Disparities In Screening Research Articles

Breast Cancer Incidence Among Asian American Women in New York City: Disparities in Screening and Presentation.

Asian American (AsAm) women have some of the lowest rates of up-to-date breast cancer screening, and lack of disaggregated racial/ethnic data can mask disparities. We evaluated presentation patterns among AsAms at two hospitals with distinct communities: New York Presbyterian-Queens (NYPQ), in Flushing, Queens and Weill Cornell Medical Center (WCM), on the Upper East Side (UES) neighborhood of Manhattan. Patients with newly diagnosed breast cancer between January 2019 and December 2022 were identified using a prospective database and clinical data collected. Patients were categorized as self-reported Asian versus Non-Asian. The Asian group was disaggregated as Chinese-Asian versus Other-Asian. Physician workforce data were obtained from public records. A total of 3546 patients (1162 NYPQ, 2384 WCM) were included. More NYPQ patients identified as Asian compared with WCM (49 vs. 14%, p < 0.001). Asian patients were mostly East Asian Chinese (NYPQ 61%, WCM 53%). More Chinese patients at NYPQ reported Chinese as their preferred language (81 vs. 33%, p < 0.001). Greatest differences of screen-detected disease frequency were seen between NYPQ and WCM Chinese patients (75 vs. 59%, p < 0.001). Eighty percent of NYPQ Chinese patients presented with stage 0/I disease versus 69% at WCM (p = 0.007), a difference not observed between Other-Asian patients (75% NYPQ, 68% WCM, p = 0.095). 3% of UES physicians versus 16% in Flushing reported speaking Chinese. Chinese patients residing in a neighborhood with more Chinese-speaking physicians more frequently presented with screen-detected, early-stage breast cancer. Stage distribution differences were not apparent among the aggregated pool of Other-Asian patients, suggesting cancer disparities may be masked when ethnic groups are studied in aggregate.

Development of a Digital Storytelling Intervention to Increase Breast, Cervical, and Colorectal Cancer Screening in the Hispanic/Latino Community: a Qualitative Evaluation.

Digital storytelling (DST) interventions may be one way to address disparities in cancer screening experienced by the Hispanic/Latino population. Digital stories are short, first-person narratives that include voice-over narration and images. With storytellers' permission, researchers can screen digital stories as a health intervention. Digital stories can inspire viewers to adopt or change their behavior, such as completing cancer screening. Rochester Healthy Community Partnership (a 20-year community-based participatory research partnership) together with eight Hispanic/Latino, Spanish speaking cancer survivors, co-survivors, or recently screened individuals, developed digital stories about breast, cervical, and colorectal cancer screening. Here, we describe our qualitative evaluation of the DST workshop. To understand what the storytellers thought viewers would find relatable in their digital stories, we applied Narrative Theory. We also assessed workshop successes and opportunities for improvement. We used the constant comparative method for data analysis. We learned that the storytellers anticipated their stories would be engaging and that viewers would connect with Hispanic/Latino cultural values. During the workshop, the storytellers felt like they were making an important contribution. The storytellers highlighted specific opportunities for improvement including sharing the stories more quickly after the workshop. Future research is needed to test whether this intervention follows the Narrative Theory causal pathway by persuading viewers to complete recommended cancer screenings.

Abstract C131: Disparities in breast cancer screening resumption among health plan enrollees in the US following the COVID-19 pandemic: Are all groups back on track?

Abstract Purpose: The COVID-19 pandemic disproportionately impacted racial/ethnic minority and low-income individuals and resulted in significant disruptions in preventive care for all groups. While severe declines in routine cancer screening were observed during pandemic shutdown periods, it is unclear whether return-to-screening rates following healthcare reopening are consistent across all groups. In this study we examine rates of breast cancer screening pre- and post- pandemic shutdown periods across race/ethnicity, age, and income among health plan enrollees in the United States (US) to inform screening catch-up strategies after COVID-19 disruptions. Methods: We conducted a retrospective analysis of breast cancer screening claims (including codes for mammography, breast MRI, digital breast tomography, and breast imaging) from Optum Clinformatics Data Mart among female enrollees from 2019-2021. Eligible enrollees included women, ages 40-75 with continuous enrollment 12 months prior to screening index month. Screening volume was calculated each calendar month during the three-year period, with January 2019-February 2020 as the pre-pandemic period, March 2020 through June 2020 as the pandemic closure period, and July 2020-December 2021 as the post-closure (reopening) pandemic period. We conducted an event study to calculate group-level monthly predicted probabilities of screening using a linear probability model with group interactions by month, controlling for demographic variables and comorbidities. Additionally, we used difference-in-difference (DD) regressions including group interacted with a post-closure pandemic dummy. The pandemic closure period months were excluded from our DD analysis. Results: Our study included 8,378,296 health plan enrolled women. Overall mammography screening decreased significantly during the pandemic closure phase (March-June 2020) but rebounded to higher levels in the post-closure period relative to baseline (3.76% to 3.96%). Screening rates were highest among non-Hispanic White women in the pre-pandemic period compared to other racial-ethnic groups. Our DD model suggests that White-Asian disparities increased in the post-pandemic period while other race/ethnic disparities remained constant. Additionally, disparities in screening by age changed during the pandemic. Although the oldest age group (65-75) had the highest screening rates in the pre-closure phase, they were slower to return to pre-pandemic levels of screening compared to younger age groups. Implications: Return to breast cancer screening among health plan enrollees in the US was robust. However, disparities in screening rates between groups in the pre-pandemic period were again observed in the reopening period, signaling lost opportunities to revamp structural inequities in care delivery following the pandemic. Further monitoring of return-to-screening disparities, particularly among more medically underserved groups, will be critical in informing interventions to address the long-term consequences resulting from the disruption of COVID-19 on cancer care. Citation Format: Jennifer Tsui, Sarah Axeen, John Thacker, Sonali Saluja, Laura Solano, Willow Pastard, Chun Nok Lam, Todd Schneberk, Cameron Kaplan. Disparities in breast cancer screening resumption among health plan enrollees in the US following the COVID-19 pandemic: Are all groups back on track? [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C131.

