Patterns of Cancer-Related Healthcare Access across Pennsylvania: Analysis of Novel Census Tract-Level Indicators of Persistent Poverty.

BACKGROUND: Persistent poverty census tracts have had ≥20% of the population living below the federal poverty line for 30+ years. We assessed the relationship between persistent poverty and cancer-related healthcare access across census tracts in Pennsylvania. METHODS: We gathered publicly available census tract-level data on persistent poverty, rurality, and sociodemographic variables, as well as potential access to healthcare (i.e., prevalence of health insurance, last-year check-up), realized access to healthcare (i.e., prevalence of screening for cervical, breast, and colorectal cancers), and self-reported cancer diagnosis. We used multivariable spatial regression models to assess the relationships between persistent poverty and each healthcare access indicator. RESULTS: Among Pennsylvania's census tracts, 2,789 (89.8%) were classified as non-persistent poverty, and 316 (10.2%) were classified as persistent poverty (113 did not have valid data on persistent poverty). Persistent poverty tracts had lower prevalence of health insurance [estimate = -1.70, standard error (SE) = 0.10], screening for cervical cancer (estimate = -4.00, SE = 0.17) and colorectal cancer (estimate = -3.13, SE = 0.20), and cancer diagnosis (estimate = -0.34, SE = 0.05), compared with non-persistent poverty tracts (all P < 0.001). However, persistent poverty tracts had higher prevalence of last-year check-up (estimate = 0.22, SE = 0.08) and screening for breast cancer (estimate = 0.56, SE = 0.15; both P < 0.01). CONCLUSIONS: Relationships between persistent poverty and cancer-related healthcare access outcomes differed in direction and magnitude. Health promotion interventions should leverage data at fine-grained geographic units (e.g., census tracts) to motivate focus on communities or outcomes. IMPACT: Future studies should extend these analyses to other states and outcomes to inform public health research and interventions to reduce geographic disparities.

Relationship Between Availability of Urologists and Primary Care Providers and Stage of Diagnosis for Invasive Urinary Bladder Cancer.

INTRODUCTION: With no recommended screening approach, urinary bladder cancer patients rely on referral to urologists to ensure timely diagnosis of bladder cancer. This requires coordination between primary and specialty care. We provide estimates of the relative association between primary care physician and urologist density on stage of urinary bladder cancer diagnosis. METHODS: We used 2010 to 2016 Pennsylvania Cancer Registry data to identify all adult patients diagnosed with bladder cancer. Our primary outcome was locoregional stage of diagnosis, since treatment modality changes and prognosis worsens beyond this stage. Based on patient's residential location at the time of diagnosis we defined both density of urologists and number of primary care providers (defined as providers per population) within the patient's county. We used univariate and multivariate logistic regression to estimate the association between provider density and likelihood of locoregional stage of diagnosis. We also controlled for age, sex, race/ethnicity, insurance type, and year. RESULTS: Our sample included 11,771 urinary bladder cancer patients with 10,607 diagnosed at locoregional stage and 1164 at distant stage. Multivariate regression results show primary care density was associated with significantly higher odds of locoregional stage of diagnosis (odds ratio of 1.05 [95% CI: 1.02-1.08]) while urologist density was associated with significantly lower odds of locoregional stage (odds ratio of 0.65 [95% CI: 0.48-0.89]). CONCLUSIONS: We found primary care density but not urologist density was associated with earlier stage of diagnosis, highlighting the importance of access to primary care and need for timely referral to urologic care.

Evaluating the relationship between physical activity and quality of life in a racially diverse sample of breast cancer survivors.

