Disparities In Cancer Mortality Research Articles

Racial and Ethnic Disparities in Intensity of Care at the End of Life for Patients With Lung Cancer: A 13-Year Population-Based Study.

Lung cancer is the leading cause of cancer death in the United States. Disparities in lung cancer mortality among racial and ethnic minorities are well documented. Less is known as to whether racial and ethnic minority patients with lung cancer experience higher rates of intensity of care at the end of life (EOL) compared with non-Hispanic White (NHW) patients. We conducted a population-based analysis of patients 18 years and older with a lung cancer diagnosis who died between 2005 and 2018 using the California Cancer Registry linked to patient discharge data abstracts. Our primary outcome was intensity of care in the last 14 days before death (defined as any hospital admission or emergency department [ED] visit, intensive care unit [ICU] admission, intubation, cardiopulmonary resuscitation [CPR], hemodialysis, and death in an acute care setting). We used multivariable logistic regression models to evaluate associations between race and ethnicity and intensity of EOL care. Among 207,429 patients with lung cancer who died from 2005 to 2018, the median age was 74 years (range, 18-107) and 106,821 (51%) were male, 146,872 (70.8%) were NHW, 1,045 (0.5%) were American Indian, 21,697 (10.5%) were Asian Pacific Islander (API), 15,490 (7.5%) were Black, and 22,325 (10.8%) were Hispanic. Compared with NHW patients, in the last 14 days before death, API, Black, and Hispanic patients had greater odds of a hospital admission, an ICU admission, intubation, CPR, and hemodialysis and greater odds of a hospital or ED death. Compared with NHW patients, API, Black, and Hispanic patients who died with lung cancer experienced higher intensity of EOL care. Future studies should develop approaches to eliminate such racial and ethnic disparities in care delivery at the EOL.

Disparities in treatment patterns and mortality in prostate cancer: Interaction between Black race and end-stage kidney disease.

Black men and men with end-stage kidney disease have lower rates of treatment and higher mortality for prostate cancer. We studied the interaction of end-stage kidney disease (ESKD) with Black race for treatment rates and mortality for men with prostate cancer. We included 516 Black and 551 White men with ESKD before prostate cancer 22,299 Black men, and 141,821 White men without ESKD who were 40 years or older from the Surveillance, Epidemiology, and End-Results-Medicare data (2004-2016). All Black men with or without ESKD and White men with ESKD had higher prostate-specific antigen levels at diagnosis than White men without ESKD. Black men with ESKD had the lowest rates for treatment in both local and advanced stages of prostate cancer (age-adjusted risk ratio: 0.76, 95% Confidence Interval (CI): 0.71-0.82 for local stage and age-adjusted risk ratio: 0.82, 95% CI: 0.76-0.9 for advanced stages) compared to White men without ESKD. Compared to White men without ESKD, prostate cancer-specific mortality was higher in White men with ESKD for both local and advanced stages (age-adjusted hazard ratio: 1.8, 95% CI: 1.2-2.8 and HR: 1.6, 95% CI: 1.2-2.2) and it was higher for ESKD Black men only in advanced stage prostate cancer (age-adjusted hazard ratio: 2.4, 95% CI: 1.5-3.6). Our findings suggest that having a comorbidity such as ESKD makes Black men more vulnerable to racial disparities in prostate cancer treatment and mortality.

Culturally Competent Education and Human Papillomavirus Self-Sampling Achieves Healthy People 2030 Cervical Screening Target Among Low-Income Non-Hispanic Black and Hispanic Women

PURPOSE Disparities in cervical cancer screening, incidence, and mortality exist in the United States. Cervical cancer incidence and mortality rates in Texas are 20% and 32% higher, respectively, than national averages. Within Texas, these rates are significantly higher among non-Hispanic (NH) Black and Hispanic women. Cervical cancer screening uptake is lower among NH Black and Hispanic women (72.9% and 75.9%, respectively) compared with White women (85.5%) in Texas. METHODS During March-August 2023, we conducted a pilot study that offered culturally competent education and human papillomavirus (HPV) self-sampling kits to women in two public housing projects in Houston, TX, that have predominantly NH Black or Hispanic residents. Among those eligible for cervical cancer screening, 35% (n = 24) of the NH Black and 34% (n = 16) of the Hispanic women were found to be underscreened per the US Preventive Services Task Force Guideline. We recruited 40 (24 NH Black and 16 Hispanic) eligible women for our study. The study was approved by the MD Anderson institutional review board and registered with ClinicalTrials.gov ( NCT04614155 —March 11, 2020). RESULTS Seventy-five percent of the NH Black and 87% of the Hispanic participants completed the HPV self-sampling procedures per protocol. Samples of 17% NH Black and 12% Hispanic participants showed a performance error. Overall, cervical cancer screening uptake improved from 65% to 91% among NH Black and from 66% to 96% among Hispanic participants. CONCLUSION Culturally competent education and HPV self-sampling resulted in remarkable improvement in cervical cancer screening uptake among underscreened NH Black and Hispanic women residents of Houston public housing projects. Implementing this strategy could significantly reduce cervical cancer incidence and mortality among similar populations in the United States and globally.

