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2.
Lancet Psychiatry ; 2021 09 23.
Artigo em Inglês | MEDLINE | ID: mdl-34563316

RESUMO

BACKGROUND: Racial and ethnic minorities face disparities in access to health care. Culturally competent care might lessen these disparities. Few studies have studied the patients' view of providers' cultural competence, especially in psychiatric care. We aimed to examine the associations of race, ethnicity, and mental health status with patient-reported importance of provider cultural competence. METHODS: Our retrospective, population-based, cross-sectional study used data extracted from self-reported questionnaires of adults aged at least 18 years who participated in the US National Health Interview Survey (NHIS; 2017 cycle). We included data on all respondents who answered supplementary cultural competence questions and the Adult Functioning and Disability survey within the NHIS. We classified participants as having anxiety or depression if they reported symptoms at least once a week or more often, and responded that the last time they had symptoms the intensity was "somewhere between a little and a lot" or "a lot." Participant answers to cultural competency survey questions (participant desire for providers to understand or share their culture, and frequency of access to providers who share their culture) were the outcome variables. Multivariable ordinal logistic regressions were used to estimate adjusted odds ratios (aORs) for the outcome variables in relation to sociodemographic characteristics (including race and ethnicity), self-reported health status, and presence of symptoms of depression, anxiety, or both. FINDINGS: 3910 people had available data for analysis. Mean age was 52 years (IQR 36-64). 1422 (39·2%, sample weight adjusted) of the participants were men and 2488 (60·9%) were women. 3290 (82·7%) were White, 346 (9·1%) were Black or African American, 31 (0·8%) were American Indian or Alaskan Native, 144 (4·8%) were Asian American, and 99 (2·6%) were Mixed Race. 380 (12·5%) identified as Hispanic ethnicity and 3530 (87·5%) as non-Hispanic. Groups who were more likely to express a desire for their providers to share or understand their culture included participants who had depression symptoms (vs those without depression or anxiety symptoms, aOR 1·57 [95% CI 1·13-2·19], p=0·008) and participants who were of a racial minority group (Black vs White, aOR 2·54 [1·86-3·48], p=0·008; Asian American vs White, aOR 2·57 [1·66-3·99], p<0·001; and Mixed Race vs White, aOR 1·69 [1·01-2·82], p=0·045) or ethnic minority group (Hispanic vs non-Hispanic, aOR 2·69 [2·02-3·60], p<0·001); these groups were less likely to report frequently being able to see providers who shared their culture (patients with depression symptoms vs those without depression or anxiety symptoms, aOR 0·63 (0·41-0·96); p=0·030; Black vs White, aOR 0·56 [0·38-0·84], p=0·005; Asian American vs White, aOR 0·38 [0·20-0·72], p=0·003; Mixed Race vs White, aOR 0·35 [0·19-0·64], p=0·001; Hispanic vs non-Hispanic, aOR 0·61 [0·42-0·89], p=0·010). On subgroup analysis of participants reporting depression symptoms, patients who identified their race as Black or African American, or American Indian or Alaskan Native, and those who identified as Hispanic ethnicity, were more likely to report a desire for provider cultural competence. INTERPRETATION: Racial and ethnic disparities exist in how patients perceive their providers' cultural competence, and disparities are pronounced in patients with depression. Developing a culturally competent and humble approach to care is crucial for mental health providers. FUNDING: None.

3.
Cancer Epidemiol Biomarkers Prev ; 30(8): 1455-1458, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34233916

RESUMO

Since the start of the COVID-19 pandemic, Asian Americans have been subjected to rising overt discrimination and violent hate crimes, highlighting the health implications of racism toward Asian Americans. As Asian Americans are the only group for whom cancer is the leading cause of death, these manifestations of anti-Asian racism provoke the question of the impact of racism across the cancer continuum for Asian Americans. In this Commentary, we describe how the myth of the "model minority" overlooks the diversity of Asian Americans. Ignoring such diversity in sociocultural trends, immigration patterns, socioeconomic status, health behaviors, and barriers to care masks disparities in cancer risk, access to care, and outcomes across Asian American populations. We recommend cancer epidemiologists, population science researchers, and oncology providers direct attention toward: (i) studying the impacts of structural and personally mediated racism on cancer risk and outcomes; (ii) ensuring studies reflect the uniqueness of individual ethnic groups, including intersectionality, and uncover underlying disparities; and (iii) applying a critical race theory approach that considers the unique lived experiences of each group. A more nuanced understanding of cancer health disparities, and how drivers of these disparities are associated with race and differ across Asian American ethnicities, may elucidate means through which these disparities can be alleviated.


