Low nSES Research Articles

Trends in Cervical and Anal Cancer Incidence and Mortality in the United States.

We describe trends in the incidence and mortality of cervical (CC) and anal (AC) cancers by race and neighborhood socioeconomic status. The Surveillance, Epidemiology, and End Results (SEER) database was used to construct a cohort of CC and AC cases from 2006 to 2018. Incidence rates and survival were calculated by race and neighborhood socioeconomic status (nSES). Annual percent change (APC) in incidence was calculated using linear regression, and 5-year overall survival (OS) by the Kaplan-Meier method. Of the cases, 33,487 CC and 16,018 AC cases were identified. Women of low nSES were nearly 4 times more likely to be diagnosed with cervical cancer than those of high nSES. Cervical cancer incidence declined marginally in all groups except for low nSES women who are White (APC 0.0). Women who are Black had lower 5-year OS than their nSES counterparts of other races (most notably for Black women of low nSES 53% vs White 63%). Similarly, the low nSES AC cohort contained nearly 3 times the number of diagnoses as the high nSES cohort. AC incidence increased most in women who are White (APC 1.8 and 2.2 for low and high nSES) and men who are Black and low nSES (APC 3.3). Five-year OS was lowest for men who are Asian American and Pacific Islander (40% and 50% for low and high nSES, respectively). These data suggest a strong correlation between nSES, race, and their interaction on the incidence and survival trends of HPV-related disease and highlight inconsistent effects between cervical and anal cancers.

The Prognostic Significance of Nativity, Enclave Residence, and Socioeconomic Status Among Hispanic Patients with Hepatocellular Carcinoma.

Residence in ethnic enclaves and nativity are both associated with survival in Hispanic patients with cancer, although their prognostic significance in patients with hepatocellular carcinoma (HCC) is unknown. We aimed to determine the association between nativity, neighborhood socioeconomic status (nSES), and ethnic enclave residency with overall survival in Hispanic patients with HCC. Hispanic patients diagnosed with HCC from 2004 to 2017 were identified in the Texas Cancer Registry. Existing indices were applied to tract-level 2000 US Census data to measure enclave residence and nSES. Enclaves were defined by seven measures. Multivariable Cox proportional hazard models were used to evaluate the association between nativity, enclave residency, and nSES with survival. Among 9496 Hispanic patients with HCC, 2283 (24%) were foreign-born. Compared with US-born Hispanic patients, foreign-born Hispanic patients were less likely to present with localized HCC (45.3% vs. 48.8%, p=0.03) and less likely to receive HCC treatment (53.9% vs. 47.6%, p<0.001); however, foreign-born Hispanic patients had lower mortality in adjusted models (adjusted hazard ratio [aHR] 0.86, 95% confidence interval [CI] 0.79-0.93). Neighborhood SES, but not enclave residence, was also associated with overall survival. Compared with those in low nSES non-enclaves, Hispanic patients in high nSES neighborhoods, with either enclave (aHR 0.80, 95% CI 0.72-0.88) or non-enclave (aHR 0.89, 95% CI 0.80-0.98) residence status and low nSES enclaves (aHR 0.93, 95% CI 0.86-0.98) had improved survival. In Hispanic patients with HCC, foreign birthplace and higher nSES, but not enclave residence, are associated with improved survival. Additional research on intersectionality between ethnicity, nativity, and neighborhood context is warranted.

Disparities in cancer stage shifts associated with the COVID-19 pandemic in California, 2020-2021.

