Inequalities In Survival Research Articles

Epidemiology trends and progress in breast cancer survival: earlier diagnosis, new therapeutics.

In this review we will critically appraise the latest evidence on breast cancer (BC) survival trends and discuss how these may reflect breakthroughs in early diagnosis and treatment approaches. We will address the wide global inequalities in BC survival and review the ongoing initiatives aimed at improving cancer control worldwide. BC outcomes have improved in high-income countries during the last decades, following the implementation of strategies for early detection and optimal multimodality treatment. Novel therapeutics, such as anti-HER2 targeted treatments, have also contributed to the progress in BC survival. However, BC mortality is still high in low-income countries, due to the lack of optimal healthcare infrastructures. In the context of marked inequities in BC management across world regions, international collaborations such as the Global Breast Cancer Initiative and the Global Initiative for Cancer Registry Development work to foster capacity-building in developing countries, tackle the burden of BC and deliver the Sustainable Development Goals by 2030. Collection of robust, high-quality data from population-based cancer registries is crucial to drive and refine public health interventions. Population-based data are also the litmus paper to evaluate the real-world impact of clinical advances and monitor progress.

Socioeconomic status and inequities in treatment initiation and survival among patients with cancer, 2011-2022.

Lower neighborhood socioeconomic status (SES) is associated with suboptimal cancer care and reduced survival. Most studies examining cancer inequities across area-level socioeconomic status tend to use less granular or unidimensional measures and pre-date the COVID-19 pandemic. Here, we examined the association of area-level socioeconomic status on real-world treatment initiation and overall survival among adults with 20 common cancers. This retrospective cohort study used electronic health record-derived deidentified data (Flatiron Health Research Database, 2011-2022) linked to US Census Bureau data from the American Community Survey (2015-2019). Area-level socioeconomic status quintiles (based on a measure incorporating income, home values, rental costs, poverty, blue-collar employment, unemployment, and education information) were computed from the US population and applied to patients based on their mailing address. Associations were examined using Cox proportional hazards models adjusted for diagnosis year, age, sex, performance status, stage, and cancer type. This cohort included 291 419 patients (47.7% female; median age = 68 years). Patients from low-SES areas were younger and more likely to be Black (21.9% vs 3.3%) or Latinx (8.4% vs 3.0%) than those in high-SES areas. Living in low-SES areas (vs high) was associated with lower treatment rates (hazard ratio = 0.94 [95% confidence interval = 0.93 to 0.95]) and reduced survival (median real-world overall survival = 21.4 vs 29.5 months, hazard ratio = 1.20 [95% confidence interval = 1.18 to 1.22]). Treatment and survival inequities were observed in 9 and 19 cancer types, respectively. Area-level socioeconomic inequities in treatment and survival remained statistically significant in the COVID-19 era (after March 2020). To reduce inequities in cancer outcomes, efforts that target marginalized, low-socioeconomic status neighborhoods are necessary.

Survival inequalities in head and neck cancers: A hospital-based cohort study.

We investigated whether the socioeconomic status (SES) influenced survival rates in oropharynx cancers (OPC), oral cavity cancers (OCC), and larynx cancers (LC) in Brazilian patients. This hospital-based cohort study assessed the age-standardized 5-year relative survival (RS) using the Pohar Perme estimator. Overall, we identified 37 191 cases, and 5-year RS were 24.4%, 34.1%, and 44.9% in OPC, OCC, and LC, respectively. In multiple Cox regression, the highest risk of death occurred in the most vulnerable social strata for all subsites-that is, illiterates or patients relying on publicly funded healthcare services. Disparities increased over time by 34.9% in OPC due to the rising of survival rates in the highest SES, whereas they reduced by 10.2% and 29.6% in OCC and LC. The potential inequities were more significant for OPC than for OCC and LC. It is urgent to tackle social disparities to improve prognoses in highly unequal countries.

The contribution of prognostic factors to socio-demographic inequalities in breast cancer survival in Victoria, Australia.

