow-up care adherence for survivors of AYA cancer that are amenable to interventions, including clearer provider recommendations, flexible appointment times, and childcare availability in clinics.