The COVID-19 pandemic and associated shutdowns disrupted healthcare access and resulted in decreased cancer screenings. Cancer diagnosis delays have concerning downstream effects on late-stage cancer, especially for marginalized populations. The study population included 349,458 adults in the California Cancer Registry diagnosed with cancer between January 2019-December 2021, during which California experienced two stay-at-home orders. We examined the percentage of late-stage (III-IV) cancer diagnoses across five periods: Pre-Pandemic (January 2019-February 2020), Shutdown #1 (March-June 2020), Post-Shutdown #1 (July-November 2020), Post-Shutdown #2 (December 2020-March 2021), and Post-Vaccine Rollout (April-December 2021). To examine the association between time-period and late-stage diagnoses, we conducted a multivariable log binomial regression model adjusted for sociodemographic and neighborhood factors. The percentage of late-stage cancer diagnoses increased during Shutdown #1 (+5.2%) and returned to baseline Post-Vaccine Rollout. Groups with notably higher increases in the percentage of late-stage cancer (vs. overall population) during Shutdown #1 include: Pacific Islander (+13.7%), Thai (+11.2%), Chinese (+8.1%), Native Hawaiian (+7.4%), Filipino (+6.6%), and uninsured (+7.4%). Uninsured (vs. private insurance) (PR: 1.41), low neighborhood SES (nSES) (vs. high) (PR: 1.19), and racial and ethnic minoritized groups (vs. NH White) (PR's: 1.04-1.19) had higher likelihood for late-stage cancer diagnosis. The pandemic exacerbated late-stage cancer disparities for racial and ethnic minoritized groups, underinsured, and low nSES communities in California (2020-2021). Interventions to improve cancer screening must be focused on racial and ethnic minoritized, underinsured, and low nSES communities, as they are likely to be more vulnerable to healthcare disruptions like the pandemic.

Abstract B152: Joint Associations of Neighborhood Socioeconomic Status and Education on the Incidence of Colorectal Cancer: The Multiethnic Cohort Study

Abstract Background: Colorectal cancer (CRC) is the 3rd most diagnosed cancer worldwide. When considered separately, both neighborhood- and individual-level SES exposures have been associated with CRC incidence. However, the joint associations of neighborhood- and individual-level SES on CRC incidence have not been examined. Methods: In a prospective study of 153,725 Multiethnic Cohort (MEC) participants (24,764 African American, 44,447 Japanese American, 34,974 Latino, 11,511 Native Hawaiian, and 38,029 White participants) recruited from predominantly Los Angeles County, California (CA), and Hawaii (HI), we examined the joint association of neighborhood SES (nSES) and individual-level education with CRC incidence (CA: 2,519, HI: 2,210 cases). Education, other demographics, and health behaviors were self-reported in the baseline questionnaire (1993-1996). CRC diagnosis was determined via linkages with state cancer registries. nSES was derived using a composite score based on 1990 US Census block group data and assigned to geocoded baseline addresses. Our joint SES measure included four categories: high nSES (quintiles 4-5) and high education (&amp;gt; high school), high nSES and low education (≤ high school), low nSES (quintiles 1-3) and high education, and low nSES and low education. State-specific hazards ratios (HR) for CRC incidence were estimated for joint SES categories. Cox regression adjusted for age at cohort entry, CRC family history, polyp history, obesity, diabetes, diet, alcohol, smoking, physical activity, and NSAID, multivitamin, and hormone therapy use. Subgroup analyses were conducted by sex, race, and ethnicity. Results: For HI MEC participants, compared to individuals with high nSES and high education, risk for CRC was highest among those with low nSES and low education (HR=1.27; 95% CI:1.11-1.45) followed by high nSES and low education (HR=1.25; 95% CI:1.12-1.41), and low nSES and high education (HR=1.17; 95% CI: 1.03-1.31). This pattern of association was observed across sex but differed across race and ethnicity (p-heterogeneity=0.04). The overall pattern of association was observed among White participants in HI. However, for Japanese American individuals in HI, compared to those with high nSES and high education, risk for CRC was highest for low nSES and high education (HR=1.29; 95% CI:1.09-1.53) and high nSES and low education (HR= 1.28; 95% CI; 1.10-1.50). For Native Hawaiian individuals, compared to those with high nSES and high education, CRC risk was highest for those with low nSES and low education (HR=1.70; 95% CI: 1.20-2.42). Associations were not statistically significant between the joint SES measure and CRC risk in CA (HRs: 0.92-0.97). Conclusion: Among MEC participants in HI, CRC risk varied with the joint measure of nSES and education across racial and ethnic groups. These findings emphasize the importance of considering the joint associations of neighborhood- and individual-level SES in understanding racial and ethnic disparities in CRC. Citation Format: Catherine Walsh, Meera Sangaramoorthy, Songyi Park, Sung-shim (Lani) Park, Gertraud Maskarinec, Lynne Wilkens, Christopher Haiman, Anna Wu, Salma Shariff-Marco, Loic Le Marchand, Iona Cheng. Joint Associations of Neighborhood Socioeconomic Status and Education on the Incidence of Colorectal Cancer: The Multiethnic Cohort Study [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B152.