Abstract C112: Improving breast cancer screening disparities through A3 problem solving: Design of a quality improvement initiative

Abstract Introduction: Extensive research studies on breast cancer disparities have had limited impact on reducing breast cancer disparities. Quality improvement initiatives use data-driven, rigorous approaches to plan, execute, and study the delivery of healthcare services. There have been limited studies using quality improvement methods to address health disparities. The purpose of our study was to describe the design of a quality improvement initiative to address breast cancer disparities using the A3 problem solving method. Methods: A3 problem solving method was used to reduce breast cancer screening disparities. The A3 method is a quality improvement tool used to identify problems, organize and synthesize data, and propose solutions to achieve goals (summarized on one side of a sheet of paper). A3 methods are outlined by the FOCUS-PDCA acronym: F - Find process to improve, O - Organize team of stakeholders, C - Clarify current state, U - Understand sources of variation that contribute to the problem, S - Select change ideas, P - Plan and do the improvement, C - Check the results, A - Act. Quantitative data was derived from the electronic medical record. Qualitative data was derived from divergent thinking exercises asking participants from diverse standing urban stakeholder groups about barriers to cancer screening. Results: Design of the A3 problem solving process was conducted between November 2022 until May 2023 yielding the following FOCUS-PDCA design and initial results. F - Increase the percentage of patients who have undergone mammography screening within the last two years. O - Team includes representative leaders from primary care, community health, ambulatory operations, diversity, equity, and inclusion, radiology, breast center, population health, information services, and federally qualified health centers. C and U - Quantitative data collection revealed that 74% of 37,509 eligible patients (women between 50-74 years old) received a mammogram within the last two years (75% White, 58% Black, 67% Asian, 60% American Indian, 64% Hispanic). Divergent thinking exercises revealed the following root causes for mammography screening disparities: patients don’t know they are due, transportation issues, barriers to scheduling, access to mammography facilities, financial concerns, and fears about returning to clinics during COVID-19. S - Process improvements included multilingual and modality reminders, marketing campaigns, transportation vouchers, co-location of screening centers with federally qualified health centers, expanded access to mammography screening facilities, educational activities for primary care physicians, participation in community events, equity-focused review of screening guidelines. PDCA - Based on selected improvements, changes in breast cancer screening percentages will be displayed using run charts until December 2024, stratified by race and ethnicity. Conclusion: A3 problem solving tools represent structured, scientifically rigorous approaches that cancer centers can use to reduce screening disparities. Citation Format: Nia Foster, Arissa J. Milton, Mai A. Elezaby, Roberta M. Strigel, Meeghan A. Lautner, Ryan W. Woods, Nicci O. Brackett, Noelle K. LoConte, Anand K. Narayan. Improving breast cancer screening disparities through A3 problem solving: Design of a quality improvement initiative [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C112.

Abstract B053: Rural-urban disparities in cancer risk factors and screening by United States census region

Abstract We examined rural-urban differences in the prevalence of cancer risk factors and screening behaviors across U.S. census regions to better understand variations within and between geographic regions and inform strategies to address rural cancer inequities. Using an ecological cross-sectional design, we examined rural-urban differences in the self-reported prevalence of county-level cancer risk factors (i.e., obesity, physical inactivity, alcohol consumption) and cancer screening behaviors (i.e., breast, colorectal and cervical) ascertained from the Behavioral Risk Factor Surveillance System and National Health Interview Survey (2008-2013) across four U.S. census regions (Northeast, Midwest, South, and West). County-level rurality was defined using 2013 U.S. Office of Management and Budget rural-urban classification codes, and the U.S. Department of Agriculture, Economic Research Service’s rural-urban continuum codes. Chi-square tests assessed differences in the mean prevalence of county-level cancer risk factors and cancer screening behaviors in each geographic region. Analysis of variance (ANOVA) models estimated the p-values for trends in cancer risk factors and screening prevalence across the rural-urban continuum. Within each geographic region, rural counties had a higher prevalence of smoking, obesity and physical inactivity. Yet, rural-urban differences in cancer risk factors were not statistically significant in all geographic regions (e.g., prevalence of obesity for Western rural vs. urban counties was 26.5% vs. 25.7% [p=0.08] and physical inactivity for Northeastern rural vs. urban counties was 23.2% vs. 22.5% [p=0.15]). Moreover, the mean prevalence of obesity was higher in urban areas of the Midwest (31%) and South (31.3%) compared to rural areas in the West (26.5%) and Northeast (29.5%). Binge alcohol use was higher in rural vs. urban counties in the West (19.8% vs. 17.7%; p&amp;lt;0.001) and Midwest (22.3% vs. 21.5%; p=0.006), but lower in the South (13.5% vs. 15.2%; p&amp;lt;0.001). Obesity and smoking prevalence increased with increasing rurality across all regions (ptrend&amp;lt;0.045). Breast, cervical and colorectal cancer screening prevalence were lower in rural vs. urban counties in each geographic region (all p-values&amp;lt;0.04). However, the overall prevalence of screening across all cancer sites was higher in rural Northeast counties compared to both rural and urban counties in the South and West regions. Across all regions, cervical and breast cancer screening decreased with increasing rurality (all ptrend&amp;lt;0.001). A significant inverse trend in prevalence of colorectal cancer screening with increasing rurality was observed in all regions except the Northeast (ptrend=0.17). Our findings suggest notable variations in rural-urban cancer risk factors and screening disparities across U.S. geographic regions. Further exploration of the source of this geographic variation is warranted to ensure the development and implementation of relevant cancer control interventions targeting rural populations most in need. Citation Format: Kelly A. Hirko, Huiwen Xu, Laura Q. Rogers, Michelle Y. Martin, Siddhartha Roy, Kimberly M. Kelly, Shannon M. Christy, Kimlin Tam Ashing, Jean C. Yi, Marquita W. Lewis-Thames, Cathy D. Meade, Qian Lu, Clement K. Gwede, Rachel M. Ceballos, Usha Menon, Katie Cueva, Karen Yeary, Lisa Klesges, Monica L. Baskin, Kassandra I. Alcaraz, Sabrina Ford. Rural-urban disparities in cancer risk factors and screening by United States census region [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B053.