Breast cancer survival in Australia varies according to socio-economic status (SES) and between rural and urban places of residence. Part of this disparity may be due to differences in prognostic factors at the time of diagnosis. Women with invasive breast cancer diagnosed from 2008 until 2012 (n = 14,165) were identified from the Victorian Cancer Registry and followed up for 5 years, with death from breast cancer or other causes recorded. A prognostic score, based on stage at diagnosis, cancer grade, whether the cancer was detected via screening, reported comorbidities and age at diagnosis, was constructed for use in a mediation analysis. Five-year breast cancer mortality for women with breast cancer who were in the lowest quintile of SES (10.3%) was almost double that of those in the highest quintile (5.7%). There was a small survival advantage (1.7% on average, within each socio-economic quintile) of living in inner-regional areas compared with major cities. About half of the socio-economic disparity was mediated by prognostic factors, particularly stage at diagnosis and the presence of comorbidities. The inner-regional survival advantage was not due to differences in prognostic factors. Part of the socio-economic disparity in breast cancer survival could be addressed by earlier detection in, and improved general health for, more disadvantaged women. Further research is required to identify additional causes of socio-economic disparities as well as the observed inner-regional survival advantage.

HPR7 Racialized Economic Segregation and Inequities in Survival Among Patients with Multiple Myeloma

Structural racism – including racial and economic segregation – may drive persistent inequities in multiple myeloma (MM) treatment and survival. Here we examined the association of the Index of Concentration at the Extremes (ICE) for area-level racialized economic segregation, and real-world overall survival (rwOS) among patients with MM.

Patient-level interventions to increase guideline concordant treatment among Black breast cancer patients: Can they close the racial gap in survival after diagnosis?

6549 Background: While we have seen impressive improvements in breast cancer (BC) survival over the last few decades, substantial racial disparities persist. Inequities in the receipt of guideline-concordant treatment contribute to worse survival in Black BC patients. Previous studies have shown that patient-level disparity reduction interventions (e.g., patient navigation) can significantly increase guideline-concordant treatment receipt among Black patients, with positive spillover effects in nonBlack patients. The aim of this study was to estimate the potential impact of disparity reduction interventions on racial inequities in survival after BC diagnosis in North Carolina. Methods: We used data from the Cancer Information and Population Health Resource, which links multipayer claims to North Carolina’s cancer registry for biological women diagnosed with BC in 2004-2017. We calculated Black/nonBlack disparities in the receipt of chemotherapy (CTx) within 4 months of diagnosis for patients ages <70 with hormone-receptor negative stage Ib-III BC (CTx cohort; N=2223) and the receipt of endocrine therapy (ET) within 12 months of diagnosis for stage I-III hormone receptor-positive BC (ET cohort=16220). We then simulated the potential increase in the proportion of patients receiving CTx and ET if proven patient-level disparity-reduction interventions were implemented across the state. Based on the literature, we assumed that the effects of these interventions in increasing treatment receipt would be same in the CTx and ET cohorts. We estimated the effect of this potential increase in CTx and ET receipt on 10-year overall survival using cohort-, race-, and treatment receipt-stratified Markov models. We report confidence bounds representing 95% of simulation results. Results: Over the 2004-2017 period, 72.9% and 70.8% of Black patients in our cohorts received CTx and ET, respectively. This was significantly lower than among nonBlack patients (p<.05). State-wide implementation of disparity reduction interventions could increase CTx and ET receipt among Black patients to 86.7% (80.9-92.5%) and 84.2% (78.5-89.9%), respectively. As a result, the racial 10-year survival gap would decrease from 9.4 to 8.1 (5.7-10.5) percentage points in the CTx cohort, and from 6.2 to 5.4 (4.0-6.7) percentage points in the ET cohort. Conclusions: Patient-level interventions can reduce disparities in guideline-concordant-treatment receipt. However, increases in treatment receipt alone would not be enough to close the racial survival gap, suggesting that, in isolation, patient-level interventions are unable to eliminate disparities. Action on the structural factors that disadvantage Black BC patients is needed. Our team is conducting community-engaged work to share and interpret these findings.

Attendance characteristics of the breast and colorectal cancer screening programmes in a highly urbanised region of the Netherlands: a retrospective observational study

ObjectivesThroughout Europe, many countries offer population-based cancer screening programmes (CSPs). In the Netherlands, two implemented CSPs are targeting people of 50 years and older, aiming at breast cancer (BC) and...