Congenital Anomalies among Offspring of Women Living in Low Socioeconomic Status Neighborhoods or Hispanic/Latino Enclaves, Texas, 1999-2018

Objectives and ApproachNeighborhood influences pregnancy outcomes through effects on maternal health. We evaluated prevalence of &gt;140 congenital anomalies monitored by the population-based Texas Birth Defects Registry among residents of Hispanic/Latino enclaves (census tracts with high proportions of Hispanic/Latino residents, immigrants, and Spanish-speaking households) and tracts with low socioeconomic status (low nSES). We included all cases regardless of pregnancy outcome (1999-2018) and a reference population of all livebirths, identified by linkage to Texas vital records. We calculated Yost socioeconomic index and Hispanic/Latino enclave index scores using linked U.S. Census Bureau data. We used Poisson regression to estimate the prevalence ratio (PR) and 95% confidence interval of anomalies among residents of: low nSES/enclave (34.5%); low nSES/non-enclave (25.6%); high nSES/enclave (4.6%); and high nSES/non-enclave (referent; 35.3%) tracts. We adjusted for maternal age, education, race/ethnicity, parity, and pre-pregnancy body mass index. ResultsLow nSES was associated with microcephaly, pulmonary artery anomalies, atrial septal defect, and Down syndrome (PRs 1.1-1.6), and inversely associated with hypospadias and other male genital anomalies (PRs 0.8-0.9). Offspring of women in low nSES enclaves were at increased risk of several congenital heart defects relative to those in other neighborhoods. Conversely, prevalence of hypospadias was lowest among offspring of women in low nSES enclaves. ConclusionsLinkage between a population-based registry, vital records, and Census Bureau data revealed novel associations between neighborhood characteristics and congenital anomalies. ImplicationsFurther research is warranted to understand mechanisms linking neighborhood factors to congenital anomalies.

Utilization of allogeneic hematopoietic stem cell transplantation among patients with newly diagnosed acute myeloid leukemia in California: a population-based linked dataset study.

Acute myeloid leukemia (AML) often requires allogeneic hematopoietic cell transplantation (alloHCT) for cure, but historically alloHCT has been strikingly underutilized. Reasons for this remain uncertain at the population level. We examined alloHCT utilization over time and explored associations between demographic/healthcare factors and use of alloHCT by age group (AYA 15-39y, adult 40-64y, older adult 65-79y) using a linked dataset merging the Center for International Blood and Marrow Transplant Research, California Cancer Registry, and California Patient Discharge Database. Eligibility included patients newly diagnosed with AML in California between 2001-2016 who received induction therapy and had no prior HCT. Multivariable Fine-Gray regression analyses were fitted separately across age groups. Among 7,925 patients with AML, alloHCT utilization increased over time across all age groups; however, in the most recent time period studied (2011-2016), utilization within 2 years of diagnosis remained lowest in older adults (13%) relative to adults (41%) and AYAs (49%). Factors statistically significantly associated with lower alloHCT utilization: (1) AYAs: female sex, lower neighborhood socioeconomic status (nSES), uninsured or Indian Health Services (IHS) coverage; (2) adults: older age, male sex, non-Hispanic Black or Asian race and ethnicity, unmarried, lower nSES, uninsured or covered by Medicaid, Medicare, or IHS, higher comorbidity, and living 100+ miles from a transplant center; and (3) older adults: older age, Asian race, and unmarried. In conclusion, using a population-based linked dataset, we demonstrate that utilization of alloHCT among older patients newly diagnosed with AML remains low in California, and factors associated with utilization vary by age group.