Y Chromosome Loss and Implications for Oncology.

The Y chromosome has recognized functions in promoting male sex determination and regulating aspects of fertility. However, recent work has demonstrated important roles for the Y chromosome and Y-encoded genes in multiple domains of male health, including cancer. It is well-established that males experience shorter life spans than females, and this sex bias on overall mortality is ac-centuated in populations with longer life expectancy, in part related to elevated rates of cancer. The majority of human malignancies exhibit a sex bias with elevated frequencies in males. For many of these cancer types, the disparity has not been explained by environmental risk factors such as tobacco use. Notably, loss of the Y chromosome (LOY) detected in blood cells, termed mosaic LOY (mLOY) is a common event that is related to advancing age and is associated with a shortened lifespan. mLOY is linked to increased incidence and mortality across a range of malignancies. Further, tumors arising in different anatomic sites exhibit different frequencies of partial or complete Y chromosome loss. Causal oncogenic or tumor suppressive roles have been documented for several Y-encoded genes, such as KDM5D, that exert pleiotropic effects on cellular functions by virtue of genome-wide regulation of gene activity. In this review, we discuss aspects of the Y chromosome relevant to oncology. The recent completion of the entire human Y-chromosome sequence provides a reference map of Y-encoded genes and regulatory elements to enable causal molecular studies that may explain and exploit the marked disparity in male cancer risk and mortality.

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

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

Socioecologic Factors and Racial Differences in Breast Cancer Multigene Prognostic Scores in US Women

Disproportionately aggressive tumor biology among non-Hispanic Black women with early-stage, estrogen receptor (ER)-positive breast cancer contributes to racial disparities in breast cancer mortality. It is unclear whether socioecologic factors underlie racial differences in breast tumor biology. To examine individual-level (insurance status) and contextual (area-level socioeconomic position and rural or urban residence) factors as possible mediators of racial and ethnic differences in the prevalence of ER-positive breast tumors with aggressive biology, as indicated by a high-risk gene expression profile. This retrospective cohort study included women 18 years or older diagnosed with stage I to II, ER-positive breast cancer between January 1, 2007, and December 31, 2015. All data analyses were conducted between December 2022 and April 2023. The primary outcome was the likelihood of a high-risk recurrence score (RS) (≥26) on the Oncotype DX 21-gene breast tumor prognostic genomic biomarker. Among 69 139 women (mean [SD] age, 57.7 [10.5] years; 6310 Hispanic [9.1%], 274 non-Hispanic American Indian and Alaskan Native [0.4%], 6017 non-Hispanic Asian and Pacific Islander [8.7%], 5380 non-Hispanic Black [7.8%], and 51 158 non-Hispanic White [74.0%]) included in our analysis, non-Hispanic Black (odds ratio [OR], 1.33; 95% CI, 1.23-1.43) and non-Hispanic American Indian and Alaska Native women (OR, 1.38; 95% CI, 1.01-1.86) had greater likelihood of a high-risk RS compared with non-Hispanic White women. There were no significant differences among other racial and ethnic groups. Compared with non-Hispanic White patients, there were greater odds of a high-risk RS for non-Hispanic Black women residing in urban areas (OR, 1.35; 95% CI, 1.24-1.46), but not among rural residents (OR, 1.05; 95% CI, 0.77-1.41). Mediation analysis demonstrated that lack of insurance, county-level disadvantage, and urban vs rural residence partially explained the greater odds of a high-risk RS among non-Hispanic Black women (proportion mediated, 17%; P < .001). The findings of this cohort study suggest that the consequences of structural racism extend beyond inequities in health care to drive disparities in breast cancer outcome. Additional research is needed with more comprehensive social and environmental measures to better understand the influence of social determinants on aggressive ER-positive tumor biology among racial and ethnic minoritized women from disadvantaged and historically marginalized communities.

Estimating the Impact of Rurality in Disparities in Cancer Mortality.