Association of Socioeconomic Position With Racial and Ethnic Disparities in Survival After Lung Transplant

A recent National Academies of Sciences, Engineering, and Medicine study found that transplant outcomes varied greatly based on multiple factors, including race, ethnicity, and geographic location. They proposed a number of recommendations including studying opportunities to improve equity in organ allocation. To evaluate the role of donor and recipient socioeconomic position and region as a mediator of observed racial and ethnic differences in posttransplant survival. This cohort study included lung transplant donors and recipients with race and ethnicity information and a zip code tabulation area-defined area deprivation index (ADI) from September 1, 2011, to September 1, 2021, whose data were in the US transplant registry. Data were analyzed from June to December 2022. Race, neighborhood disadvantage, and region of donors and recipients. Univariable and multivariable Cox proportional hazards regression were used to study the association of donor and recipient race with ADI on posttransplant survival. Kaplan-Meier method estimation was performed by donor and recipient ADI. Generalized linear models by race were fit, and mediation analysis was performed. Bayesian conditional autoregressive Poisson rate models (1, state-level spatial random effects; 2, model 1 with fixed effects for race and ethnicity, 3; model 2 excluding region; and 4: model 1 with fixed effects for US region) were used to characterize variation in posttransplant mortality and compared using ratios of mortality rates to the national average. Overall, 19 504 lung transplant donors (median [IQR] age, 33 [23-46] years; 3117 [16.0%] Hispanic individuals, 3667 [18.8%] non-Hispanic Black individuals, and 11 935 [61.2%] non-Hispanic White individuals) and recipients (median [IQR] age, 60 [51-66] years; 1716 [8.8%] Hispanic individuals, 1861 [9.5%] non-Hispanic Black individuals, and 15 375 [78.8%] non-Hispanic White individuals) were included. ADI did not mediate the difference in posttransplant survival between non-Hispanic Black and non-Hispanic White recipients; it mediated only 4.1% of the survival difference between non-Hispanic Black and Hispanic recipients. Spatial analysis revealed the increased risk of posttransplant death among non-Hispanic Black recipients may be associated with region of residence. In this cohort study of lung transplant donors and recipients, socioeconomic position and region of residence did not explain most of the difference in posttransplant outcomes among racial and ethnic groups, which may be due to the highly selected nature of the pretransplant population. Further research should evaluate other potentially mediating effects contributing to inequity in posttransplant survival.

Exploring the most dominant drivers of inequalities in child survival in Ethiopia: Dominance analysis

Inequalities in child survival are a global public health concern. Over the past decade, Ethiopia has made remarkable progress in improving child survival. Despite this promising development, inequalities in child survival among the various population groups remained a pressing public health concern. The purpose of this paper is to examine the dominant drivers of inequality in child survival indicators (undernutrition, anemia, and under-five mortality) in Ethiopia. Dominance analysis was used based on a pooled total sample of 48,422 under-five children drawn from five rounds of Ethiopia Demographic and Health Surveys conducted from year 2000 to 2019. Childhood undernutrition, childhood anemia, and under-five mortality were the three outcome variables, and the five dimensions of inequality were considered as key predictor variables. The dominance analysis revealed that maternal education, place of residence, and household wealth index were the three most dominant drivers of inequalities in childhood undernutrition, accounting for 83.48% of the predicted variances. The regional category was found to be the first-ranked key driver of inequalities in childhood anemia, accounting for 50.56% of the predicted variance. The dominance analysis also indicated that maternal education, child sex, and place of residence were the three most dominant drivers of inequality in under-five mortality, accounting for 89.3% of the predicted variance. This study provides empirical evidence that maternal education (individual level), household asset based wealth index (household level), and place of residence (community level) were the most dominant drivers of inequality in child survival. This suggests interventions in reducing inequalities in child survival need to start at the community level, notwithstanding the importance of household and individual level influences.

Inequalities in survival and care across social determinants of health in a cohort of advanced lung cancer patients in Quebec (Canada): A high-resolution population-level analysis.