Multiple Environmental Exposures and the Development of Hypertension in a Prospective US-Based Cohort of Female Nurses: A Mixture Analysis.

We investigated the independent and joint associations between multiple environmental exposures and incident hypertension in a US nationwide prospective cohort of women: the Nurses' Health Study II. We followed 107,532 nonhypertensive participants from 1989 to diagnosis of hypertension, loss to follow-up, death, or end of follow-up in June 2019. We applied Cox proportional hazards models to assess associations of incident hypertension with time-varying residential exposure to air pollution, noise, surrounding greenness, temperature, and neighborhood socioeconomic status (nSES), adjusting for potential confounders and coexposures. We evaluated the joint association of simultaneous exposure using quantile g-computation. We observed 38,175 hypertension cases over 2,062,109 person-years. Increased hypertension incidence was consistently associated with lower nSES and higher levels of fine particles (PM2.5) and nighttime noise exposures: hazard ratio (HRs) and 95% confidence intervals (CIs) of 1.06 (1.04, 1.08), 1.04 (1.01, 1.07), and 1.01 (1.00, 1.03), respectively, per interquartile range change. Joint HR for a one-quartile change in simultaneous exposure to the mixture was 1.05 (95% CI: 1.02, 1.09), assuming additivity, or 1.13 (95% CI: 1.06, 1.20), considering potential interactions within the mixture. Hypertension prevention should focus on enhancing nSES and reducing PM2.5 and noise levels, recognizing that reducing the overall exposures may yield additional benefits.

Area Socioeconomic Status is Associated with Refusal of Recommended Surgery in Patients with Metastatic Bone and Joint Disease

BackgroundThis study sought to identify associations between the Yost Index, a geocoded area neighborhood socioeconomic status (nSES) score, and race/ethnicity with patient refusal of recommended surgery for metastatic bone disease.MethodsPatients with metastatic bone disease were extracted from the Surveillance, Epidemiology, and End Results database. The Yost Index was geocoded using factor analysis and categorized into quintiles using census tract-level American Community Service (ACS) 5-year estimates and seven nSES measures. Multivariable logistic regression models calculated odds ratios (ORs) of refusal of recommended surgery and 95% confidence intervals (CIs), adjusting for clinical covariates.ResultsA total of 138,257 patients were included, of which 14,943 (10.8%) were recommended for surgical resection. Patients in the lowest nSES quintile had 57% higher odds of refusing surgical treatment than those in the highest quintile (aOR = 1.57, 95% CI 1.30–1.91, p < 0.001). Patients in the lowest nSES quintile also had a 31.2% higher age-adjusted incidence rate of not being recommended for surgery compared with those in the highest quintile (186.4 vs. 142.1 per 1 million, p < 0.001). Black patients had 34% higher odds of refusing treatment compared with White patients (aOR = 1.34, 95% CI 1.14–1.58, p = 0.003). Advanced age, unmarried status, and patients with aggressive cancer subtypes were associated with higher odds of refusing surgery (p < 0.001).ConclusionsnSES and race/ethnicity are independent predictors of a patient refusing surgery for metastatic cancer to bone, even after adjusting for various clinical covariates. Effective strategies for addressing these inequalities and improving the access and quality of care of patients with a lower nSES and minority backgrounds are needed.

Impact of patient demographics and neighborhood socioeconomic variables on clinical trial participation patterns for NHL