Estimation of the independent effect of rurality on cancer mortality requires causal inference methodology and consideration of area-level socioeconomic status and rural designations. Using SEER data, we identified key incident cancers diagnosed between 2000 and 2016 at age ≥20 years (N = 3,788,273), examining a 20% random sample (n = 757,655). Standardized competing risk and survival models estimated the association between rural residence, defined by Rural-Urban Continuum Codes, and cancer-specific and all-cause mortality, controlling for age at cancer diagnosis, sex, race/ethnicity, year of diagnosis, and Area Deprivation Index (ADI). We estimated the attributable fraction (AF) of rurality and high ADI (ADI > median) to the probability of mortality. Finally, we examined county measurement issues contributing to mortality rates discordant from hypothesized rates. The 5-year standardized failure probability for cancer mortality for rural patients was 33.9% versus 31.56% for urban. The AF for rural residence was 1.04% at year 1 (0.89% by year 5), the highest among local stage disease (Y1 2.1% to Y5 1.9%). The AF for high ADI was 3.33% in Y1 (2.87% in Y5), while the joint effect of rural residence and high ADI was 4.28% in Y1 (3.71% in Y5). Twenty-two percent of urban counties and 30% of rural were discordant. Among discordant urban counties, 30% were only considered urban because of adjacency to metro area. High ADI was associated with urban discordance and low ADI with rural discordance. Rural residence independently contributes to cancer mortality. The rural impact is the greatest among those with localized disease and in high deprivation areas. Rural-urban county designations may mask high-need urban counties, limiting eligibility to state and federal resources dedicated to rural areas.

Defining the Role of Social Vulnerability in Treatment and Survival in Localized Colon Cancer: A Retrospective Cohort Study.

To determine whether variations in Social Vulnerability Index (SVI) are associated with disparities in colon cancer surgery and mortality. Colon cancer mortality is influenced by health care access, which is affected by individual and community-level factors. Prior studies have not used the SVI to compare surgical access and survival in localized colon cancer patients. Further, it is unclear if those above 65 years are more vulnerable to variations in SVI. We queried the Texas and California Cancer Registries from 2004-2017 to identify patients with localized colonic adenocarcinoma and categorized patients into <65 and ≥65 years. Our outcomes were survival and access to surgical intervention. The independent variable was census tract social vulnerability index, with higher scores indicating more social vulnerability. We used multivariable logistic regression and Cox proportional hazards for analysis. We included 73,923 patients with a mean age of 68.6 years (SD 13.0), mean SVI of 47.2 (SD 27.6), and 51.1% male. After adjustment, increasing SVI was associated with reduced odds of undergoing surgery (OR 0.996; 95% CI 0.995-0.997; P < 0.0001 and increased mortality (HR 1.002; 95% CI 1.001-1.002; P < 0.0001). Patients < 65 years were more sensitive to variation in SVI. Increased social vulnerability was associated with reduced odds of receiving surgery for early-stage colon cancer as well as increased mortality. These findings amplify the need for policy changes at the local, state, and federal level to address community-level vulnerability to improve access to surgical care and reduce mortality.

Abstract 4837: Perceived discrimination, medical mistrust, and their associations with ovarian cancer mortality among women in the African American Cancer Epidemiology Study

Abstract Background: There are pronounced racial disparities in ovarian cancer mortality wherein Black women are on average 30% more likely to succumb to their disease than White women. Factors that contribute to these disparities are complex and multifactorial. Racial discrimination is hypothesized to affect cancer health disparities through three distinct pathways including the impact on socioeconomic inequities, chronic stress, and restricted access to goods and services. In this study, we examined the role of perceived discrimination and medical mistrust on all-cause mortality among ovarian cancer patients. Methods: Using data from the African American Cancer Epidemiology Study (AACES), we included 592 ovarian cancer patients who self-identified as Black or African American and completed a telephone interview. Perceived discrimination was measured with a modified version of the 5-question Williams Everyday Discrimination scale. Medical mistrust was measured with the Trust in Physician scale (ranged 0-48 based on a combination of 12 questions). We used Cox proportional hazard models to compute hazard ratios (HR) and 95% confidence intervals (CIs) associating perceived discrimination and medical mistrust with all-cause mortality, adjusting for age, stage, and histotype. Results: Nearly two-thirds of the cohort passed away by the end of follow-up (mean follow-up 5.5 years, ranging 0.5-12 years). We observed that 231 participants patients (39%) reported experiencing discrimination in at least one of the domains assessed. Reporting any experience of discrimination was associated with lower all-cause mortality (HR=0.78, 95% CI: 0.62, 0.97). In multivariable adjusted models, higher trust in physicians (above vs. below the median of 35) was associated with a decreased risk of mortality (HR=0.87, 95% CI: 0.70, 1.08). Conclusion: In our preliminary results, we observed an association between any experience of discrimination and better survival, and that a higher trust in physicians was associated with better survival. Further work on this project will try to understand the paradoxical association with perceived discrimination, and evaluate the associations of discrimination and medical mistrust with ovarian cancer treatment, leading to more insight into drivers of racial disparities in ovarian cancer mortality. Citation Format: Lindsay Jane Collin, Courtney Johnson, Maxwell Akonde, Mary Kan, Elisa V. Bandera, Lauren Peres, Anthony Alberg, Theresa Hastert, Joellen Schildkraut. Perceived discrimination, medical mistrust, and their associations with ovarian cancer mortality among women in the African American Cancer Epidemiology Study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4837.