Advanced lung cancer patients exposed to breakthrough therapies like EGFR tyrosine kinase inhibitors (EGFR-TKI) may experience social inequalities in survival, partly from differences in care. This study examined survival by neighborhood-level socioeconomic and sociodemographic status, and geographical location of advanced lung cancer patients who received gefitinib, an EGFR-TKI, as first-line palliative treatment. Differences in the use and delay of EGFR-TKI treatment were also examined. Lung cancer patients receiving gefitinib from 2001 to 2019 were identified from Quebec's health administrative databases. Accounting for age and sex, estimates were obtained for the median survival time from treatment to death, the probability of receiving osimertinib as a second EGFR-TKI, and the median time from biopsy to receiving first-line gefitinib. Among 457 patients who received first-line treatment with gefitinib, those living in the most materially deprived areas had the shortest median survival time (ratio, high vs. low deprivation: 0.69; 95% CI: 0.47-1.04). The probability of receiving osimertinib as a second EGFR-TKI was highest for patients from immigrant-dense areas (ratio, high vs. lowdensity: 1.95; 95% CI: 1.26-3.36) or from Montreal (ratio, other urban areas vs. Montreal: 0.39; 95% CI: 0.16-0.71). The median wait time for gefitinib was 1.27 times longer in regions with health centers peripheral to large centers in Quebec or Montreal in comparison to regions with university-affiliated centers (95% CI: 1.09-1.54; n = 353). This study shows that real-world variations in survival and treatment exist among advanced lung cancer patients in the era of breakthrough therapies and that future research on inequalities should also focus on this population.

Abstract PD1-05: Racial/Ethnic Segregation and Inequities in Metastatic Breast Cancer Treatment Initiation and Overall Survival

Abstract Background While racial/ethnic segregation, a form of structural racism, has been linked to health inequities, there is limited information regarding segregation and its potential impact on breast cancer care and outcomes. Here we assessed whether and to what extent racial/ethnic segregation is associated with timeliness of care and real-world overall survival (rwOS) in patients diagnosed with metastatic breast cancer (mBC). Methods This retrospective study used the nationwide Flatiron Health electronic health record-derived de-identified database. The cohort included community oncology patients (≥ 18 years) diagnosed with mBC between January 2011 and April 2022. Census tract data from the American Community Survey (2015-2019) was used to characterize neighborhoods based on the most recent recorded patient address. Segregation was defined as predominant race/ethnicity (e.g., tracts whose population was ≥ 50% non-Latinx Black were labeled as predominantly Black neighborhoods). Timeliness of care was defined as biomarker (estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2) testing within 30 days and systemic treatment initiation within 60 days of metastatic diagnosis (evaluated using Χ2 tests). We estimated Cox proportional hazard models adjusted for age and sex to examine rwOS (patients were followed from diagnosis to death or last recorded activity). Results Among 18,884 patients diagnosed with mBC (median age: 65 years), 71.0% lived in predominantly White neighborhoods, 7.5% in Black neighborhoods, and 8.7% in Latinx neighborhoods. Compared with patients residing in predominantly White neighborhoods, patients in Black and Latinx neighborhoods were more likely to be diagnosed with de novo mBC (30.7% vs. 34.8% and 33.5%, respectively) and have Medicaid (7.6% vs. 15.8% and 15.3%). Fewer patients in predominantly Black (74.4%) and Latinx (69.9%) neighborhoods received timely biomarker testing compared to patients in White (77.7%) neighborhoods (p <.01). Similarly, fewer patients in predominantly Black (73.5%) and Latinx (72.6%) neighborhoods had timely treatment initiation compared to patients in White (79.6%) neighborhoods (p <.01). Patients in Black neighborhoods (HR 1.24, 95% CI 1.16-1.33) had worse rwOS than patients in White (ref.) and Latinx neighborhoods (HR 0.90, 95% CI 0.83-0.97). Conclusions Our results suggest that racial/ethnic segregation is associated with inequities in breast cancer care and outcomes, where patients in predominantly Black and Latinx neighborhoods are less likely to receive timely care than those in White neighborhoods. Living in predominantly Black neighborhoods was also associated with reduced survival. Therefore, efforts to reduce cancer inequities should target higher-order structural factors associated with worse cancer care and outcomes, including segregation and other forms of structural racism. Citation Format: Jenny S. Guadamuz, Gregory S. Calip, Alemseged A. Asfaw, Xiaoliang Wang, Harlan Pittell, Maneet Kaur, Amy E. Pierre, Cleo A. Ryals. Racial/Ethnic Segregation and Inequities in Metastatic Breast Cancer Treatment Initiation and Overall Survival [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD1-05.