AbstractPrior studies have demonstrated that certain populations including older patients, racial/ethnic minority groups, and women are underrepresented in clinical trials. We performed a retrospective analysis of patients with non-Hodgkin lymphoma (NHL) seen at MD Anderson Cancer Center (MDACC) to investigate the association between trial participation, race/ethnicity, travel distance, and neighborhood socioeconomic status (nSES). Using patient addresses, we ascertained nSES variables on educational attainment, income, poverty, racial composition, and housing at the census tract (CT) level. We also performed geospatial analysis to determine the geographic distribution of clinical trial participants and distance from patient residence to MDACC. We examined 3146 consecutive adult patients with NHL seen between January 2017 and December 2020. The study cohort was predominantly male and non-Hispanic White (NHW). The most common insurance types were private insurance and Medicare; only 1.1% of patients had Medicaid. There was a high overall participation rate of 30.5%, with 20.9% enrolled in therapeutic trials. In univariate analyses, lower participation rates were associated with lower nSES including higher poverty rates and living in crowded households. Racial composition of CT was not associated with differences in trial participation. In multivariable analysis, trial participation varied significantly by histology, and participation declined nonlinearly with age in the overall, follicular lymphoma, and diffuse large B-cell lymphoma (DLBCL) models. In the DLBCL subset, Hispanic patients had lower odds of participation than White patients (odds ratio, 0.36; 95% confidence interval, 0.21-0.62; P = .001). In our large academic cohort, race, sex, insurance type, and nSES were not associated with trial participation, whereas age and diagnosis were.

Disparities in Survival and NCCN Guideline-Concordant Care in Patients With Extremity Soft Tissue Sarcoma.

Based on the NCCN Guidelines for Soft Tissue Sarcoma (STS), treatment of extremity STS (ESTS) includes radiation therapy (RT) and surgical resection for tumors that are high-grade and >5 cm. ​​The aim of this study was to describe the association between neighborhood socioeconomic status (nSES), concordance with NCCN Guidelines recommendations, and outcomes in patients with ESTS. Patients with ESTS diagnosed from 2006 through 2018 were identified in SEER registries. The analytic cohort was restricted to patients with high-grade tumors >5 cm without nodal or distant metastases who received limb-sparing surgery. Patient demographics and tumor characteristics associated with receipt of RT were analyzed using adjusted regression analyses. Kaplan-Meier curves and adjusted accelerated failure time models were used to examine disparities in cancer-specific survival. Of 2,249 patients, 29.0% (n=648) received neoadjuvant RT, 49.7% (n=1,111) received adjuvant or intraoperative RT, and 21.3% (n=476) did not receive RT. In adjusted analyses, lower nSES was associated with lower likelihood of receiving RT (odds ratio, 0.70 [95% CI, 0.57-0.87]; P<.001). Low nSES was associated with worse cancer-specific survival (hazard ratio, 1.19 [95% CI, 1.01-1.40]; P=.04). Race and ethnicity were not significant predictors of receipt of RT or cancer-specific survival in the fully adjusted models. Patients from lower nSES areas were less likely to receive NCCN Guideline-recommended RT for their ESTS and had worse cancer-specific survival. Efforts to better define and resolve disparities in the treatment and survival of patients with ESTS are warranted.

Abstract WP250: The Changing Impact of Neighborhood Socioeconomic Status on Stroke Incidence in the BASIC Project

Background: Poverty is associated with increased stroke risk, but it is unclear how this has changed over time. We sought to evaluate temporal trends in stroke incidence by neighborhood socioeconomic status (nSES) in a south Texas community. Methods: Within the BASIC project, we identified all first-ever ischemic and hemorrhagic strokes among Mexican American or non-Hispanic White persons, age &gt;45, from 2010-2021, geocoded to census tract by patient home address (n=4,137). Using 5 year rolling average annual data from the American Community Survey, a composite nSES score was assigned to each census tract, reflecting aggregate neighborhood income, wealth, education, and occupation (range -1.60, 1.95; lower=poorer). For each year, the nSES percentile of each tract was determined. Incidence rates were estimated using Poisson regression, with annual population estimates as offsets, including a quadratic term for time to account for nonlinear trends. The model included annual nSES percentile, age, sex, ethnicity, and nSES-time and ethnicity-time interactions. Results: Incidence rates for high vs low nSES neighborhoods for the 45-65-year age group are shown in the Figure. Incidence rate ratios for nSES changed over time (p&lt;0.01 for interaction) in a u-shaped fashion, with no association present in 2010, a significant association in 2015 (RR for 90th vs 10th percentile nSES=0.59, 95% CI=0.49-0.70), and no association in 2021 (Figure). Conclusions: The gap in stroke incidence between the richest and poorest neighborhoods peaked in 2015 and was no longer present in 2021, due to declining rates in low nSES neighborhoods. Future work should explore the causes underlying these trends.