Abstract 6135: Racial and ethnic differences in site of de novo metastases in patients with colorectal cancer: A SEER analysis

Abstract Purpose: Disparities in colorectal cancer (CRC) mortality may be driven by differences in access to care, tumor biology, and propensity to spread to distant sites. We examine differences in patterns of de novo metastases by race/ethnicity and age. Methods: We identified 248,732 CRC patients listed in the Surveillance, Epidemiology, and End Results (SEER) database diagnosed with a first primary invasive CRC from 2010-2020, aged 20+ years at diagnosis, with complete data on SEER summary stage, and not diagnosed only by autopsy/death certificate. Outcomes included de novo metastatic site (no metastasis, liver, lung, brain, bone) and pattern (no metastasis, liver only, lung only, liver and lung, other). We used logistic regression to calculate odds ratios (OR) and 95% confidence intervals (95% CI) for the associations between 1) demographic and tumor characteristics (site, side, T stage, N stage) and site of de novo metastases , and 2) race/ethnicity and site of de novo metastases stratified by age (20-49, 50-74, 75+). We used multinomial logistic regression to assess the association between demographic and tumor characteristics and pattern of metastasis. Models adjusted for age, race/ethnicity, sex, site (colon, rectum), side (left, right), T stage, and N stage. Results: 62,844 stage IV CRC cases were diagnosed from 2010-2020, and liver was the most common metastatic site (72%). Relative to age 50-74, age 20-49 at diagnosis was more strongly associated with de novo liver metastases (OR: 1.07; 95% CI: 1.02-1.11) and less with lung (OR: 0.86; 95% CI: 0.80-0.92) or brain (OR: 0.69; 95% CI: 0.52-0.93) metastases. Relative to Non-Hispanic White (NHW) patients, Non-Hispanic American Indian/Alaskan Native (AI/AN) patients had a higher risk of lung metastases (OR: 1.33; 95% CI: 1.07-1.65), Non-Hispanic Asian/Pacific Islander (API) patients had lower risks of liver (OR: 0.87; 95% CI: 0.83-0.92) and brain (OR: 0.67; 95% CI: 0.48-0.95) metastases, and Non-Hispanic Black (NHB) patients had higher risks of liver (OR: 1.35; 95% CI: 1.29-1.41), lung (OR: 1.36; 95% CI: 1.27-1.45), and bone (OR: 1.23; 95% CI: 1.08-1.41) metastases. In age-stratified analyses, the risks for NHB patients persisted across groups, while lower risks for API patients were not observed in the 20-49 group. API patients aged 20-49 had a higher risk of de novo lung (OR: 1.31; 95% CI: 1.06-1.61) and bone (OR: 1.63; 95% CI: 1.13-2.37) metastases, and the increased risk of lung metastases for AI/AN patients was larger in magnitude (OR: 2.26; 95% CI: 1.39-3.68). Age 20-49 was more strongly associated with a liver-only pattern (OR: 1.14; 95% CI: 1.09-1.19) and with less common distant sites (OR: 1.33; 95% CI: 1.25-1.41). Conclusions: Racial/ethnic differences in de novo metastatic CRC patterns exist overall and across age groups. These findings are consistent with disparities in risk of stage IV CRC and can inform surveillance priorities in CRC survivors. Citation Format: Nicole C. Loroña, Mariana C. Stern, Stephanie L. Schmit, Jane C. Figueiredo. Racial and ethnic differences in site of de novo metastases in patients with colorectal cancer: A SEER analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6135.

Abstract 4791: Characterizing interventions to reduce disparities in lung-cancer screening uptake by state Medicaid expansion status: A scoping review