PURPOSE: Physical activity (PA) has been shown to improve quality of life (QoL) in predominantly White cancer survivors. Very few studies have examined the association between PA and QoL among Black breast cancer survivors (BCS). We investigated the association between PA and multiple QoL domains and the effects of race on the proposed association in a racially diverse group of BCS. METHODS: This was an exploratory study using secondary data from a completed 12-month randomized controlled  trial (RCT). Mixed effects models were tested on a subset of participants in the control and exercise groups of the RCT. The primary outcomes were changes in the QoL domains (baseline to 12 months post baseline). RESULTS: There were 173 participants included in this analysis, averaging 59 years of age; about 33% of the participants were Black women. There were no significant differences in the QoL outcomes between the control and exercise groups at 12 months post baseline. Race was not a significant moderator. Exercise improved emotional/mental wellbeing and body image as it relates to social barriers at 12 months post baseline in Black and White BCS, but the changes in these outcomes were only statistically significant in White BCS (p < 0.05). CONCLUSIONS: Results show that exercise can improve multiple QoL domains over time in Black BCS. However, the significance of the effect on QoL was isolated to White BCS. The small sample size in Black women could constrain the statistical significance of observed effects. Future studies are warranted to assess associations between exercise and QoL in larger samples of Black women.

Exploring Quality of Life Experiences and Concerns of Black Breast Cancer Survivors: a Narrative Approach.

Black breast cancer survivors (BCS) in comparison with White BCS are more likely to experience suboptimal quality of life (QoL). QoL is a multi-dimensional concept that focuses on different aspects of well-being (e.g., emotional well-being). There is limited evidence on the perspectives and experiences of QoL (e.g., the influence of breast cancer on QoL) and the QoL concerns (e.g., negative perceptions of body appearance) among Black BCS. The purpose of this study was to explore the QoL experiences and QoL concerns of Black BCS. Primary data was collected in semi-structured interviews and analyzed using a thematic analysis. A narrative approach (detailed stories or life experiences of a small group of people) was used to better understand the research topic among the target group. Ferrell's Conceptual Framework on QoL in Breast Cancer was used to guide the development of the interview questions, codes, and themes. There were 10 Black BCS, averaging 58 years of age. Two coders achieved a moderate level of agreement (i.e., Kappa) of 0.77. Five major themes were identified: defining QoL (what QoL means to them), behavioral changes (e.g., altering behaviors due to cancer), phases of cancer (e.g., breast cancer diagnosis), QoL experiences and factors affecting QoL, and impactful statements from cancer survivors (other meaningful information shared by the participants). The survivors reported multiple QoL concerns and body image issues. The study findings warrant cancer education interventions or programs to address the relevant survivorship issues of Black BCS.

Assessing the Feasibility of a Faith-Based Colorectal Cancer Education and Screening Intervention for Latino Men in Pennsylvania.

Introduction: Limited health knowledge, literacy, engagement in preventive health services, participation in health promotion behaviors, and cultural factors place Latino men at high risk for colorectal cancer (CRC). This pilot study aimed to determine the feasibility and acceptability of a faith-based cancer education intervention focusing on Latino men between 45 and 74 years old. Methods: This pilot study used a single group pre- and post-intervention research design to compare changes in knowledge, perceived benefit of screening, perceived susceptibility and severity of CRC, and the completion of CRC screening after the intervention. Results: In this study, Latino men were willing to participate in a CRC educational intervention supported by a faith-based institution. The participants had limited knowledge about CRC, yet most recognized that screening is beneficial and that getting CRC is serious. Sixty percent of the participants completed the fecal immunochemical screening test, which showed that the intervention impacted the screening uptake among this group. Conclusion: The findings of this study support the further development of faith-based interventions focusing on Latino men.

LionVu: A Data-Driven Geographical Web-GIS Tool for Community Health and Decision-Making in a Catchment Area.

In 2018, the Penn State Cancer Institute developed LionVu, a web mapping tool to educate and inform community health professionals about the cancer burden in Pennsylvania and its catchment area of 28 counties in central Pennsylvania. LionVu, redesigned in 2023, uses several open-source JavaScript libraries (i.e., Leaflet, jQuery, Chroma, Geostats, DataTables, and ApexChart) to allow public health researchers the ability to map, download, and chart 21 publicly available datasets for clinical, educational, and epidemiological audiences. County and census tract data used in choropleth maps were all downloaded from the sources website and linked to Pennsylvania and catchment area county and census tract geographies, using a QGIS plugin and Leaflet JavaScript. Two LionVu demonstrations are presented, and 10 other public health related web-GIS applications are reviewed. LionVu fills a role in the public health community by allowing clinical, educational, and epidemiological audiences the ability to visualize and utilize health data at various levels of aggregation and geographical scales (i.e., county, or census tracts). Also, LionVu is a novel application that can translate and can be used, for mapping and graphing purposes. A dialog to demonstrate the potential value of web-based GIS to a wider audience, in the public health research community, is needed.