Neighborhood-Level Socioeconomic Status and Prescription Fill Patterns Among Patients With Heart Failure

Medication nonadherence is common among patients with heart failure with reduced ejection fraction (HFrEF) and can lead to increased hospitalization and mortality. Patients living in socioeconomically disadvantaged areas may be at greater risk for medication nonadherence due to barriers such as lower access to transportation or pharmacies. To examine the association between neighborhood-level socioeconomic status (nSES) and medication nonadherence among patients with HFrEF and to assess the mediating roles of access to transportation, walkability, and pharmacy density. This retrospective cohort study was conducted between June 30, 2020, and December 31, 2021, at a large health system based primarily in New York City and surrounding areas. Adult patients with a diagnosis of HF, reduced EF on echocardiogram, and a prescription of at least 1 guideline-directed medical therapy (GDMT) for HFrEF were included. Patient addresses were geocoded, and nSES was calculated using the Agency for Healthcare Research and Quality SES index, which combines census-tract level measures of poverty, rent burden, unemployment, crowding, home value, and education, with higher values indicating higher nSES. Medication nonadherence was obtained through linkage of health record prescription data with pharmacy fill data and was defined as proportion of days covered (PDC) of less than 80% over 6 months, averaged across GDMT medications. Among 6247 patients, the mean (SD) age was 73 (14) years, and majority were male (4340 [69.5%]). There were 1011 (16.2%) Black participants, 735 (11.8%) Hispanic/Latinx participants, and 3929 (62.9%) White participants. Patients in lower nSES areas had higher rates of nonadherence, ranging from 51.7% in the lowest quartile (731 of 1086 participants) to 40.0% in the highest quartile (563 of 1086 participants) (P < .001). In adjusted analysis, patients living in the lower 2 nSES quartiles had significantly higher odds of nonadherence when compared with patients living in the highest nSES quartile (quartile 1: odds ratio [OR], 1.57 [95% CI, 1.35-1.83]; quartile 2: OR, 1.35 [95% CI, 1.16-1.56]). No mediation by access to transportation and pharmacy density was found, but a small amount of mediation by neighborhood walkability was observed. In this retrospective cohort study of patients with HFrEF, living in a lower nSES area was associated with higher rates of GDMT nonadherence. These findings highlight the importance of considering neighborhood-level disparities when developing approaches to improve medication adherence.

Abstract A103: Joint associations of education and neighborhood socioeconomic status on smoking prevalence: The Multiethnic Cohort Study