Assuntos
Americanos Asiáticos/estatística & dados numéricos , Ética em Pesquisa/educação , Disparidades em Assistência à Saúde , Neoplasias/terapia , Racismo/prevenção & controle , Americanos Asiáticos/psicologia , Comportamentos Relacionados com a Saúde , Humanos , Racismo/etnologia , Racismo/psicologia , Classe Social
4.
Radiother Oncol ; 161: 241-250, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34171451

RESUMO

BACKGROUND: Prostate radiotherapy has been associated with an increased risk of developing a second malignancy (SM). However, relative SM probabilities following treatment with contemporary radiation techniques such as stereotactic body radiotherapy (SBRT) or moderately hypofractionated intensity modulated radiotherapy (HF-IMRT) remain unknown. METHODS: A cohort analysis was performed of men from a nationally representative database with localized prostate cancer with at least 60 months of follow-up comparing SM probability amongst men receiving either radical prostatectomy (RP), conventionally fractionated intensity-modulated radiotherapy (CF-IMRT), HF-IMRT, brachytherapy (BT), or SBRT, using multivariable logistic models, which were used to generate predicted probabilities. Additionally, propensity score-adjusted pairwise assessments of modalities were performed. RESULTS: For 303,432 patients included in the study, median follow-up was 9.08 years (IQR 7.01-11.21). Predicted rates of SM by treatment modality and adjusted odds ratios (AOR) for development of SM (referent: RP) were: 6.0% for RP (AOR n/a), 7.1% for CF-IMRT (AOR 1.20, 95%CI 1.14-1.25, P < 0.001), 7.3% for HF-IMRT (AOR 1.25, 95%CI 1.01-1.55, P = 0.045), 6.6% for BT (AOR 1.11, 95%CI 1.07-1.16, P < 0.001), and 5.7% for SBRT (AOR 0.95, 95%CI 0.81-1.12, P = 0.567). On propensity score-adjusted analysis, SBRT was associated with lower odds of SM compared to CF-IMRT (AOR 0.78, 95%CI 0.66-0.93, P = 0.005); no significant difference was found when SBRT was compared to RP (AOR 0.86, 95%CI 0.73-1.03, P = 0.102). CONCLUSIONS: Conventionally fractionated intensity-modulated radiotherapy, moderately hypofractionated intensity-modulated radiotherapy, and brachytherapy but not stereotactic body radiotherapy were associated with increased probability of a second malignancy compared to radical prostatectomy. Patients treated with SBRT may be at lower risk of second malignancy due to improved conformality, radiobiological differences or patient selection. The possibility that SBRT in select patients may minimize the probability of SM underscores the need for assessment of second malignancy risk in prospective studies of SBRT.


Assuntos
Braquiterapia , Segunda Neoplasia Primária , Neoplasias da Próstata , Radiocirurgia , Radioterapia de Intensidade Modulada , Humanos , Masculino , Segunda Neoplasia Primária/epidemiologia , Segunda Neoplasia Primária/etiologia , Pontuação de Propensão , Estudos Prospectivos , Neoplasias da Próstata/radioterapia , Radiocirurgia/efeitos adversos , Radioterapia de Intensidade Modulada/efeitos adversos
6.
Cancer Rep (Hoboken) ; : e1407, 2021 May 02.
Artigo em Inglês | MEDLINE | ID: mdl-33934574