How Zambia reduced inequalities in under-five mortality rates over the last two decades: a mixed-methods study

BackgroundZambia experienced a major decline in under-five mortality rates (U5MR), with one of the fastest declines in socio-economic disparities in sub-Saharan Africa in the last two decades. We aimed to understand the extent to which, and how, Zambia has reduced socio-economic inequalities in U5MR since 2000.MethodsUsing nationally-representative data from Zambia Demographic Health Surveys (2001/2, 2007, 2013/14 and 2018), we examined trends and levels of inequalities in under-five mortality, intervention coverage, household water and sanitation, and fertility. This analysis was integrated with an in-depth review of key policy and program documents relevant to improving child survival in Zambia between 1990 and 2020.ResultsThe under-five mortality rate (U5MR) declined from 168 to 64 deaths per 1000 live births between 2001/2 and 2018 ZDHS rounds, particularly in the post-neonatal period. There were major reductions in U5MR inequalities between wealth, education and urban–rural residence groups. Yet reduced gaps between wealth groups in estimated absolute income or education levels did not simultaneously occur. Inequalities reduced markedly for coverage of reproductive, maternal, newborn and child health (RMNCH), malaria and human immunodeficiency virus interventions, but less so for water or sanitation and fertility levels.Several policy and health systems drivers were identified for reducing RMNCH inequalities: policy commitment to equity in RMNCH; financing with a focus on disadvantaged groups; multisectoral partnerships and horizontal programming; expansion of infrastructure and human resources for health; and involvement of community stakeholders and service providers.ConclusionZambia’s major progress in reducing inequalities in child survival between the poorest and richest people appeared to be notably driven by government policies and programs that centrally valued equity, despite ongoing gaps in absolute income and education levels. Future work should focus on sustaining these gains, while targeting families that have been left behind to achieve the sustainable development goal targets.

A global assessment of the impact of violence on lifetime uncertainty.

Uncertainty around age at death, or lifetime uncertainty, is a key public health indicator and a marker of inequality in survival. How does the extent of violence affect lifetime uncertainty? We address this question by quantifying the impact of violence on dispersion in the ages at death, the metric most used to measure lifetime uncertainty. Using mortality data from the Global Burden of Disease Study and the Internal Peace Index between 2008 and 2017, we find that the most violent countries are also those with the highest lifetime uncertainty. In the Middle East, conflict-related deaths are the largest contributor to lifetime uncertainty. In Latin America, a similar pattern is attributable to homicides. The effects are larger in magnitude for men, but the consequences remain considerable for women. Our study points to a double burden of violence on longevity: Not only does violence shorten individual lives, but it also makes the length of life less predictable.

Immune Checkpoint Inhibitor (ICI) Genes and Aging in Clear Cell Renal Cell Carcinoma (ccRCC): Clinical and Genomic Study.

Background: It is anticipated that there will be a large rise in the number of tumor diagnoses and mortality in those aged 65 and older over the course of upcoming decades. Immune checkpoint inhibitors, often known as ICIs, boost immune system activity by selectively targeting ICI genes. On the other hand, old age may be connected with unfavorable results. Methods: The Cancer Genome Atlas (TCGA) provided gene expression data from ccRCC tissue and key clinical variables. ICI gene databases were applied and verified using the GEO database. Results: We identified 14 ICI genes as risk gene signatures among 528 ccRCC patients using univariate and multivariable cox hazard models, and the elderly group was linked with poor survival. Then, by utilizing a new nomogram method, the TNFSF15 gene and age predicting values were estimated at one, three, and five years (85%, 81%, and 81%), respectively, and our age-related risk score was significant even after multivariable analysis (HR = 1.518, p = 0.009, CI = 1.1102.076). TNFSF15 gene expression was lower in elderly ccRCC patients (p = 0.0001). A negative connection between age and the TNFSF15 gene expression was discovered by correlation analysis (p = 0.0001). The verification of the gene by utilizing GEO (GSE167093) with 604 patients was obtained as external validation that showed significant differences in the TNFSF15 gene between young and elderly patients (p = 0.007). Additionally, the protein-protein interactions of the TNFSF15 gene with other ICI genes and aging-related genes was determined. In addition, the TNFSF15 expression was significantly correlated with pathological stages (p = 0.018). Furthermore, it was discovered that the biological processes of senescence, cellular senescence, the immune system, and many immune cell infiltration and immune function types are all closely tied. Conclusions: Along with the risk score evaluation, the ICI gene TNFSF15 was identified as a tumor suppressor gene related to inequalities in age survival and is associated with pathological stages and different immunity statuses. The aging responses of ccRCC patients and related gene expression need further investigation in order to identify potential therapeutic targets.