Abstract Background: Smoking is the leading cause of cancer and cancer death. Individual- and neighborhood-level measures of socioeconomic status (SES) have been separately associated with racial and ethnic differences in smoking rates. However, the joint associations of individual- and neighborhood-level SES on smoking have not been studied. Thus, we examined the joint association of education and neighborhood SES (nSES) on smoking status in the Multiethnic Cohort (MEC) study. Methods: We conducted a cross-sectional study of the joint association of nSES and education with smoking for 166,475 MEC participants (26,350 African American, 50,207 Japanese American, 34,490 Latino, 12,326 Native Hawaiian, and 43,102 White participants) recruited from predominately Los Angeles County and Hawaii. Smoking status, education, and other demographics and health behaviors were reported at baseline (1993-1996). Neighborhood SES (nSES) was derived using 1990 US Census data on education, occupation, unemployment, household income, poverty, rent, and house values and assigned to geocoded baseline addresses; and categorized into quintiles using LA County and Hawaii nSES distributions. The joint nSES and education measure was categorized into 4 levels using high nSES (quintiles 4-5), low nSES (quintiles 1-3), high education (≥ high school), and low education (&amp;lt; high school). The study outcome was current smoking vs. non-smoking (never or former smoking). Poisson regression was used to estimate prevalence ratios (PR) and 95% CIs for the joint association of nSES and education with current smoking, adjusting for sex, race/ethnicity, marital status, physical activity, occupation, alcohol, obesity, 2015 healthy eating index, and clustering by census block group. Subgroup analyses were conducted by state (CA and HI), sex, and race/ethnicity. Results: For CA MEC participants, smoking prevalence was highest with low nSES and low education, followed by low nSES and high education, and high nSES and low education (PR=1.50, 1.33, and 1.29, respectively). This pattern was found in females but not males and in African American and Japanese American participants but not Latino or White participants. For HI MEC participants, smoking prevalence was highest with low nSES and low education, followed by high nSES and low education, and low nSES and high education (PR=1.41, 1.36, and 1.20, respectively). This pattern was found in males and females in HI and across all racial and ethnic groups. Interestingly, in Native Hawaiian participants, the smoking prevalence with low nSES and low education was similar to those with high nSES and low education (PR=1.54 and 1.52, respectively). Conclusion: In the MEC, smoking prevalence was highest in CA for females, African American, and Japanese American participants in joint SES categories with low nSES, while in HI, low education appeared more influential, especially among Native Hawaiian participants. These findings demonstrate the importance of considering both individual and neighborhood-level SES measures on smoking prevalence. Citation Format: Catherine P. Walsh, Younghan Lee, Salma Shariff-Marco, Lynne Wilkens, Loic Le Marchand, Christopher A. Haiman, Iona Cheng, S. Lani Park. Joint associations of education and neighborhood socioeconomic status on smoking prevalence: The Multiethnic Cohort Study [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 A103.

Police Violence as Containment of Black Bodies during Urban Renewal: A Spatial Analysis of Civilian Deaths by Police in Florida

abstract: This study presents a geospatial analysis of police killings within two areas in Florida over a twenty-year period. Fatalities were mapped against social and economic characteristics of neighborhoods to ascertain if police violence ending in civilian death was concentrated in areas with high-minority and low-income populations, and those areas in proximity to gentrifying neighborhoods. We evaluated the theory that police violence against minority residents serves as a process of containment and ultimately supports the continued generation of wealth by a specific sector of society through the process of gentrification. The cycle of destruction and renewal in the urban landscape is deeply intertwined with processes of capital accumulation, class differentiation, and racial subordination. Both the West Florida and Southeast Florida areas contained a significantly higher proportion of fatal encounters occurring within tracts that were eligible to gentrify than in tracts that were in the process of gentrifying. Fort Lauderdale in particular had little overlap despite containing concentrated hotspots of incidents in combination with high-minority and low–NSES tracts. This same pattern is apparent in the Lakeland area in west Florida. Our findings are consistent with Laniyonu's observation that police interactions tend to increase in tracts just outside of gentrified areas, but seldom within them.

Neighborhood socioeconomic status and race are associated with incidence disparities in oral cavity cancers

ObjectivesTo determine the association between neighborhood socioeconomic status (nSES), race and incidence rate trends of oral cavity cancer (OCC). Materials and methodsWe used data from the SEER (Surveillance, Epidemiology, and End Results) 18 Census Tract-level SES and Rurality Database (2006–2018) database of the National Cancer Institute to create cohorts of OCC patients between 2006 and 2018. Annual incidence rates were calculated and trends in rates were estimated using joinpoints regression. ResultsThe incidence of OCC is the highest among low nSES White Americans (2.86 per 100 000 persons) and the lowest among high nSES Black Americans (1.17 per 100 000 persons). Incidence has significantly increased among Asian Americans (annual percent change [APC]: low nSES-2.4, high nSES-2.6) and White Americans (APC: low nSES-1.4, high nSES-1.6). Significant increases in the incidence of oral tongue cancer in these groups primarily drive this increase. Other increases were noted in alveolar ridge cancer among White Americans and hard palate cancer among Asian Americans. OCC incidence decreased significantly in Hispanic Americans of high nSES (APC: −2.5) and Black Americans of low nSES (APC: −2.7). Floor of mouth cancer incidence decreased among most groups. ConclusionDespite the overall decreasing incidence of OCC, these trends are inconsistent among all OCC subsites. Differences are seen by race, nSES, and subsite, indicating intersectional barriers that extend beyond nSES and race and ethnicity alone. Further research on risk factors and developing interventions targeting vulnerable groups is needed.