RESUMO

BACKGROUND: Currently, little is known about the effect of the Patient Protection and Affordable Care Act's Medicaid expansion on care delivery and outcomes in cervical cancer. AIM: We evaluated whether Medicaid expansion was associated with changes in insurance status, stage at diagnosis, timely treatment, and survival outcomes in cervical cancer. METHODS AND RESULTS: Using the National Cancer Database, we performed a difference-in-differences (DID) cross-sectional analysis to compare insurance status, stage at diagnosis, timely treatment, and survival outcomes among cervical cancer patients residing in Medicaid expansion and nonexpansion states before (2011-2013) and after (2014-2015) Medicaid expansion. January 1, 2014 was used as the timepoint for Medicaid expansion. The primary outcomes of interest were insurance status, stage at diagnosis, treatment within 30 and 90 days of diagnosis, and overall survival. Fifteen thousand two hundred sixty-five patients (median age 50) were included: 42% from Medicaid expansion and 58% from nonexpansion states. Medicaid expansion was significantly associated with increased Medicaid coverage (adjusted DID = 11.0%, 95%CI = 8.2, 13.8, p < .01) and decreased rates of uninsured (adjusted DID = -3.0%, 95%CI = -5.2, -0.8, p < .01) among patients in expansion states compared with non-expansion states. However, Medicaid expansion was not associated with any significant changes in cancer stage at diagnosis or timely treatment. There was no significant change in survival from the pre- to post-expansion period in either expansion or nonexpansion states, and no significant differences between the two (DID-HR = 0.95, 95%CI = 0.83, 1.09, p = .48). CONCLUSION: Although Medicaid expansion was associated with an increase in Medicaid coverage and decrease in uninsured among patients with cervical cancer, the effects of increased coverage on diagnosis and treatment outcomes may have yet to unfold. Future studies, including longer follow-up are necessary to understand the effects of Medicaid expansion.

7.
BMC Ophthalmol ; 21(1): 228, 2021 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-34020592

RESUMO

Cho et al. report deep learning model accuracy for tilted myopic disc detection in a South Korean population. Here we explore the importance of generalisability of machine learning (ML) in healthcare, and we emphasise that recurrent underrepresentation of data-poor regions may inadvertently perpetuate global health inequity.Creating meaningful ML systems is contingent on understanding how, when, and why different ML models work in different settings. While we echo the need for the diversification of ML datasets, such a worthy effort would take time and does not obviate uses of presently available datasets if conclusions are validated and re-calibrated for different groups prior to implementation.The importance of external ML model validation on diverse populations should be highlighted where possible - especially for models built with single-centre data.


Assuntos
Aprendizado de Máquina , Miopia , Atenção à Saúde , Humanos
8.
Urology ; 154: 208-214, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33857569

RESUMO

OBJECTIVE: To characterize the presentation, patterns of care, and outcomes of radiation-associated muscle-invasive bladder cancer (RA-MIBC) compared to primary (non-radiation associated) MIBC. RA-MIBC has been suggested to represent a more aggressive disease variant and be more difficult to treat compared to primary (non-radiation associated) MIBC. METHODS: We identified 60,090 patients diagnosed with MIBC between 1988-2015 using the Surveillance, Epidemiology, and End Results database and stratified patients based on whether radiation had been administered to a prior pelvic primary cancer. We used Fine-Gray competing risks regression to compare adjusted bladder cancer-specific mortality (BCSM) for RA-MIBC compared to primary MIBC. RESULTS: There were 1,093 patients with RA-MIBC and 58,997 patients with primary MIBC. RA-MIBCs were more likely to be T4 at diagnosis (21.0% vs 17.3%, P < .001), and less likely to be node-positive (10.3% vs 17.1%, P < .001). The rate of 5-year BCSM was significantly higher for patients with RA-MIBC vs primary MIBC (56.1% vs 35.3%, AHR 1.24, P < .001), even after stratification by other tumor, treatment and patient-specific factors. CONCLUSION: RA-MIBCs tended to present with higher grade and T stage disease and were less likely to receive curative treatment. Even when accounting for stage, grade, and receipt of treatment, patients with RA-MIBC had worse survival compared to those with primary MIBC. These findings suggest that RA-MIBC present unique clinical challenges and may also represent a biologically more aggressive disease compared to primary MIBC. Future research is needed to better understand the biology of RA-MIBC and develop improved treatment approaches.