The Impact of the COVID-19 Pandemic on Cancer Mortality in Pennsylvania: A Retrospective Study with Geospatial Analysis.

BACKGROUND: We sought to quantify the impact of the COVID-19 pandemic on cancer mortality and identify associated factors in Pennsylvania. METHODS: The retrospective study analyzed cross-sectional cancer mortality data from CDC WONDER for 2015 through 2020 for Pennsylvania and its 67 counties. The spatial distributions of 2019, 2020, and percentage change in age-adjusted mortality rates by county were analyzed via choropleth maps and spatial autocorrelation. A Wilcoxon Signed Rank Test was used to analyze whether the rates differed between 2019 and 2020. Quasi-Poisson and geographically weighted regression at the county level were used to assess the association between the 2019 rates, sex (percent female), race (percent non-White), ethnicity (percent Hispanic/Latino), rural-urban continuum codes, and socioeconomic status with the 2020 rates. RESULTS: At the state level, the rate in 2020 did not reflect the declining annual trend (-2.7 per 100,000) in the rate since 2015. Twenty-six counties had an increase in the rate in 2020. Of the factors examined, the 2019 rates were positively associated with the 2020 rates, and the impact of sociodemographic and geographic factors on the 2020 rates varied by county. CONCLUSIONS: In Pennsylvania, the 2020 cancer mortality rates did not decline as much as reported before the COVID-19 pandemic. The top five cancer types by rate were the same type for 2019 and 2020. Future cancer control efforts may need to address the impact of the COVID-19 pandemic on trends and geospatial distribution in cancer mortality.

Behaviors and Advocacy Related to COVID-19 among Cancer Patients: The Health Belief Model and Opportunities for Messaging and Education.

Cancer patients have an increased risk of severe COVID-19 outcomes and were recommended to be vaccinated, wear a mask, practice social distancing, and increase hand hygiene. We used the Health Belief Model (HBM) to identify constructs that were associated with the likelihood of adhering to and advocating for CDC COVID-19 prevention recommendations. We surveyed adult cancer patients who had an onsite appointment at the Penn State Cancer Institute or at the Hematology and Oncology Associates of Northeastern Pennsylvania. Survey measures included adherence to and informing others of COVID-19 recommendations as well as HBM constructs. Relationships between HBM constructs and outcomes were assessed with Spearman's correlation and multivariable ordinal logistic regression. Of the 106 participants who completed the survey for our objectives of interest, 76% always wore a mask, 29% always practiced social distancing, and 24% washed their hands at least 10 times a day. Limited advocacy behaviors were captured for the COVID-19 vaccine (30%), social distancing (36%), and wearing masks (27%). Perceived benefits, perceived barriers, and cues-to-action were positively associated with the likelihood of adherence or advocacy of COVID-19 recommendations among cancer patients, whereas perceived susceptibility and self-efficacy were negatively associated with the likelihood of adherence or advocacy of COVID-19 recommendations among cancer patients. Perceived benefits may be the strongest predictor for adherence and advocacy for specific COVID-19 guidelines. Future messaging and educational campaigns focused on improving adherence to or advocacy of specific health behaviors should be informed by the HBM and originate from multiple outlets.

Evaluation of the Spanish-Language Cancer Educational Webinar Series "Vamos a educarnos contra el cáncer" with the RE-AIM Framework.