Inequalities in adverse birth outcomes and survival in early childhood: birth cohort in South Korea

Abstract Background Adverse birth outcomes (ABOs) are considered the most common factor of deaths in early childhood. Inequalities in child mortality occur due to interactions between intrinsic and socio-environmental factors related to socioeconomic disadvantage. There are, however, few studies investigating the impact of ABOs on mortality in terms of parental SEP. Methods Using the Under-5 Infant Birth-Death Cohort Data in Korea, a pooled retrospective birth cohort of all children born in 2012-2014 was built (N = 1,356,584). We analyzed neonatal, post-neonatal, and childhood mortality by ABOs and with the interaction of parental SEP using the Cox proportional hazard regression model for survival analyses. We further stratified the analysis both by parental SEP and child age. Multiple logistic regression was performed to confirm the social inequalities in ABO itself. Results After adjusting for covariates, children born with ABOs presented higher risk of mortality for all periods. For post-neonatal period, lower maternal education showed significant interaction effect with LBW (HR = 0.57; 95% CI = [0.39-0.85]), PTB (HR = 0.53; 95% CI = [0.33-0.86]), LBW & PTB ([HR = 0.67; 95% CI = [0.54-0.83]) while lower paternal education (HR = 0.67; 95% CI = [0.54-0.82]) and maternal unemployment (HR = 0.80; 95% CI = [0.63-0.99]) showed significance for babies with LBW & PTB. However, stratification analyses suggested that the impact of ABOs on mortality was greater for children born to lower parental SEP in neonatal period. Meanwhile apparent social inequalities in ABOs were suggested from regression analyses. Conclusions We confirmed social inequalities in the incidence of ABOs as well as mortalities from ABOs. However, the difference in mortality between babies with and without ABOs was greater for advantaged children. Policies to reduce the mortality of children with ABOs as well as those of healthy children among socioeconomically disadvantaged families are required. Key messages • Social inequalities in mortality from ABOs were apparent especially in the neonatal period while the incidence of ABOs itself was greater among children from disadvantaged families. • Disadvantaged children are more likely to die not only from ABOs but also from other socio-environmental determinants, especially in the post-neonatal period than their counterparts.

Cancer survival differentials for Aboriginal and Torres Strait Islander peoples in Queensland: the impact of remoteness

PurposeIn Australia, Aboriginal and Torres Strait Islander peoples (First Nations population) often have low overall cancer survival, as do all residents of geographically remote areas. This study aimed to quantify the survival disparity between First Nations and other Queenslanders for 12 common cancer types by remoteness areas.MethodsFor all Queensland residents aged 20–89 years diagnosed with a primary invasive cancer during 1997–2016, we ran flexible parametric survival models incorporating age, First Nations status, sex, diagnosis time period, area-level socioeconomic status, remoteness categories and where appropriate, broad cancer type. Three survival measures were predicted: cause-specific survival, survival differences and the comparative survival ratio, each standardised to First Nations peoples’ covariate distributions.ResultsThe standardised five-year cause-specific cancer survival was 60% for urban First Nations and 65% for other Queenslanders, while remote residents were 54% (First Nations) and 58% (other). The absolute survival differential between First Nations and other Queenslanders was often similar, regardless of remoteness of residence. The greatest absolute difference in five-year standardised cancer survival was for head and neck cancers, followed by cervical cancer.The five-year comparative survival ratio (First Nations: other Queenslanders) for urban cancer patients was 0.91 (95% CI 0.90–0.93), similar to outer regional, inner regional and remote areas. The greatest comparative survival differential was for oesophageal cancer.ConclusionFirst Nations’ survival inequalities are largely independent of geographical remoteness. It remains a priority to determine the contribution of other potential factors such as the availability of culturally acceptable diagnostic, management and/or support services.