9.
Addict Behav ; 119: 106913, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33798916

RESUMO

INTRODUCTION: Electronic cigarettes (e-cigarettes) have become increasingly popular in the United States, including among cancer survivors; however, the majority of prior studies do not report frequency of active e-cigarette usage. METHODS: Using data from the National Health Interview Survey (2014-2018), frequency of active e-cigarette usage was estimated among cancer survivors reporting history of e-cigarette usage. Multivariable logistic regression analyses defined adjusted odds of active e-cigarette usage (either every day and some days vs. not at all) by year of survey and baseline demographic characteristics. RESULTS: Among 1529 cancer survivors who reported ever using e-cigarettes, 1172 (76.7%) were not active users, while 145 (9.5%) and 212 (13.9%) actively used e-cigarettes every day or some days, respectively. Later year of survey was negatively associated with active e-cigarette usage (p < 0.001) as was Black race (as compared to white race, AOR 0.47, p = 0.02). Age 45-54 was positively associated with active usage (as compared to 18-34 years, AOR 1.58, p = 0.02). Notably, individuals who were former or current traditional cigarette smokers had greater odds of reporting active e-cigarette use (27.0%, AOR 4.39, p < 0.001, 23.4%, AOR 3.28, p = 0.002, respectively) as compared to never traditional cigarette smokers (7.6%). CONCLUSIONS: The majority of cancer survivors who have ever used e-cigarettes do not appear to be actively using them. Rather, our findings suggest that the reported increasing popularity of e-cigarettes may be driven by a growing absolute proportion of individuals trying e-cigarettes over time. Those who were current or former traditional cigarette smokers were more likely to actively use e-cigarettes. Our findings can help inform current policies on e-cigarettes and contextualize studies on long-term effects of e-cigarettes among survivors of cancer.


Assuntos
Sistemas Eletrônicos de Liberação de Nicotina , Neoplasias , Vaping , Humanos , Pessoa de Meia-Idade , Neoplasias/epidemiologia , Fumantes , Fumar/epidemiologia , Sobreviventes , Estados Unidos/epidemiologia
11.
Cancers (Basel) ; 13(6)2021 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-33801992

RESUMO

Prior to the 1980s, the primary management of localized anal cancer was surgical resection. Dr. Norman Nigro and colleagues introduced neoadjuvant chemoradiotherapy prior to abdominoperineal resection. Chemoradiotherapy 5-fluorouracil and mitomycin C afforded patients complete pathologic response and obviated the need for upfront surgery. More recent studies have attempted to alter or exclude chemotherapy used in the Nigro regimen to mitigate toxicity, often with worse outcomes. Reductions in acute adverse effects have been associated with marked advancements in radiotherapy delivery using intensity-modulated radiation therapy (IMRT) and image-guidance radiation delivery, resulting in increased tolerance to greater radiation doses. Ongoing trials are attempting to improve IMRT-based treatment of locally advanced disease with efforts to increase personalized treatment. Studies are also examining the role of newer treatment modalities such as proton therapy in treating anal cancer. Here we review the evolution of radiotherapy for anal cancer and describe recent advances. We also elaborate on radiotherapy's role in locally persistent or recurrent anal cancer.

12.
Support Care Cancer ; 29(9): 5523-5535, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33725174

RESUMO

BACKGROUND: A growing proportion of cancer survivors experience financial toxicity. However, the psychological burden of cancer costs and associated mental health outcomes require further investigation. We assessed prevalence and predictors of self-reported financial worry and mental health outcomes among cancer survivors. PATIENTS AND METHODS: Data from the 2013-2018 National Health Interview Survey (NHIS) for adults reporting a cancer diagnosis were used. Multivariable ordinal logistic regressions defined adjusted odds ratios (AORs) of reporting financial worry by relevant sociodemographic variables, and sample weight-adjusted prevalence of financial worry was estimated. The association between financial worry and psychological distress, as defined by the six-item Kessler Psychological Distress Scale was also assessed. RESULTS: Among 13,361 survey participants (median age 67; 60.0% female), 9567 (71.6%) self-reported financial worry, including worries regarding costs of paying for children's college education (62.7%), maintaining one's standard of living (59.7%), and medical costs due to illness or accident (58.3%). Female sex, younger age, and Asian American race were associated with increased odds of financial worry (P < 0.05 for all). Of 13,218 participants with complete responses to K6 questions, 701 (5.3%) met the threshold for severe psychological distress. Participants endorsing financial worry were more likely to have psychological distress (6.6 vs. 1.2%, AOR 2.89, 95% CI 2.03-4.13, P< 0.001) with each additional worry conferring 23.9% increased likelihood of psychological distress. CONCLUSIONS: A majority of cancer survivors reported financial worry, which was associated with greater odds of reporting psychological distress. Policies and guidelines are needed to identify and mitigate financial worries and psychologic distress among patients with cancer, with the goal of improving psychological well-being and overall cancer survivorship care.