The COVID-19 pandemic disrupted healthcare for patients with chronic diseases, including cancer. Barriers to healthcare increased, especially for racial and ethnic minorities. While many institutions developed webinars to educate community members, few webinars used a community-based participatory approach, employed a theory-based engagement design, and were evaluated. This manuscript reports the outcomes of "Vamos a educarnos contra el cáncer," a 2021 webinar series. Monthly educational webinars were conducted in Spanish on cancer-related topics. The presentations were delivered by Spanish-speaking content experts from different organizations. Webinars were conducted using the video conferencing platform Zoom. Polls were launched during the webinar to collect data and evaluate each webinar. The RE-AIM model of reach, effectiveness, adoption, implementation, and maintenance was used to evaluate the series. The SAS Analytics Software was used for analysis and data management. Two hundred ninety-seven people participated with over 3000 views of the webinar recordings (Reach); 90% rated the sessions as good or excellent (Effectiveness); 86% agreed to adopt or improve a cancer-related behavior, and 90% reported willingness to adopt or improve a cancer-related action for someone else (Adoption); 92% reported feeling engaged (Implementation). The series has produced a resource library, manual of operations, and agreement of the Hispanic/Latino Cancer Community Advisory Board (CAB) to continue the webinar series in the future (Maintenance). Overall, these results highlight the impact of this webinar series and provide a standard approach to planning, delivering, and evaluating webinars as a strategy for cancer prevention and control in a culturally appropriate manner.

Current Approaches to Serving Catchment Areas in Cancer Centers: Insights from the Big Ten Cancer Research Consortium Population Science Working Group.

In 2021, the NCI issued updated guidance clarifying the mission and organizational structure for Community Outreach and Engagement (COE) for Cancer Center Support Grants. These guidelines outlined how cancer centers should address the cancer burden of the catchment area (CA) and define how COE would partner with the community to inform cancer research and implement programs to reduce the cancer burden. In this paper, the Common Elements Committee of the Population Science Working Group in the Big Ten Cancer Research Consortium describes their respective approaches to implementing these guidelines. We discuss our definitions and rationales for each CA, data sources used, and our approach to assessing the impact of COE efforts on the burden of cancer in our respective CA. Importantly, we describe methods of translating unmet CA needs into our cancer-relevant outreach activities, and cancer research addressing the needs of respective CAs. Implementing these new guidelines is a challenge, and we hope that sharing approaches and experiences will foster cross-center collaborations that may more effectively reduce the burden of cancer in the US and meet the mission of the NCI's Cancer Center Program.

Association of human papillomavirus vaccination with cervical cancer screening: A systematic review and meta-analysis.

INTRODUCTION: Prophylactic vaccination and routine screening are effective at preventing most cases of cervical cancer. Globally, cervical cancer is the fourth most frequently diagnosed cancer among women. The aim of this study was to investigate the association between human papillomavirus virus (HPV) vaccination (1, 2, or 3 doses) and cervical cancer screening. METHODS: PubMed (MEDLINE), Scopus, Web of Science, and Cochrane Library electronic databases were systematically searched from July 1, 2006, up to September 30, 2021. We pooled estimates using random-effects models. Heterogeneity between studies was quantified using Cochran Q test and I2 statistics. In total, 12 studies involving 2.4 million individuals were included in the meta-analysis. RESULTS: In the adjusted estimates, uptake of HPV vaccination was associated with increased cervical cancer screening (pooled relative risk [RR]: 1.35; 95% confidence interval [CI]: 1.21, 1.50; n = 12). Between-study heterogeneity was large (I2 = 99%). Compared to unvaccinated, those who received 3 doses of HPV vaccine had the highest uptake of cervical cancer screening (RR: 1.85; 95% CI: 1.58, 2.17), followed by those who received 2 doses (RR: 1.34; 95% CI: 1.21, 1.47). No statistically significant association with screening was found for those who received a single dose of the HPV vaccine. CONCLUSION: In this meta-analysis, uptake of HPV vaccination was associated with higher cervical cancer screening. It is plausible that vaccinated individuals are more likely to engage in preventive health behaviors. Healthcare providers should remind patients to continue with routine screening for cervical cancer regardless of their HPV vaccine status since vaccination does not protect against all HPV types.