Abstract Background: Lung cancer is the leading cause of cancer-related deaths in the United States, and yet, lung cancer screening rates remain persistently low. Many interventions are being developed to address the low rates of lung cancer screening (LCS), including interventions that address the additional barriers faced by historically marginalized racial and ethnic populations as well as low-income and rural populations. However, the impact of Medicaid expansion on the types of interventions developed in non-expansion states and the efficacy of those interventions is not well understood. Methods: A research librarian conducted searches in MEDLINE via PubMed, Web of Science, and Embase. Results were screened and evaluated for eligibility by three reviewers in Covidence. Data was extracted from included studies after full-text review and analyzed using both a thematic analysis and a descriptive numerical summary of studies. The chosen framework was based on scoping review guidelines by Levac et al. and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). Results: Of 4696 studies found through the initial search, 53 met inclusion criteria. This includes 34 studies in Medicaid expansion states (M) and 17 studies in non-Medicaid expansion states (NM). Two additional studies compared interventions implemented in a Medicaid expansion state to a similar intervention implemented in a non-expansion state. Studies in both groups were primarily focused on addressing disparities by race and ethnicity (M=74%; NM=65%), with fewer studies focusing on rurality (M=9%; NM=12%), income (M=9%; NM=0%), or multiple disparities (M=9%; NM=24%). In non-expansion states, the most common interventions were patient navigation (29%) and community outreach (24%). While in Medicaid expansion states, the most common interventions were EHR algorithms (24%) and decision aids (21%). The intervention setting for both Medicaid expansion and non-expansion states were most commonly in a hospital/health system (M=53%; NM=47%) or community setting (M=24%; NM=47%). Interventions in both groups typically showed some improvement in uptake of LCS, though the degree of impact was variable between studies. Conclusion: Due to continued barriers to access posed by inadequate insurance coverage, there is a critical need for interventions to reduce disparities in lung cancer mortality in states that have not expanded Medicaid. Interventions focused on patient navigation and community outreach have been effective in multiple settings in these states and could fill that gap. Citation Format: Miranda J. Reid, Caretia Washington, Meghann Wheeler, Lauren Adkins, Dejana Braithwaite, Ramzi Salloum. Characterizing interventions to reduce disparities in lung-cancer screening uptake by state Medicaid expansion status: A scoping review [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4791.

Abstract 2162: Framework and pilot testing for the recruitment of a U.S.-based prospective cohort study of 100,000 Black women

Abstract Background: As of 2020, 46.9 million people in the United States (14.2% of the total population) identify as Black or African American. Collectively, Black Americans have the highest cancer death rate and shortest survival of any racial or ethnic group in the U.S. The drivers of cancer and other health conditions among Black women are likely multi-level, complex, and include contributions from environmental, behavioral, community, and system-level factors. Inadequate representation in research has limited the understanding of drivers of disparate outcomes, which, in turn, has hindered our ability to identify successful, culturally appropriate strategies for intervention. Approach: The American Cancer Society is establishing a cohort of at least 100,000 Black women to better understand cancer risk and outcomes in this population. The cohort will include two recruitment arms: (1) an “at risk” group of 85,000 participants between the ages of 25-55 years old with no prior cancer history and (2) a “survivorship” group of 15,000 participants previously diagnosed with breast, colorectal, or endometrial cancers. Pilot enrollment of the “at risk” group launched in October 2023 and will focus on understanding the disproportionate burden of early-onset cancer among Black women. For the “survivorship” group, pilot enrollment will launch in late 2024. The cancers of focus account for 95% of the absolute cancer mortality rate difference for Black vs. White women and offer the greatest opportunity for learning how to reduce cancer mortality disparities. Enrollment will focus on Black women who reside in the District of Columbia or one of 20 U.S. states representing &amp;gt;90% of the U.S. Black population. Results: Approximately 200 women were successfully consented into the cohort between October-November 2023. Study activities are conducted through an online portal optimized for mobile use. Through the portal, participants confirmed eligibility by completing an electronic survey, and reviewing and signing the informed consent. Upon consent, participants will complete a baseline survey and be sent follow-up surveys twice per year for at least 30 years. These surveys will track exposures, health outcomes, and participants’ lived experiences. Conclusions: Pilot work in 2023 demonstrated feasibility to engage Black women into a prospective cohort study. Based on the early feasibility success, full launch of enrollment is planned for May 2024. Citation Format: Alpa V. Patel, Lauren R. Teras, Elizabeth Kirkland, Jeshondria McCrary, Holly Vins, Jeuneviette E. Bontemps-Jones, Eunice Larbi, Maddison L. Hall, Peter J. Briggs, Daniela M. Dudas, Cari Lichtman, Lauren E. McCullough. Framework and pilot testing for the recruitment of a U.S.-based prospective cohort study of 100,000 Black women [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2162.

Rural-urban disparity in cancer burden and care: findings from an Indian cancer registry