Abstract C111: Do electronic health records assist providers to provide equitable referral for breast and cervical cancer screening between black and white women?

Abstract Background: Breast and Cervical Cancer screening (BCS and CCS) are essential tools to prevent cancer. Yet, non-Hispanic Black (NHB) women die at a much higher rate from Breast and Cervical cancer than non-Hispanic White (NHW) women. Thus, it is important that providers recommend BCS (Mammogram) and CCS (Pap test), equitably, for maximum cancer prevention. Meaningful Use (MU), as part of the HITECH Act, incentivized providers to utilize electronic health records (EHR) not only for billing, but to increase the quality of patient care. MU also included an aim to reduce health disparities using EHR. The intent of this study was to evaluate BCS and CCS rates before and after the advent of MU to examine potential cancer screening disparities between NHW and NHB. It is imperative that cancer screenings are recommended, equally, to address grave disparities for NHB cancer mortality. Methods: Using a pre-post design, we examined BCS and CCS rates before the enactment of MU (2013) in a Medicaid population and after MU implementation for years 2014-2016. Medicaid data were extracted from the Michigan Department of Health &amp; Human Services data warehouse for Medicaid enrollees. Inclusion criteria were physicians who were continually enrolled in MU from 2014-2016 who saw women of BCS and CCS screening age. Odds Ratios were used to examine differences in screening rates over time between Black and White women. Results: For BCS, no differences were detected between NHW and NHB women, although a trend was observed for post-MU for 2015 (OR = 1.167, 95% CI [0.876, 1.580]). Analyses of CCS rates post-MU showed differences (p&amp;lt;0.01) between NHW and NHB for 2014 (OR = 1.211, 95% CI [1.079, 1.377] and 2015 (OR = 1.141, 95% CI [1.029, 1.266], respectively. Regression analyses from 2013 to 2016 showed differences between NHW and NHB women for both BCS and CCS over time with NHW and NHB screening rates converging in 2016 (p&amp;lt;0.05). Conclusion: We did not find any discernable differences in BCS between NHW and NHB women after providers subscribed to MU. CCS screening rates for NHB were higher than NHW in 2014-2015, but not in 2016. However, changes in BCS and CCS rates were significant by year and over time. For both BCS and CCS, rates converged over time for both NHW and NHB reducing screening disparities, but screening rates decreased over time. This decrease over time was attributable to changes in screening recommendations for both BCS and CCS (ACOG, ACS, CDC). Notably, the guidelines changed from yearly CCS to every three years for women at low-risk for cervical cancer. Further analyses are warranted to adjust for the change in screening guidelines. These findings are complex and will be fully discussed to discern screening differences between NHW and NHB women, and use of EHR as a tool to reduce health disparities. Citation Format: Sabrina Ford, Laura Houdeshell-Putt, Molly Polverento, Kevin Brooks. Do electronic health records assist providers to provide equitable referral for breast and cervical cancer screening between black and white women? [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C111.

Abstract C117: Implementing on overdue colorectal cancer (CRC) screening in the Federally Qualified Health Center (FQHC) primary care setting: 12-month post intervention results