Improving Caregiver Burden by a Peer-Led Mentoring Program for Caregivers of Patients With Chronic Kidney Disease: Randomized Controlled Trial.

Chronic kidney disease (CKD) is associated with substantial morbidity, mortality, cost, and increased caregiver burden. Peer mentoring (PM) improves multiple outcomes in various chronic diseases. The effect of PM on caregiver burden among caregivers of patients with CKD has not been studied. We conducted a randomized clinical trial to test the effectiveness of a structured PM program on burden of care among caregivers of patients with CKD. We randomized 86 caregivers to receive 6 months of intervention in 1 of 3 groups: (1) face-to-face PM (n = 29); (2) online PM (n = 29); and (3) usual care: textbook-only (n = 28). Peer mentors were caregivers of patients with CKD, who received 16 h of instruction. All participants received a copy of a textbook, which contains detailed information about kidney disease. Participants in the PM groups received FTF or online PM for 6 months. The outcome was time-related change in the Zarit Burden Interview (ZBI) score. There was a statistically significant decrease in the ZBI score (SE: -3.44; CI: -6.31, -0.57 [p = 0.002]) compared with baseline, among the online PM group. Online PM led to decreased caregiver burden among caregivers of patients with CKD. The study was limited to English-speaking subjects with computer literacy.

Effect of Peer Mentoring on Quality of Life among CKD Patients: Randomized Controlled Trial.

INTRODUCTION: CKD is associated with decreased quality of life (QOL). Peer mentoring (PM) leads to improved QOL in various chronic diseases. The effectiveness of PM on QOL of patients with CKD has not been previously studied. We conducted a randomized clinical trial to test the effectiveness of face-to-face (FTF) and online mentoring by trained peers, compared with usual care, on CKD patients' QOL. METHODS: We randomized 155 patients in one of 3 groups: (1) FTF PM (n = 52), (2) online PM (n = 52), and (3) textbook only (n = 51). Peer mentors were patients with CKD, who received formal training through 16 h of instruction. Participants in all 3 groups received a copy of an informational textbook about CKD. Participants assigned to PM received either 6 months of FTF or online PM. The outcomes included time-related changes in domain scores of the Kidney Disease Quality of Life (KDQOL)-36 for each of the groups over the 18-month study period. RESULTS: Compared with baseline, online PM led to improved scores in domains of the KDQOL-36 at 18 months: Effects of Kidney Disease (p = 0.01), Burden of Kidney Disease (p = 0.01), Symptoms and Problems of Kidney Disease (p = 0.006), SF-12 Physical Composite Summary (p = 0.001), and SF-12 Mental Composite Summary (p < 0.001). There were no statistically significant changes from baseline in domain scores of KDQOL-36 within the FTF PM and textbook-only groups. CONCLUSIONS: Among patients with CKD, online PM led to increased scores in domains of the KDQOL-36 at 18 months. The study was limited to English-speaking subjects with computer literacy and internet access.

Association Between Dense Breast Legislation and Cancer Stage at Diagnosis.

INTRODUCTION: Many states have mandated breast density notification and insurance coverage for additional screening; yet, the association between such legislation and stage of diagnosis for breast cancer is unclear. This study investigates this association and examines the differential impacts among different age and race/ethnicity subgroups. METHODS: The Surveillance, Epidemiology, and End Results database was queried to identify patients with breast cancer aged 40-74 years diagnosed between 2005 and 2016. Using a difference-in-differences multinomial logistic model, the odds of being diagnosed at different stages of cancer relative to the localized stage depending on legislation and individual characteristics were examined. Analyses were conducted in 2020-2021. RESULTS: The study included 689,641 cases. Overall, the impact of notification legislation was not significant, whereas insurance coverage legislation was associated with 6% lower odds (OR=0.94, 95% CI=0.91, 0.96) of being diagnosed at the regional stage. The association between insurance coverage legislation and stage of diagnosis was even stronger among women aged 40-49 years, with 11% lower odds (OR=0.89, 95% CI=0.82, 0.96) of being diagnosed at the regional stage and 12% lower odds (OR=0.88, 95% CI=0.81, 0.96) of being diagnosed at the distant stage. Hispanic women benefited from notification laws, with 11% lower odds (OR=0.89, 95% CI=0.82, 0.97) of being diagnosed at distant stage. Neither notification nor supplemental screening insurance coverage legislation showed a substantial impact on Black women. CONCLUSIONS: The findings imply that improving insurance coverage is more important than being notified overall. Raising awareness is important among Hispanic women; improving communication about dense breasts and access to screening might be more important than legislation among Black women.