13.
JCO Oncol Pract ; 17(10): e1489-e1501, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33630666

RESUMO

PURPOSE: We assessed sociodemographic factors associated with and survival implications of refusal of potentially survival-prolonging locoregional treatment (LT, including radiotherapy and surgery) despite provider recommendation among men with localized prostate adenocarcinoma. METHODS: The National Cancer Database (2004-2015) identified men with TxN0M0 prostate cancer who either received or refused LT despite provider recommendation. Multivariable logistic regression defined adjusted odds ratios (AORs) with 95% CI of refusing LT, with sociodemographic and clinical covariates. Models were stratified by low-risk and intermediate- or high-risk (IR or HR) disease, with a separate interaction analysis between race and risk group. Multivariable Cox proportional hazard ratios compared overall survival (OS) among men who received versus refused LT. RESULTS: Of 887,839 men (median age 64 years, median follow-up 6.14 years), 2,487 (0.28%) refused LT. Among men with IR or HR disease (n = 651,345), Black and Asian patients were more likely to refuse LT than White patients (0.35% v 0.29% v 0.17%; Black v White AOR, 1.75; 95% CI, 1.52 to 2.01; P < .001; Asian v White AOR, 1.47; 95% CI, 1.05 to 2.06; P = .027, race * risk group interaction P < .001). Later year of diagnosis, community facility type, noninsurance or Medicaid, and older age were also associated with increased odds of LT refusal, overall and when stratifying by risk group. For men with IR or HR disease, LT refusal was associated with worse OS (5-year OS 80.1% v 91.5%, HR, 1.65, P < .001). CONCLUSION: LT refusal has increased over time; racial disparities were greater in higher-risk disease. Refusal despite provider recommendation highlights populations that may benefit from efforts to assess and reduce barriers to care.

18.
Anat Sci Educ ; 14(1): 110-116, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32515172

RESUMO

As curricular emphasis on anatomy in undergraduate medical education continues to evolve, new approaches to anatomical education are urgently needed to prepare medical students for residency. A surgical anatomy class was designed for third- and fourth-year medical students to explore important anatomical relationships by performing realistic surgical procedures on anatomical donors. Under the guidance of both surgeons and anatomists, students in this month-long elective course explored key anatomical relationships through performing surgical approaches, with the secondary benefit of practicing basic surgical techniques. Procedures, such as left nephrectomy, first rib resection for thoracic outlet syndrome, and carotid endarterectomy, were adapted from those used clinically by multiple surgical subspecialties. This viewpoint commentary highlights perspectives from students and instructors that suggest the value of a surgical approach to anatomical education for medical students preparing for procedure-oriented residencies, with the goals of: (1) describing the elective at the authors' institution, (2) promoting similar efforts across different institutions, and (3) encouraging future qualitative and quantitative studies of similar pedagogic efforts.

20.
J Cancer Educ ; 36(1): 178-188, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31485916

RESUMO

Little is known about the availability of high-quality online health information (OHI) for adverse effects (AEs) of radiotherapy (RT) and chemotherapy (CHT). Optimal search strategies for gaining access to high-quality OHI for these topics are not well-established. This study explores the quality of, potential disparities in, and possible search strategies for OHI pertaining to AEs of RT and CHT. One hundred twenty phrases on generalized and malignancy site-specific AEs of RT and CHT were searched on Google. The Health on the Net Foundation (HONcode) framework was applied to assess the quality of the first 100 websites for each search phrase. Comparisons of the availability of high-quality OHI were made between different languages, malignancy sites, and treatment modalities (RT vs CHT). Of the 12,000 RT and CHT AE websites analyzed, approximately half of the first 10 websites returned for each search were HONcode-accredited; approximately a fifth of the first 100 websites returned were HONcode-accredited. Such low availability of high-quality OHI persisted throughout different languages (English, French, Spanish) and common malignancy sites (breast, prostate, lung), with some variations between languages, malignancy sites, and RT vs CHT. Despite the important role of OHI in cancer patients' approach to health information gathering and decision-making, the availability of high-quality OHI for the AEs of common oncologic treatments, RT and CHT, is low across different languages and common malignancy sites. Our findings demonstrate the need for improvement in the availability of high-quality OHI. Therefore, providers should take an active stance in directing patients to high-quality OHI.

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