Abstract PURPOSE: We partnered with the largest FQHC in New Haven, CT to address overdue colorectal cancer screening with evidence-based interventions (EBI). We report on the 12-month follow up of a cohort of 3,127 patients overdue for CRC screening who received 1 or more evidence based interventions (EBIs) in October, 2021. BACKGROUND: Sociocultural and medical concerns are barriers to colonoscopy uptake contributing to disparities in CRC screening. An additional barrier is system level capacity. COVID-19 associated delays exacerbated the existing backlog of individuals overdue for CRC screening, underscoring the need to expand Fecal Immunochemical Testing (FIT) screening capacity. At the time of the study, colonoscopy was the front-line cancer screening strategy in this and other primary care settings in this region. METHODS: We tested the unique and additive value of multiple EBIs for increasing CRC screening in this low-income urban population. The EBIs included: medical reminder to all recipients (Arms 1-4), supplemented with information to address social determinants of health [SDOH]) barriers (Arm 2), offer of assistance from trained community health workers (CHW) to address SDOH barriers (Arm 3), and offer of educational intervention (video and pre- and post- survey) (Arm 4). Twelve-month outcomes include: 1) CRC screening test ordered; 2) CRC screening completed. RESULTS: Of the 3,127 randomized patients, ages 50-75, 77% were Hispanic (33%) or Black (44%). At 12 months post-intervention, 1,692 (54.1%) of the cohort received an order for CRC screening, and 541 (17.3%) of the cohort completed screening. With no path to CRC screening other than a provider order, among patients for whom CRC screening was ordered, nearly one-third (32%) completed screening within 12 months of the intervention. There were no differences in either outcome based on intervention Arm. DISCUSSION: Among the 3,127 individuals who were due or overdue for screening at the time of intervention, only 9 had documented CRC cancer screening in the 5 years before randomization. The promotion of stool-based testing may have brought individuals into CRC screening. There were no differences in CRC screening (colonoscopy or FIT) orders or completed tests across the 4 arms of the study, suggesting that the provider endorsed mailed screening reminder with information on in-home, stool-based testing option (FIT), and notice that CRC screening is now recommended beginning at age 45 was key to behavior change. Provider engagement and post-pandemic care-seeking on part of patients, as well as increased awareness of CRC screening following the death of high-profile actor at age 43 likely contributed to increased uptake of CRC screening. SUMMARY: A mailed reminder is a cost effective, scalable intervention that may be effective in safety net primary care settings that serve high-risk individuals. Closing the screening gap in CRC screening should include educating patients about their CRC screening options as well as the change in recommended age to begin CRC screening. Citation Format: Beth A. Jones, Sakinah C. Suttiratana, Sarah A. DeGiovanni, Levita Robinson, Michael Couturie, Steven J. Parra, Louie M. Gangcuangco, Laney Zhang, Denise Stevens, Margarita Vargas-Torres. Implementing on overdue colorectal cancer (CRC) screening in the Federally Qualified Health Center (FQHC) primary care setting: 12-month post intervention results [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C117.

Abstract C129: Impact of COVID-19 on colorectal cancer screening disparities: Results from a large commercially insured population in the United States

Abstract Background: Although colorectal cancer (CRC) screening reduces both CRC incidence and CRC-related mortality, it is underutilized, especially among those with lower socioeconomic status (SES) and in racial and ethnic minoritized populations who have been disproportionately impacted by COVID-19. The shift in healthcare priorities to contain and mitigate COVID-19 over the last few years reduced clinical capacity for non-urgent care, including CRC screening. This study aimed to assess the impact of COVID-19 on disparities in CRC screening. Methods: Blue Cross Blue Shield (BCBS) insures approximately one third of Americans. We leveraged BCBS Axis data to examine temporal patterns in CRC screening among individuals aged 45-75 years during 2017-2021, focusing on three periods: 1) first wave of COVID-19 outbreak (Mar-Apr 2020); 2) second wave of COVID-19 outbreak (i.e., the Delta variant, Jan-Feb 2021); and 3) the most recent 2-month interval for which data are available (Nov-Dec 2021). Both invasive and non-invasive CRC screening procedures were identified, and beneficiaries who received screening one year before were excluded. Screening rates within each 2-month interval were calculated. Neighborhood SES was assessed by Social Deprivation Index at the zip code level and categorized into quintiles. Results: The study cohort included 27,628,570 individuals. Throughout the 5-year period, except for the 1st wave of COVID-19 outbreak, screening rates were higher in areas with higher SES. Prior to the pandemic (Jan 2017–Feb 2020), the average bimonthly screening rate in areas with the highest SES was 2.1%, compared to 1.7% in areas with the lowest SES (p &amp;lt;0.001). During the 1st wave of COVID-19 outbreak, screening rate decreased to approximately 0.8% across all SES quintiles. During the 2nd wave of COVID-19 outbreak, screening rates were 1.7% and 1.3% in the highest and lowest SES areas, respectively. For the last 2-month interval in our study period (Nov-Dec 2021), screening rates increased to 2.4% and 1.8% in areas with the highest and lowest SES, respectively. Among 9,565,516 beneficiaries with known race and ethnicity, 8.0%, 11.0%, 3.3% and 0.4% were non-Hispanic Black, Hispanic/Latino, Asian, and Native Americans/Pacific Islanders, respectively. Across all racial and ethnic groups, the average bimonthly screening rate was 1.9% prior to the pandemic, 0.7% in Mar-Apr 2020, 1.5% in Jan-Feb 2021, and 2.1% in Nov-Dec 2021. Conclusion: After the onset of COVID-19, CRC screening rate decreased broadly and reached a similar level in all SES groups in early 2020, but it then recovered at a different pace for individuals with different SES, maintaining and even exacerbating inequities that existed prior to the pandemic. Screening patterns were comparable across different racial and ethnic groups who were privately insured through BCBS. Findings from this very large study may help inform interventions to address social and structural determinants of health and reduce the disproportionate burden of CRC in individuals residing in socially deprived areas. Citation Format: Arfan Siddique, Rong Wang, Jacquelyne Gaddy, Cary Gross, Xiaomei Ma. Impact of COVID-19 on colorectal cancer screening disparities: Results from a large commercially insured population in the United States [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C129.