Mediating Effects of Diagnostic Route on the Comorbidity Gap in Survival of Patients with Diffuse Large B-Cell or Follicular Lymphoma in England.

Simple SummaryThere are inequalities in cancer survival between patients with or without comorbidities. The healthcare pathway (i.e., diagnostic route) of a patient is thought to explain some of these inequalities. We explore how much of the effect of comorbidity on survival of patients with diffuse large B-cell lymphoma (DLBCL) or follicular lymphoma (FL) is explained by the diagnostic route (i.e., emergency diagnosis). We used mediation analysis to separate the effect of comorbidity on survival from its effect through diagnostic route. We found that, for DLBCL and FL, emergency diagnosis accounted for 24% and 16% of the inequalities in survival between comorbidity groups within 12 months since cancer diagnosis. This proportion reduced over time and was small after 5 years of follow up. Comorbidities can complicate the diagnosis and management of patients with DLBCL or FL. Our results show that greater research is needed to ensure patients with comorbidities have a timely diagnosis and will help to reduce the inequalities in cancer survival.Background: Socioeconomic inequalities in survival from non-Hodgkin lymphoma persist. Comorbidities are more prevalent amongst those in more deprived areas and are associated with diagnostic delay (emergency diagnostic route), which is also associated with poorer survival probability. We aimed to describe the effect of comorbidity on the probability of death mediated by diagnostic route (emergency vs. elective route) amongst patients with diffuse large B-cell (DLBCL) or follicular lymphoma (FL). Methods: We linked the English population-based cancer registry and hospital admission records (2005–2013) of patients aged 45–99 years. We decomposed the effect of comorbidity on survival into an indirect effect acting through diagnostic route and a direct effect not mediated by diagnostic route. Furthermore, we estimated the proportion of the comorbidity effect on survival mediated by diagnostic route. Results: For both DLBCL (n = 27,379) and FL (n = 14,043), those with any comorbidity, or living in more deprived areas, were more likely to experience diagnostic delay and poorer survival. The indirect effect of comorbidity on mortality through diagnostic route was highest at 12 months since diagnosis (DLBCL: Odds Ratio 1.10 [95% CI 1.07–1.13], FL: OR 1.09 [95% CI 1.04–1.14]). Within the first 12 months since diagnosis, emergency diagnostic route accounted for 24% (95% CI 17.5–29.5) and 16% (95% CI 6.0–25.6) of the comorbidity effect on mortality, for DLBCL and FL, respectively. Conclusion: Efforts to reduce diagnostic delay (emergency diagnosis) amongst patients with comorbidity would reduce inequalities in DLBCL and FL survival by 24% and 16%, respectively. Further public health programs and interventions are needed to reduce diagnostic delay amongst lymphoma patients with comorbidities.

Persistent racial and ethnic inequities in cancer-specific mortality of head and neck cancers by human papillomavirus infection.

148 Background: Overlapping racial and ethnic disparities exist in the prevalence of risk factors that drive the prognosis of head and neck cancers in the US, including the use of tobacco products, socioeconomic status and human papillomavirus (HPV) infection. Our objective was to describe inequities in cancer-specific survival among patients diagnosed with head and neck cancers by HPV status and racial/ethnic group. Methods: We conducted a retrospective cohort study using the Surveillance, Epidemiology and End Results Head and Neck with HPV Status Database. Patients diagnosed with first primary cancers of the hypopharynx, nasopharynx, oropharynx, pharyngeal tonsil, other pharyngeal, soft palate and tongue base between 2010 and 2016 were included, and information on clinical and demographic characteristics including tumor information, cancer-directed treatment, area-level socioeconomic status and HPV status were collected from population-based cancer registry data. Estimates of 5-year cancer-specific survival were calculated using the Kaplan-Meier method, and multivariable Cox proportional hazards models were used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for racial/ethnic inequities in survival stratified by HPV status. Results: Among 15,393 patients diagnosed with head and neck cancer with documented HPV status, the median age was 59 years (interquartile range 53-66) and 10,457 (68%) were HPV+. Compared to patients diagnosed with HPV- head and neck cancers, a higher proportion of patients with HPV+ head and neck cancers were male (87% vs. 77%), diagnosed at stage IV (75% vs. 66%) and non-Hispanic White (84% vs. 68%%); and a lower proportion of HPV+ patients were non-Hispanic Black (6% vs. 13%) and uninsured or had Medicaid coverage (13% vs. 25%). Overall, 5-year cancer-specific survival was higher among HPV+ patients (82%) than among HPV- patients (62%), with a wider disparity observed among Black head and neck cancer patients (HPV+ 74%, HPV- 44%). In multivariable models, significant differences in cancer-specific survival were found across racial/ethnic groups and HPV status (P-interaction: 0.045). Compared to White patients, persistent inequities in cancer-specific survival were observed among Black HPV+ (HR 1.49, 95% CI 1.19-1.87) and HPV- (HR 1.42, 95% CI 1.21-1.66); and among Latinx HPV+ patients (HR 1.32, 95% CI 1.03-1.69). Conclusions: In this population-based study of patients with head and neck cancers, significant disparities in cancer-specific survival were observed that differed by both race/ethnicity and HPV status. The complex inequities in outcomes of head and cancers likely reflect the clinical impacts of socioeconomic and demographic risk factors in addition to HPV-related dysregulation of tumor metabolism and the immune microenvironment.