BackgroundCancer incidence and mortality vary across the globe, with nearly two-thirds of cancer-related deaths occurring in low- and middle-income countries. The rural-urban disparity in socio-demographic, behavioural, and lifestyle-related factors, as well as in access to cancer care, is one of the contributing factors. Population-based cancer registries serve as a measure for understanding the burden of cancer. We aimed to evaluate the rural-urban disparity in cancer burden and care of patients registered by an Indian population-based cancer registry.MethodsThis study collected data from Varanasi, Uttar Pradesh, India, between 2017 and 2019. Sex and site-specific age-standardised rates for incidence and mortality per 100,000 population were calculated. Rural-urban disparities in cancer incidence and mortality were estimated through rate differences and standardised rate ratios (with 95% confidence intervals). Univariable and multivariable regressions were applied to determine any significant differences in socio-demographic and cancer-related variables according to place of residence (rural/urban). Crude and adjusted odds ratios with 95% confidence intervals were calculated.Results6721 cancer patients were registered during the study duration. Urban patients were older and had better literacy and socioeconomic levels, while rural patients had higher odds of having unskilled or semi-skilled professions. Diagnostic and clinical confirmation for cancer was significantly higher in urban patients, while verbal autopsy-based confirmation was higher in rural patients. Rural patients were more likely to receive palliative or alternative systems of medicine, and urban patients had higher chances of treatment completion. Significantly higher incidence and mortality were observed for oral cancer among urban men and for cervical cancer among rural women. Despite the higher incidence of breast cancer in urban women, significantly higher mortality was observed in rural women.ConclusionsLow- and middle-income countries are facing dual challenges for cancer control and prevention. Their urban populations experience unhealthy lifestyles, while their rural populations lack healthcare accessibility. The distinctness in cancer burden and pattern calls for a re-evaluation of cancer control strategies that are tailor-made with an understanding of urban-rural disparities. Context-specific interventional programmes targeting risk-factor modifications, cancer awareness, early detection, and accessibility to diagnosis and care are essential.

Burden of liver cancer mortality by county, race, and ethnicity in the USA, 2000–19: a systematic analysis of health disparities

Understanding how specific populations are affected by liver cancer is important for identifying priorities, policies, and interventions to mitigate health risks and reduce disparities. This study aims to provide comprehensive analysis of rates and trends in liver cancer mortality for different racial and ethnic populations in the USA nationally and at the county level from 2000 to 2019. We applied small-area estimation methods to death registration data from the US National Vital Statistics System and population data from the US National Center for Health Statistics to estimate liver cancer mortality rates by county, racial and ethnic population, and year (2000-19) in the USA. Race and ethnicity were categorised as non-Latino and non-Hispanic American Indian or Alaska Native (AIAN), non-Latino and non-Hispanic Asian or Pacific Islander (Asian), non-Latino and non-Hispanic Black (Black), Latino or Hispanic (Latino), and non-Latino and non-Hispanic White (White). Estimates were adjusted using published misclassification ratios to correct for inaccuracies in race or ethnicity as recorded on death certificates, and then age-standardised. Mortality rate estimates are presented for all county and racial and ethnic population combinations with a mean annual population greater than 1000. Nationally, the age-standardised liver cancer mortality rate increased between the years 2000 (4·2 deaths per 100 000 population [95% uncertainty interval 4·1-4·3]) and 2016 (6·0 per 100 000 [5·9-6·1]), followed by a stabilisation in rates from 2016 to 2019 (6·1 per 100 000 [6·0-6·2]). Similar trends were observed across the AIAN, Black, Latino, and White populations, whereas the Asian population showed an overall decrease across the 20-year study period. Qualitatively similar trends were observed in most counties; however, the mortality rate and the rate of change varied substantially across counties, both within and across racial and ethnic populations. For the 2016-19 period, mortality continued to increase at a substantial rate in some counties even while it stabilised nationally. Nationally, the White population had the lowest mortality rate in all years, while the racial and ethnic population with the highest rate changed from the Asian population in 2000 to the AIAN population in 2019. Racial and ethnic disparities were substantial: in 2019, mortality was highest in the AIAN population (10·5 deaths per 100 000 [9·1-12·0]), notably lower for the Asian (7·5 per 100 000 [7·1-7·9]), Black (7·6 per 100 000 [7·3-7·8]), and Latino (7·7 per 100 000 [7·5-8·0]) populations, and lowest for the White population (5·5 [5·4-5·6]). These racial and ethnic disparities in mortality were prevalent throughout the country: in 2019, mortality was higher in minoritised racial and ethnic populations than in the White population living in the same county in 408 (87·7%) of 465 counties with unmasked estimates for the AIAN population, 604 (90·6%) of 667 counties for the Asian population, 1207 (81·2%) of 1486 counties for the Black population, and 1073 (73·0%) of 1469 counties for the Latino population. Although the plateau in liver cancer mortality rates in recent years is encouraging, mortality remains too high in many locations throughout the USA, particularly for minoritised racial and ethnic populations. Addressing population-specific risk factors and differences in access to quality health care is essential for decreasing the burden and disparities in liver cancer mortality across racial and ethnic populations and locations. US National Institutes of Health (Intramural Research Program, National Institute on Minority Health and Health Disparities; National Heart, Lung, and Blood Institute; Intramural Research Program, National Cancer Institute; National Institute on Aging; National Institute of Arthritis and Musculoskeletal and Skin Diseases; Office of Disease Prevention; and Office of Behavioral and Social Sciences Research).