Abstract C134: Efficacy of mobile mammography and state-funded cancer services in reducing disparities in follow-up adherence: A retrospective analysis

Abstract Objective: Mobile mammography programs, such as the one at Stony Brook Cancer Center (SBCC), play an important role in providing breast cancer screening services to underserved communities. Follow-up to abnormal mammogram screenings is critical for early cancer detection, but patients often encounter barriers that prevent timely diagnostic procedures. We aim to evaluate the role of New York State’s Cancer Services Program (CSP) in facilitating follow-up care among underserved patients who participated in SBCC’s mobile mammography initiative. Methods: We conducted a retrospective analysis of 817 mobile mammography patients who required additional testing following an abnormal mammogram over a five-year period. Of these, 68% were beneficiaries of the CSP, while 32% were insured. Results: Our findings revealed that among CSP beneficiaries, only 3.5% were lost to follow-up, compared to a significant 16.5% of insured patients who did not adhere to recommended follow-up care. This suggests that the CSP’s supportive role is critical in ensuring follow-up care among underserved communities. Conclusions: The CSP’s substantial impact on follow-up care adherence highlights the program's effectiveness in reducing healthcare disparities. However, more work is needed to enhance follow-up care adherence among insured patients. Solutions may include identifying and addressing barriers to care and implementing targeted interventions to improve patient outcomes. Implications for Policy or Practice: Mobile mammography programs, such as SBCC’s initiative, demonstrate a potential strategy for reducing health disparities in breast cancer screening and detection. Securing access to follow-up care is crucial for improving patient outcomes. Addressing barriers to care, strengthening patient education, and enhancing outreach efforts can increase participation in screening initiatives, thus advancing health equity and reducing disparities in breast cancer outcomes. Citation Format: Patrick J. Dineen, Mollie M. Williams. Efficacy of mobile mammography and state-funded cancer services in reducing disparities in follow-up adherence: A retrospective analysis [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C134.

Exploring Disparities in Breast Cancer Screening: An Ecological Analysis of Australian Data.

The objective of this study is to analyse the socio-spatial patterns of breast cancer screening across Australian regions. The research is an ecological study. Data for breast screening participation and associated social and demographic factors are obtained from the Australian Institute of Health and Welfare and the Australian Bureau of Statistics. The unit of measurement for the analysis is spatially aggregated regions (Statistical Area 3). Geographically weighted regression is used to analyse the relationship between a dependent variable and one or more independent variables while considering the spatial or geographic relationships among the data points. Globally, there was a significant (p<0.05) association between screening participation and income, English ability, education level, Indigenous background, and transport availability. The geographically weighted regression model represented an improved fit with a higher R2 (R2=0.89) and the Akaike information criterion (AIC) has improved, (AIC= 391.92). The Monte-Carlo tests for spatial variability were significant for all independent variables (p<0.05). Visually, there was marked spatial variation in the association between breast cancer screening rates and the significant independent variables from the global model. The identification of significant spatial variability in the association between breast cancer screening participation and important social and demographic factors provides important input into the design of programs aimed at increasing participation in screening regimes.

Abstract C132: Multilevel facilitators and barriers to cancer screening programs in federally qualified health centers serving Asian American communities

Abstract Purpose: Cancer screening disparities among medically underserved Asian Americans are well documented. Assessing multilevel barriers and facilitators to cancer screening programs within safety-net settings is critical to the implementation of evidence-based strategies to improve cancer screening. This study aims to examine how community and clinic driven priorities and activities can inform multilevel processes for planning of cancer screening programs for Asian American patients within FQHCs. Methods: Academic, clinic and community partners established the Advancing Care Together (ACCT) formal network to increase knowledge, attitudes and screening behaviors among low-income Chinese, Korean and Vietnamese individuals in Orange County, California. ACCT focused on breast, cervical, and colorectal. Over three years, a series of meetings, surveys and interviews were conducted with community and clinic partners before implementing evidence-based strategies (community navigation, educational workshops) to increase cancer screening to address cultural and language barriers. We used the Implementation Research Logic Model to guide our analysis of these data and identify multilevel determinants of cancer screening with input provided by the ACCT network. Using a shared drive to gather formative data, we assembled a codebook in Excel to organize AACT activities and identify barriers and facilitators according to the Consolidated Framework for Implementation Research (CFIR). Results: Our study found barriers and facilitators that represent CFIR domains: i) Community-clinic resources can provide increased awareness of screening services (intervention characteristics); ii) patients had difficulty obtaining a provider with their preferred language (inner setting); iii) transportation issues and cultural stigma around receiving specific cancer education (outer setting); iv) clinic and patient outcomes improved as a result of ACCT activities, payers were unable to establish referrals from federally qualified health centers to comprehensive cancer centers (characteristics of individuals involved in the implementation); and v) staff turnover presented challenges to obtaining electronic medical records to evaluate screening and follow-up services (implementation process). Implications: Community-clinic-academic partnerships can facilitate increasing cancer screening and awareness, including cultural screening barriers and identification of adaptation needs for educational materials, specific to Asian American communities. Barriers identified in the cancer screening process included a lack of motivation to resolve payer-related provider networks to address patient accessibility to specialty care, high turnover among clinic quality improvement teams, and challenges of prioritizing cancer screening throughout the COVID19 pandemic. Successful implementation of evidence-based strategies to increase guideline-adherent care for Asian Americans must overcome longstanding clinic- and community-level barriers, and we believe community-clinic-academic partners hold the key. Citation Format: Samantha Garcia, Sora Tanjasiri, Cevadne Lee, Jaqueline Train, Jennifer Tsui. Multilevel facilitators and barriers to cancer screening programs in federally qualified health centers serving Asian American communities [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C132.

Applications of implementation science frameworks, models and theories in disparities-focused cancer screening interventions: a scoping review protocol

BackgroundImplementation science (IS) frameworks, models and theories (FMTs) have gained popularity in guiding the implementation and evaluation of evidence-based interventions (EBIs) for cancer screening. However, there are significant research gaps...