Community-engaged research in translational science: Innovations to improve health in Appalachia.

Health disparities between Appalachia and the rest of the country are widening. To address this, the Appalachian Translational Research Network (ATRN) organizes an annual ATRN Health Summit. The most recent Summit was held online September 22-23, 2020, and hosted by Wake Forest Clinical and Translational Science Institute in partnership with the Northwest Area Health Education Center. The Summit, titled "Community-Engaged Research in Translational Science: Innovations to Improve Health in Appalachia," brought together a diverse group of 141 stakeholders from communities, academic institutions, and the National Center for Advancing Translational Science (NCATS) to highlight current research, identify innovative approaches to translational science and community-engaged research, develop cross-regional research partnerships, and establish and disseminate priorities for future Appalachian-focused research. The Summit included three plenary presentations and 39 presentations within 12 concurrent breakout sessions. Here, we describe the Summit planning process and implementation, highlight some of the research presented, and outline nine emergent themes to guide future Appalachian-focused research.

Examining Older Adults' Attitudes and Perceptions of Cancer Screening and Overscreening: A Qualitative Study.

INTRODUCTION/OBJECTIVES: Screening guidelines for breast, cervical, and colorectal cancer (CRC) are less clear for older adults due to the potential harms that may result from screening. Understanding older adults' attitudes and perceptions, especially racial/ethnic minority and underserved adults, of cancer screening can help health care providers determine how best to communicate with older adults about cancer screening and screening cessation. The objective of this study was to determine how older adults primarily from minority/underserved backgrounds perceive cancer screening and overscreening. METHODS: Four focus groups (n = 39) were conducted with adults (>=65 years of age) in 3 community settings in south-central Pennsylvania. Two focus groups were conducted in Spanish and translated to English upon transcription. Focus group data was managed and analyzed using QSR NVivo 12. Inductive thematic analysis was used to analyze the data where themes emerged following the coding process. RESULTS: The focus group participants had an average age of 74 years and were primarily female (74%) and Hispanic (69%), with 69% reporting having less than a high school degree. Four key themes were identified from the focus groups: (1) importance of tailored and targeted education/information; (2) impact of physician/patient communication; (3) impact of barriers and facilitators to screening on cancer screening cessation; and (4) awareness of importance of screening. Participants were more likely to be agreeable to screening cessation if they received specific information regarding their health status and previous medical history from their physician as to why screening should be stopped and told by their physician that the screening decision is up to them. CONCLUSIONS: Older adults prefer individualized information from their physician in order to justify screening cessation but are against incorporating life expectancy into the discussion. Future research should focus on developing interventions to test the effectiveness of culturally tailored screening cessation messages for older adults.

A faith-based mind-body intervention to improve psychosocial well-being among rural adults.