Disparities in prostate cancer mortality and clinical trial availability across vulnerable populations.

24 Background: Clinical trials provide high-level evidence and test novel therapies that have significantly improved cancer outcomes. However, disparities in clinical trial participation and cancer mortality persist across race/ethnicity and vulnerable populations, notably in patients with prostate cancer (PCa). Adverse social determinants of health (SDOH) and systemic barriers may underlie these disparities. Identifying and overcoming these barriers may improve access to and representation in clinical trials, thereby promoting equitable advancement and applicability of science. For these reasons, we evaluate the association between clinical trial availability, cancer mortality, and population-level SDOH in PCa. Methods: Using custom data linkage from ClinicalTrials.gov, Surveillance Epidemiology and End Results (SEER) Registry, and the Centers for Disease Control and Prevention Social Vulnerability Index (SVI), we performed a cross-sectional analysis of county-level PCa clinical trial data, cancer incidence and mortality rates, and population-level SDOH. We included Phase 2 and Phase 3 interventional PCa clinical trials with start dates from 2007 to 2022. The total number of clinical trials over the study period was calculated per county and population-adjusted for 100,000 residents. Counties were stratified into quintiles based on SVI (i.e., least vulnerable to most vulnerable). Population-adjusted clinical trial availability, cancer incidence, and cancer mortality were compared across SVI quintiles. Multivariable logistic and linear regression analyses were performed to evaluate the association between SVI and clinical trial availability and cancer mortality, respectively. Results: The mean number of PCa trials per 100,000 residents was 25.6, with the most vulnerable counties having fewer clinical trials compared to the least vulnerable counties (mean 18.1 vs. 50.0, p&lt;0.05). Further, the most vulnerable counties had a lower PCa incidence rate per 100,000 residents (mean 393.8 vs. 411.7, p&lt;0.05), but a higher PCa mortality rate per 100,000 residents (mean 85.7 vs. 72.0, p&lt;0.05). On multivariable regression analysis, the most vulnerable counties were associated with significantly decreased odds of having any PCa clinical trial (OR 0.3, 95% CI 0.2 – 0.4) and significantly increased PCa mortality (10.8, 95% CI 7.4 – 14.3), while the presence of any PCa clinical trial was associated with significantly decreased PCa mortality (-6.9, 95% CI -9.1 – -4.7). Conclusions: The most vulnerable counties were far less likely to have any PCa clinical trials despite having a significantly higher PCa mortality rate. The presence of a PCa clinical trial was associated with a reduction in PCa mortality. These vulnerable counties represent scientifically underserved populations that may benefit from equity-driven clinical trial enrollment and cancer care infrastructure expansion.

Gender, Racial, and Geographical Disparities in Malignant Brain Tumor Mortality in the USA

Introduction: Malignant brain tumors are malignancies which are known for their low survival rates. Despite advancements in treatments in the last decade, the disparities in malignant brain cancer mortality among the US population remain unclear. Methods: We analyzed death certificate data from the US CDC WONDER from 1999 to 2020 to determine the longitudinal trends of malignant brain tumor mortality. Malignant brain tumor (ICD-10 C71.0–71.9) was listed as the underlying cause of death. Age-adjusted mortality rates (AAMRs) per 100,000 individuals were calculated by standardizing the AAMR to the year 2000 US population. Results: From 1999 to 2020, there were 306,375 deaths due to malignant brain tumors. The AAMR decreased from 5.57 (95% CI, 5.47–5.67) per 100,000 individuals in 1999 to 5.40 (95% CI, 5.31–5.48) per 100,000 individuals in 2020, with an annual percent decrease of −0.05 (95% CI, −0.22, 0.12). Whites had the highest AAMR (6.05 [95% CI, 6.02–6.07] per 100,000 individuals), followed by Hispanics (3.70 [95% CI, 3.64–3.76]) per 100,000 individuals, blacks (3.09 [95% CI, 3.04–3.14] per 100,000 individuals), American Indians (2.82 [95% CI, 2.64–3.00] per 100,000 individuals), and Asians (2.44 [95% CI, 2.38–2.50] per 100,000 individuals). The highest AAMRs were reported in the Midwest region (5.58 [95% CI, 5.54–5.62] per 100,000 individuals) and the rural regions (5.66 [95% CI, 5.61–5.71] per 100,000 individuals). Conclusions: Our study highlights the mortality disparity among different races, geographic regions, and urbanization levels. The findings underscore the importance of addressing the disparities in malignant brain tumors that existed among males, white individuals, and rural populations.

Trends in Cancer Mortality Disparities Between Black and White Individuals in the US, 2000-2020

This cross-sectional study compares trends in estimated age-adjusted cancer mortality rates between non-Hispanic Black and non-Hispanic White individuals in the US from 2000 to 2020.