Abstract A139: Examining the association of cardiovascular health attainment with cancer screening adherence in community-dwelling Black women

Abstract Purpose of the study Cancer and cardiovascular disease are leading causes of death in the United States and share modifiable risk factors. Increasing ideal cardiovascular health indicated by the American Heart Association’s Life’s Simple 7 metrics (LS7: blood pressure, glucose, cholesterol, body mass index, physical activity, and smoking) and cancer screening adherence are both associated with reducing cancer-related mortality. However, there have been no studies to identify associations between LS7 and cancer screening adherence. It is well documented that people adopting positive health behaviors like physical activity and healthy eating have higher cancer screening adherence. Unfortunately, disparities by race exist in both engagement in health behaviors (key metrics of LS7) and cancer screening. Cancer screening disparities between Black and White women have narrowed over time; however, there are disparities in LS7 attainment by race. Here, we examined the association of LS7 attainment with screen detectable cancer (breast, cervical, and colorectal) adherence in Black women. Methods The Partnering in Negating Statistics (P.I.N.S.) for Black Women Initiative promotes health and wellness among Black women. Its community wellness events provide health education, screenings (e.g., breast, cervical, and cardiovascular health), and research participation opportunities. At P.I.N.S. events, LS7 metrics (score range 0-14) and self-reported cancer screening history were collected. The associations of LS7 with cancer screening adherence were examined using multinomial logistic regression adjusting for age, income, and education. Results In 2021 and 2022, 296 Black women participated in cardiovascular health screenings. They had a mean age of 50.1 years (SD 14.1); 66% employed; 88% insured; 69% with educational attainment ≥ college. The 166 participants with complete LS7 data had intermediate cardiovascular health with a median score of 8 [7-10]. In age adjusted models, a 1-unit increase in LS7 attainment was associated with a 45% higher odds of breast cancer screening adherence (OR 1.45, 95%CI: 1.03, 2.05; n=93), which was similar with full adjustment (OR 1.50, 95% CI: 0.95, 2.39; n=91). There was no association of LS7 attainment with cervical (OR 1.09, p=0.40; n=124) or colorectal cancer (OR 1.05, p=0.70; n=84) screening adherence. Conclusions In community-dwelling Black women, increasing LS7 attainment may increase odds of breast cancer screening adherence. Research with a larger sample is needed. Citation Format: Timiya S. Nolan, Songzhu Zhao, Amaris Williams, Guy Brock, Stephanie S. Ogonuwe, Faith Metlock, Alicia McKoy, Loletia Davis, Aldenise P. Ewing, Karen Patricia Williams, Electra D. Paskett, Joshua J. Joseph. Examining the association of cardiovascular health attainment with cancer screening adherence in community-dwelling Black women [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A139.

Community-engaged Research Disruption: The Impact of the COVID-19 Pandemic on Research With Communities

Abstract: Background: The pandemic has had dire consequences on community-engaged research. Objectives: We describe research challenges imposed by the pandemic on our breast and cervical cancer intervention study with Southeast Asian immigrant women, and strategies used to maintain study continuity. Methods: The pandemic's impact on the research team, recruitment and retention of participants, study design, and strategies executed to these issues are described. Results: Strategies employed to address research challenges include implementing coronavirus disease 2019 protocols for conducting community research; recruiting participants online, outside of the planned community locations, and through social media; and enhancing the study design by using respondent-driven sampling. In addition to educating communities about early cancer detection, we also provided information and resources about coronavirus disease 2019, including transmission mitigation, testing, and vaccination. Conclusions: Continuing to engage the communities in our study is critical to our long-term goal of eliminating cancer screening disparities in Southeast Asian immigrant communities.

Abstract C133: Identifying sexual and gender minority colorectal cancer screening disparities via the 2020 Behavioral Risk Factor Surveillance System

Abstract Introduction: Health disparities exist for US sexual and gender minorities (SGM) relative to the general population, including cancer screening disparities with variation across disease sites. Limited data exist to describe the frequency of guideline-concordant colorectal cancer screening (CRC) among SGM people, with few studies using nationally-representative samples. This study aims to assess CRC screening participation among SGM people leveraging nationally-representative US health survey data. Methods: Data from the 2020 Behavioral Risk Factor Surveillance System (BRFSS) were used to compare CRC screening participation among screening-eligible SGM to that of the straight, cisgender population. 86,519 individuals aged 50 and older without a lifetime cancer diagnosis and with complete information on demographics, health access, and sexual orientation and gender identity (collected in 33 of 53 participating US states/territories) were included in the analysis. Odds of lifetime CRC screening participation by test type (colonoscopy, sigmoidoscopy, blood stool test, stool DNA test, virtual colonoscopy) for gender minority (GM: transgender man, transgender woman, gender non-conforming) vs. cisgender individuals and sexual minority (SM: gay/lesbian, bisexual, something else) vs. straight individuals were compared via weighted logistic regression models adjusted for age, demographics, and health access. Results: Of the overall sample, 0.44% and 3.6% identified as GM and SM, respectively. Prevalence of lifetime CRC screening by any test was 65.4% vs. 78.9% for GM vs. cisgender individuals and 77.1% vs. 78.9% for SM vs. straight individuals. GM reported lower odds of screening participation relative to cisgender individuals in 4 of 5 test types: colonoscopy adjusted odds ratio (AOR) 0.38 (95% CI 0.13, 1.08); sigmoidoscopy 0.58 (0.28, 1.22); blood stool test 0.84 (0.31, 2.28); stool DNA test 0.52 (0.22, 1.20); virtual colonoscopy 1.36 (0.64, 2.90). SM reported lower odds of screening participation relative to straight individuals in 2 of 5 test types: colonoscopy 1.05 (0.83, 1.32); sigmoidoscopy 0.94 (0.74, 1.19); blood stool test 0.95 (0.77, 1.17); stool DNA test 1.11 (0.81, 1.51); virtual colonoscopy 1.12 (0.81, 1.53). None of the AORs were statistically significant. Conclusions: Disparities in CRC screening participation persist for GM relative to cisgender individuals. These findings suggest the need for additional subgroup analyses among GM, study replication in other data sources, and interventions to improve access to CRC screening for GM. Citation Format: Frank M. Wolf, Ash Alpert, Molly Schwalb, Danielle German. Identifying sexual and gender minority colorectal cancer screening disparities via the 2020 Behavioral Risk Factor Surveillance System [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C133.