Churches are well positioned to promote better mental health outcomes in underserved populations, including rural adults. Mind-body (MB) practices improve psychological well-being yet are not widely adopted among faith-based groups due to conflicting religious or practice beliefs. Thus, "Harmony & Health" (HH) was developed as a culturally adapted MB intervention to improve psychosocial health in urban churchgoers and was adapted and implemented in a rural church. The purpose of this study was to explore the feasibility, acceptability, and efficacy of HH to reduce psychosocial distress in rural churchgoers. HH capitalized on an existing church partnership to recruit overweight or obese (body mass index [BMI] ≥25.0 kg/m2) and insufficiently active adults (≥18 years old). Eligible adults participated in an 8 week MB intervention and completed self-reported measures of perceived stress, depressive symptoms, anxiety, and positive and negative affect at baseline and postintervention. Participants (mean [M] age = 49.1 ± 14.0 years) were mostly women (84.8%), non-Hispanic white (47.8%) or African American (45.7%), high socioeconomic status (65.2% completed ≥bachelor degree and 37.2% reported an annual household income ≥$80,000), and obese (M BMI = 32.6 ± 5.8 kg/m2). Participants reported lower perceived stress (t = -2.399, p = .022), fewer depressive symptoms (t = -3.547, p = .001), and lower negative affect (t = -2.440, p = .020) at postintervention. Findings suggest that HH was feasible, acceptable, and effective at reducing psychosocial distress in rural churchgoers in the short-term. HH reflects an innovative approach to intertwining spirituality and MB practices to improve physical and psychological health in rural adults, and findings lend to our understanding of community-based approaches to improve mental health outcomes in underserved populations.

Geographic Variation in Overscreening for Colorectal, Cervical, and Breast Cancer Among Older Adults.

Importance: National guidelines balance risks and benefits of population-level cancer screening among adults with average risk. Older adults are not recommended to receive routine screening, but many continue to be screened (ie, are overscreened). Objective: To assess the prevalence of overscreening for colorectal, cervical, and breast cancers among older adults as well as differences in overscreening by metropolitan status. Design, Setting, and Participants: The cross-sectional study examined responses to a telephone survey of 176 348 community-dwelling adults. Participants were included if they met age and sex criteria, and they were excluded from each cancer-specific subsample if they had a history of that cancer. Data came from the 2018 Behavioral Risk Factor Surveillance System, administered by the US Centers for Disease Control and Prevention. Exposures: Metropolitan status, according to whether participants lived in a metropolitan statistical area. Main Outcomes and Measures: Overscreening was assessed using US Preventive Services Task Force definitions, ie, whether participants self-reported having a screening after the recommended upper age limit for colorectal (75 years), cervical (65 years), or breast (74 years) cancer. Results: Of 176 348 participants (155 411 [88.1%] women; mean [SE] age, 75.0 [0.04] years; 150 871 [85.6%] non-Hispanic white; 60 456 [34.3%] with nonmetropolitan residence) the cancer-specific subsamples contained 20 937 [11.9%] men and 34 244 [19.4%] women for colorectal cancer, 82 811 [47.0%] women for cervical cancer, and 38 356 [21.8%] women for breast cancer. Overall, 9461 men (59.3%; 95% CI, 57.6%-61.1%) were overscreened for colorectal cancer; 14 463 women (56.2%; 95% CI, 54.7%-57.6%), for colorectal cancer; 31 988 women (45.8%; 95% CI, 44.9%-46.7%), for cervical cancer; and 26 198 women (74.1%; 95% CI, 73.0%-75.3%), for breast cancer. Overscreening was more common in metropolitan than nonmetropolitan areas for colorectal cancer among women (adjusted odds ratio [aOR], 1.23; 95% CI, 1.08-1.39), cervical cancer (aOR, 1.20; 95% CI, 1.11-1.29), and breast cancer (aOR, 1.36; 95% CI, 1.17-1.57). Overscreening for cervical and breast cancers was also associated with having a usual source of care compared with not (eg, cervical cancer: aOR, 1.87; 95% CI, 1.56-2.25; breast cancer: aOR, 2.08; 95% CI, 1.58-2.76), good, very good, or excellent self-reported health compared with fair or poor self-reported health (eg, cervical cancer: aOR, 1.21; 95% CI, 1.11-1.32; breast cancer: aOR, 1.47; 95% CI, 1.28-1.69), an educational attainment greater than a high school diploma compared with a high school diploma or less (eg, cervical cancer: aOR, 1.14; 95% CI, 1.06-1.23; breast cancer: aOR, 1.30; 95% CI, 1.16-1.46), and being married or living as married compared with other marital status (eg, cervical cancer: OR, 1.36; 95% CI, 1.26-1.46; breast cancer: OR, 1.54; 95% CI, 1.34-1.77). Conclusions and Relevance: In this study, overscreening for cancer among older adults was high, particularly for women living in metropolitan areas. Overscreening could be associated with health care access and patient-clinician relationships. Additional research on why overscreening persists and how to reduce overscreening is needed to minimize risks associated with cancer screening among older adults.