The Association of Oncology Provider Density With Black-White Disparities in Cancer Mortality in US Counties.

Black-White racial disparities in cancer mortality are well-documented in the US. Given the estimated shortage of oncologists over the next decade, understanding how access to oncology care might influence cancer disparities is of considerable importance. We aim to examine the association between oncology provider density in a county and Black-White cancer mortality disparities. An ecological study of 1048 US counties was performed. Oncology provider density was estimated using the 2013 National Plan and Provider Enumeration System data. Black:White cancer mortality ratio was calculated using 2014-2018 age-standardized cancer mortality rates from State Cancer Profiles. Linear regression with covariate adjustment was constructed to assess the association of provider density with (1) Black:White cancer mortality ratio, and (2) cancer mortality rates overall, and separately among Black and White persons. The mean Black:White cancer mortality ratio was 1.12, indicating that cancer mortality rate among Black persons was on average 12% higher than that among White persons. Oncology provider density was significantly associated with greater cancer mortality disparities: every 5 additional oncology providers per 100000 in a county was associated with a .02 increase in the Black:White cancer mortality ratio (95% CI: .007 to .03); however, the unexpected finding may be explained by further analysis showing that the relationship between oncology provider density and cancer mortality was different by race group. Every 5 additional oncologists per 100000 was associated with a 1.6 decrease per 100000 in cancer mortality rates among White persons (95% CI: -3.0 to -.2), whereas oncology provider density was not associated with cancer mortality among Black persons. Greater oncology provider density was associated with significantly lower cancer mortality among White persons, but not among Black persons. Higher oncology provider density alone may not resolve cancer mortality disparities, thus attention to ensuring equitable care is critical.

Structural Racism as a Contributor to Lung Cancer Incidence and Mortality Rates Among Black Populations in the United States.

Although racial disparities in lung cancer incidence and mortality have diminished in recent years, lung cancer remains the second most diagnosed cancer among US Black populations. Many factors contributing to disparities in lung cancer are rooted in structural racism. To quantify this relationship, we examined associations between a multidimensional measure of county-level structural racism and county lung cancer incidence and mortality rates among Black populations, while accounting for county levels of environmental quality. We merged 2016-2020 data from the United States Cancer Statistics Data Visualization Tool, a pre-existing county-level structural racism index, the Environmental Protection Agency's 2006-2010 Environmental Quality Index (EQI), 2023 County Health Rankings, and the 2021 United States Census American Community Survey. We conducted multivariable linear regressions to examine associations between county-level structural racism and county-level lung cancer incidence and mortality rates. Among Black males and females, each standard deviation increase in county-level structural racism score was associated with an increase in county-level lung cancer incidence of 6.4 (95% CI: 4.4, 8.5) cases per 100,000 and an increase of 3.3 (95% CI: 2.0, 4.6) lung cancer deaths per 100,000. When examining these associations stratified by sex, larger associations between structural racism and lung cancer rates were observed among Black male populations than among Black females. Structural racism contributes to both the number of new lung cancer cases and the number of deaths caused by lung cancer among Black populations. Those aiming to reduce lung cancer cases and deaths should consider addressing racism as a root-cause.

Late-Stage Oral Cancer Detection After California and Illinois Restored Medicaid Dental Benefits.

Previous research found an association between California's Medicaid dental coverage and oral cancer detection. However, this relationship has yet to be explored in other states or by subgroup populations. In addition to controlling for sociodemographic and tumor characteristics, this study implemented a traditional difference-in-differences design to compare distant-stage diagnosis trends in states restoring Medicaid dental benefits (California [CA] and Illinois [IL]) with trends in states with constant Medicaid dental benefits. This retrospective, observational study analyzed oral cavity and pharynx cancer case data from The Surveillance, Epidemiology, and End Results program (2004-2017). The outcome was a binary variable indicating whether a patient was diagnosed at a distant stage. Subgroup analyses were conducted by state, race/ethnic group, sex, age, and county-level household income. The sample included 109,997 adults diagnosed with cancer of the oral cavity and pharynx. Restoring Medicaid dental benefits was associated with a statistically significant 2.7%-point decline in the probability of a distant-stage oral cancer diagnosis. This estimate represented a 14% relative change from baseline rates. Results were consistent for CA and IL and by county-level median income. Estimates were significantly larger for adults under age 65, males, and adults identifying as Hispanic; non-Hispanic Black; American Indian; or Asian American or Pacific Islander. Restoring Medicaid dental coverage improved early detection in both CA and IL, with the greatest reductions in distant-stage diagnoses occurring in younger adults, males, and minoritized racial/ethnic groups. Future research should investigate whether earlier detection reduces oral cancer mortality disparities.