Racial/Ethnic Differences in Bone Mineral Density for Osteoporosis.

We primarily aim to review differences in bone mineral density (BMD) for osteoporosis among different racial/ethnic groups and to highlight the magnitude of racial/ethnic differences in obesity and diabetes. We also explore the factors contributing to the BMD differences among various subgroups. In addition, we investigate the existing disparities in research, educational initiatives, screening practices, and treatment options for osteoporosis and discuss these findings' clinical and public health implications. Racial/ethnic differences in BMD for osteoporosis exist in the USA and other countries. There are disparities regarding osteoporosis screening and treatment. Understanding the factors contributing to these differences can help develop targeted interventions and policies to reduce their impact. Clinicians should consider the racial/ethnic differences in BMD when making treatment decisions and providing preventive care. Future research could contribute to developing effective strategies for preventing osteoporosis among different racial/ethnic groups. This review offered a comprehensive examination of differences in BMD across various racial and ethnic groups, elucidating the influence of genetic, lifestyle, and cultural factors on these differences. This review also highlighted the disparities in osteoporosis screening, treatment options, research on medical effectiveness, and educational outreach tailored to each subgroup. Recognizing the importance of addressing these inequalities, we present this review to advocate for targeted interventions to reduce disparities in osteoporosis and improve bone health for all populations.

Detection of Prostate Cancer Screening Disparities Using Geospatial Analysis of Laboratory Results

Abstract Black men experience higher prevalence and mortality from prostate cancer (PCa) but are less likely to undergo PCa screening with prostate-specific antigen (PSA). The reasons for this disparity are multifactorial and include lack of access, PCa education, and mistrust in the healthcare system. Identifying geographic regions with low PSA screening and high positivity rates could potentially help inform targeted interventions. This study aimed to examine racial, socioeconomic, and geospatial disparities in PSA screening and positivity rates in the Siteman Cancer Center (St. Louis, MO) catchment region. The results of all PSA screening tests ordered in the Barnes-Jewish Healthcare Corporation (St. Louis, MO) and performed from 9/2019-12/2022 were retrieved from the laboratory information system with patient demographics. Patient addresses were geocoded using ArcGIS Pro (ESRI, Redlands, CA) and assigned to a census tract of residence. The PSA screening-eligible population was defined as the number of persons ≥50 years of age based on U.S. Census data. Social Vulnerability Index (SVI) values were retrieved from the Centers for Disease Control. The PSA screening rate was calculated by census tract as the total number of PSA tests performed/PSA screening-eligible population. The PSA positivity rate was calculated by census tract as the number of PSA positive tests/total PSA tests. All census tracts with fewer than 10 PSA tests performed were omitted from PSA positivity analysis. Hotspot analysis was performed by calculating Local Moran’s I statistic per census tract and comparing with 999 randomly-generated maps. A total of 90,994 screening tests for 60,005 patients (48,024 White [80%], 10,425 Black [17%], and 1,556 Other [3%]) were performed for patients in the catchment region. Black patients were 78% more likely to receive a positive PSA screen than White patients (p&amp;lt;0.001). Of those screening positive, Black patients had a significantly higher median[IQR] (7.94[6.2-13.7 ng/mL]) PSA result compared to White patients (7.4[6.2-10.1 ng/mL]) (p&amp;lt;0.001) and a median[IQR] age of 67[61-74 years] vs. 69[63-76 years] (p&amp;lt;0.001). In a multivariate logistic regression using age, race, and census tract of residence SVI to predict PSA positivity, only census tract SVI was not statistically significant. A model using only age and race demonstrated that every 10 years of age and Black race were associated with 11% and 7% increased odds of receiving a PSA positive test, respectively (p&amp;lt;0.001). 75 and 191 of 789 census tracts in the catchment region were identified as PSA positivity hotspots and PSA screening cold spots, respectively. In conclusion, this study confirms previous reports of higher PSA values among Black patients and suggests that geospatial analysis of PSA testing can identify geographic regions with low testing and high positivity rates.

Socioeconomic disparities in mammography screening in the United States from 2012 to 2020

The potential impact of the COVID-19 pandemic on socioeconomic disparities in mammography uptake remain poorly understood. We used repeated cross-sectional data from the 2012, 2014, 2016, 2018, and 2020 waves of the Behavioral Risk Factor Surveillance System, focusing on the U.S. women aged 50–74 years and investigated the relationships of educational attainment, employment status, and household income with a missed mammogram in the past two years. We ran Poisson regression analyses accounting for survey weights. The sample numbers were 139,761 in 2012, 137,916 in 2014, 140,000 in 2016, 116,756 in 2018, and 102,774 in 2020, respectively. Women with the lower educational attainment and lower household incomes reported higher proportions of missed mammography screening. Self-employed women were most likely to miss a mammogram. Accounting for other covariates, there was an increase in the adjusted prevalence ratio (PR) of missed mammography from 2018 to 2020 (pre-pandemic versus post pandemic onset) for self-employed women compared to women in waged work. Non-Hispanic Black women who were self-employed (PR = 0.28, 95% CI: 0.16, 0.51) and employed for wages (PR = 0.58, 95% CI: 0.47, 0.73) were at lower risks of missing a mammogram compared to non-Hispanic White women in the same categories. The findings suggest that disparities for mammography uptake widened after the pandemic onset, especially for employment status, which varied by race/ethnicity.