Spatial patterns in prostate Cancer-specific mortality in Pennsylvania using Pennsylvania Cancer registry data, 2004-2014.

BACKGROUND: Spatial heterogeneity of prostate cancer-specific mortality in Pennsylvania remains unclear. We utilized advanced geospatial survival regressions to examine spatial variation of prostate cancer-specific mortality in PA and evaluate potential effects of individual- and county-level risk factors. METHODS: Prostate cancer cases, aged ≥40 years, were identified in the 2004-2014 Pennsylvania Cancer Registry. The 2018 County Health Rankings data and the 2014 U.S. Environmental Protection Agency's Environmental Quality Index were used to extract county-level data. The accelerated failure time models with spatial frailties for geographical correlations were used to assess prostate cancer-specific mortality rates for Pennsylvania and by the Penn State Cancer Institute (PSCI) 28-county catchment area. Secondary assessment based on estimated spatial frailties was conducted to identify potential health and environmental risk factors for mortality. RESULTS: There were 94,274 cases included. The 5-year survival rate in PA was 82% (95% confidence interval, CI: 81.1-82.8%), with the catchment area having a lower survival rate 81% (95% CI: 79.5-82.6%) compared to the non-catchment area rate of 82.3% (95% CI: 81.4-83.2%). Black men, uninsured, more aggressive prostate cancer, rural and urban Appalachia, positive lymph nodes, and no definitive treatment were associated with lower survival. Several county-level health (i.e., poor physical activity) and environmental factors in air and land (i.e., defoliate chemical applied) were associated with higher mortality rates. CONCLUSIONS: Spatial variations in prostate cancer-specific mortality rates exist in Pennsylvania with a higher risk in the PSCI's catchment area, in particular, rural-Appalachia. County-level health and environmental factors may contribute to spatial heterogeneity in prostate cancer-specific mortality.

Prostate Cancer Incidence and Aggressiveness in Appalachia versus Non-Appalachia Populations in Pennsylvania by Urban-Rural Regions, 2004-2014.

BACKGROUND: Few studies have examined prostate cancer incidence and aggressiveness in urban-rural Appalachian populations. We examined these rates in urban-rural Appalachia and non-Appalachia Pennsylvania (PA), and the association between these areas and more aggressive prostate cancer at diagnosis. METHODS: Men, ages ≥ 40 years with a primary prostate cancer diagnosis, were identified from the 2004-2014 Pennsylvania Cancer Registry. Age-adjusted incidence rates for prostate cancer and more aggressive prostate cancer at diagnosis were calculated by urban-rural Appalachia status. Multivariable Poisson regressions were conducted. Multiple logistic regressions were used to examine the association between the geographic areas and more aggressive prostate cancer, after adjusting for confounders. RESULTS: There were 94,274 cases, ages 40-105 years, included. Urban non-Appalachia had the highest 2004-2014 age-adjusted incidence rates of prostate cancer and more aggressive prostate cancer (293.56 and 96.39 per 100,000 men, respectively) and rural Appalachia had the lowest rates (256.48 and 80.18 per 100,000 men, respectively). Among the cases, urban Appalachia were more likely [OR = 1.12; 95% confidence interval (CI) = 1.08-1.17] and rural Appalachia were less likely (OR = 0.92; 95% CI = 0.87-0.97) to have more aggressive prostate cancer at diagnosis compared with urban non-Appalachia. CONCLUSIONS: Lower incidence rates and the proportion of aggressive disease in rural Appalachia may be due to lower prostate cancer screening rates. More aggressive prostate cancer at diagnosis among the cases in urban Appalachia may be due to exposures that are prevalent in the region. IMPACT: Identifying geographic prostate cancer disparities will provide information to design programs aimed at reducing risk and closing the disparity gap.