Colorectal cancer incidence and survival inequalities among labour immigrants in Belgium during 2004–2013

Colorectal cancer (CRC) is one of the leading causes of cancer-related morbidity and mortality. We aim to map out differences in CRC incidence and survival between first-generation traditional labour immigrants of Italian, Turkish and Moroccan descent and native Belgians; and assess the contribution of socioeconomic position (SEP) to these differences. Individually-linked data of the 2001 Belgian Census, the Crossroads Bank for Social Security and the Belgian Cancer Registry are used. Age-standardized incidence rates and incidence rate ratios are calculated by country of origin, with and without adjusting for SEP. For CRC patients, 5-year relative survival rates and the relative excess risk for dying within five years after diagnosis are calculated by migrant origin. Lower CRC incidence was observed among immigrants compared to native Belgians, in particular among non-Western immigrants, which could not be explained by SEP. Survival inequalities were less clear, yet, after adjusting for age and stage at diagnosis and educational attainment, we observed a survival advantage among Turkish and Italian immigrant men. Health gains can be made for the native population by adapting lifestyle. The later stage at diagnosis for immigrants is of concern. Barriers regarding screening as perceived by the vulnerable groups should be identified.

Immune checkpoint inhibitor (ICI) genes and aging in malignant melanoma patients: a clinicogenomic TCGA study

BackgroundCancer diagnoses and deaths among the elderly (65 +) are expected to increase significantly over the next decade. Immune checkpoint inhibitors specifically target ICI genes and enhance immune system function. However, poor outcomes may be associated with aging.MethodsWe downloaded the Genomic Data Commons from the Cancer Genome Atlas (TCGA) and collected gene expression data from malignant melanoma (MM) tissues, the third level as the primary site. The CKTTD ICI genes database were applied and validated using the GEO database and lab experiments.ResultsIn 414 patients, 13 ICI genes were obtained as risk gene signature by univariate and multivariate Cox hazard models and were associated with poor survival in the older group. At 1, 3, and 5 years (79%, 76%, and 76%, respectively), we investigate TNFRFS4 gene and age prediction using novel nomogram-associated aging (HR = 1.79, P 0.001, CI = 1.32–2.45) with higher sensitivity testing.TNFRSF4 gene expression was significantly high in younger (15 years interval) MM patients (P < 0.001). By correlation analysis, a significant negative association was determined (P < 0.001). The validation of gene correlation from GEO (GSE59455) and (GSE22153) was obtained as external validation. We tested the TNFRSF4 protein levels by IHC in 14 melanoma tissue samples. TNFRSF4 expression was observed to be lower expressed in the older of melanoma tissues, and higher in the younger age group (P = 0.02). Besides the connectivity of ICI gene proteins, the biological processes of cell aging, aging, and the immune system were found to be highly related.ConclusionsAlong with the risk score evaluation, the ICI gene (TNFRSF4) was identified as a tumor suppressor gene related to inequalities in age survival and associated with immune cell infiltrations. The aging responses of melanoma patients and related gene expression need further investigation in order to identify potential therapeutic targets.