Assessing the impact of socioeconomic status on incidental lung nodules at an urban safety net hospital

IntroductionLower socioeconomic status has been identified as an emerging risk factor for health disparities, including lung cancer outcomes. Most research investigating these outcomes includes patients from formal lung cancer screening programs. There is a paucity of studies assessing the relationship between socioeconomic status and incidental lung nodules. This study aimed to investigate the association between socioeconomic status and the size of incidental lung nodules on initial presentation at an urban safety net hospital, which did not have a formal lung cancer screening program or incidental lung nodule program.MethodsA retrospective chart review was conducted on patients with incidental lung nodules on CT chest imaging who were referred from primary care to a pulmonology clinic at a safety net hospital. Patients with incomplete nodule characteristics information were excluded. Data on demographics, comorbidities, smoking history, insurance type, immigration status, and geographical factors were collected. Less commonly studied determinants such as crime index, cost of living, and air quality index were also assessed. Logistic regression analysis was performed to assess relationships between nodule size and socioeconomic determinants.ResultsOut of 3,490 patients with chest CT scans, 268 patients with ILNs were included in the study. 84.7% of patients represented racial or ethnic minorities, and most patients (67.8%) had federal insurance. Patients with non-commercial insurance were more likely to have larger, inherently higher-risk nodules (> 8 mm) compared to those with commercial insurance (OR 2.18, p 0.01). Patients from areas with higher unemployment rates were also less likely (OR 0.75, p 0.04) to have smaller nodules (< 6 mm). Patients representing racial or ethnic minorities were also more likely to have nodules > 8 mm (OR 1.6, p 0.24), and less likely to have nodules < 6 mm (OR 0.6, p 0.32), however, these relationships were not statistically significant.ConclusionThis study found that lower socioeconomic status, indicated by having non-commercial insurance, was associated with larger incidental lung nodule size on initial presentation. While it is established that socioeconomic status is associated with disparities in lung cancer screening, these findings suggest that inequalities may also be present in those with incidental lung nodules. Further research is needed to understand the underlying mechanisms and develop interventions to address these disparities in incidental lung nodule evaluation and improve outcomes.

Cancer Screening Disparities Before and After the COVID-19 Pandemic

Breast, cervical, and colorectal cancer-screening disparities existed prior to the COVID-19 pandemic, and it is unclear whether those have changed since the pandemic. To assess whether changes in screening from before the pandemic to after the pandemic varied for immigrants and for people with limited income. This population-based, cross-sectional study, using data from March 31, 2019, and March 31, 2022, included adults in Ontario, Canada, the country's most populous province, with more than 14 million people, almost 30% of whom are immigrants. At both dates, the screening-eligible population for each cancer type was assessed. Neighborhood income quintile, immigrant status, and primary care model type. For each cancer screening type, the main outcome was whether the screening-eligible population was up to date on screening (a binary outcome) on March 31, 2019, and March 31, 2022. Up to date on screening was defined as having had a mammogram in the previous 2 years, a Papanicolaou test in the previous 3 years, and a fecal test in the previous 2 years or a flexible sigmoidoscopy or colonoscopy in the previous 10 years. The overall cohort on March 31, 2019, included 1 666 943 women (100%) eligible for breast screening (mean [SD] age, 59.9 [5.1] years), 3 918 225 women (100%) eligible for cervical screening (mean [SD] age, 45.5 [13.2] years), and 3 886 345 people eligible for colorectal screening (51.4% female; mean [SD] age, 61.8 [6.4] years). The proportion of people up to date on screening in Ontario decreased for breast, cervical, and colorectal cancers, with the largest decrease for breast screening (from 61.1% before the pandemic to 51.7% [difference, -9.4 percentage points]) and the smallest decrease for colorectal screening (from 65.9% to 62.0% [difference, -3.9 percentage points]). Preexisting disparities in screening for people living in low-income neighborhoods and for immigrants widened for breast screening and colorectal screening. For breast screening, compared with income quintile 5 (highest), the β estimate for income quintile 1 (lowest) was -1.16 (95% CI, -1.56 to -0.77); for immigrant vs nonimmigrant, the β estimate was -1.51 (95% CI, -1.84 to -1.18). For colorectal screening, compared with income quintile 5, the β estimate for quntile 1 was -1.29 (95% CI, 16 -1.53 to -1.06); for immigrant vs nonimmigrant, the β estimate was -1.41 (95% CI, -1.61 to -1.21). The lowest screening rates both before and after the COVID-19 pandemic were for people who had no identifiable family physician (eg, moving from 11.3% in 2019 to 9.6% in 2022 up to date for breast cancer). In addition, patients of interprofessional, team-based primary care models had significantly smaller reductions in β estimates for breast (2.14 [95% CI, 1.79 to 2.49]), cervical (1.72 [95% CI, 1.46 to 1.98]), and colorectal (2.15 [95% CI, 1.95 to 2.36]) postpandemic screening and higher uptake of screening in general compared with patients of other primary care models. In this cross-sectional study in Ontario that included 2 time points, widening disparities before compared with after the COVID-19 pandemic were found for breast cancer and colorectal cancer screening based on income and immigrant status, but smaller declines in disparities were found among patients of interprofessional, team-based primary care models than among their counterparts. Policy makers should investigate the value of prioritizing and investing in improving access to team-based primary care for people who are immigrants and/or with limited income.