Aircraft and road traffic noise, insulin resistance, and diabetes: The role of neighborhood socioeconomic status in San Diego County

Evidence linking traffic noise to insulin resistance and diabetes is limited and unanswered questions remain regarding the potential effect modification by neighborhood socioeconomic status (nSES). We aimed to assess socioeconomic inequalities in noise exposure, whether road and aircraft noise exposures were associated with insulin resistance or diabetes, and whether nSES modified these relationships. Among the Community of Mine Study in San Diego County, road and aircraft noise exposure at enrollment was calculated based on the static (participant's administrative boundary, and circular buffer around participant homes), and dynamic (mobility data by global positioning system, GPS) spatio-temporal aggregation methods. Associations of noise with insulin resistance (HOMA-IR) or type 2 diabetes (T2DM) were quantified using generalized estimating equation models adjusted for sex, age, ethnicity, individual income, and air pollution (nitrogen dioxide) exposure. Additive interaction between noise and nSES was assessed. Among 573 participants (mean age 58.7 y), participants living in low nSES were exposed to higher levels of aircraft and road noise using noise level at the census tract, circular buffer, or Kernel Density Estimation (KDE) of GPS data. Participants exposed to road noise greater or equal to the median (53 dB(A)) at the census tract and living in low nSES had an increased level of insulin resistance (β = 0.15, 95%CI: −0.04, 0.34) and higher odds of T2DM (Odds Ratio = 2.34, 95%CI: 1.12, 4.90). A positive additive interaction was found as participants living in low nSES had higher odds of T2DM. The impact of noise exposure on insulin resistance and T2DM differs substantially by nSES. Public health benefits of reducing exposure to road or aircraft noise would be larger in individuals living in low nSES.

The Association of Neighborhood Characteristics and Frailty in Childhood Cancer Survivors: A Report from the St. Jude Lifetime Cohort Study.

Childhood cancer survivors experience reduced physiologic reserve, or frailty, earlier and more frequently than peers. In other populations, frailty is impacted by one's neighborhood. This study's purpose was to evaluate associations between neighborhood characteristics and frailty in childhood cancer survivors. Participants in the St. Jude Lifetime Cohort Study with geocoded residential addresses were analyzed. Pre-frailty/Frailty was defined as having 1-2/≥3 of sarcopenia, muscle weakness, poor endurance, slow walking speed, and exhaustion from direct assessments. Neighborhood characteristics [e.g., access to exercise opportunities and healthy food, neighborhood socioeconomic status (nSES), and rurality/urbanicity] were determined using publicly available geospatial data. Nested multivariable logistic regression models identified associations between neighborhood characteristics and pre-frailty/frailty, adjusting for chronic health conditions, individual health behaviors and socio-demographics, and high-risk cancer treatment exposures. For our cohort (N = 3,806, 46.79% female, 81.40% white, mean age 33.63±9.91 years), compared with non-frail survivors (n = 2,573; 67.6%), pre-frail (n = 900; 23.6%) and frail survivors (n = 333; 8.7%) were more likely to live in neighborhoods with decreased exercise opportunities (frail OR: 1.62, 1.26-2.09), reduced healthy food access (pre-frail OR: 1.28, 1.08-1.51; frail OR: 1.36, 1.06-1.75), and lower nSES (pre-frail OR: 1.31, 1.12-1.52; frail OR: 1.64, 1.30-2.07). Participants had 8% increased odds (95% confidence interval, 2%-14%) of being pre-frail/frail if they lived in "resource poor" neighborhoods as opposed to "resource rich" neighborhoods after adjusting for other pre-frailty/frailty risk factors. The neighborhood a childhood cancer survivor resides in as an adult is associated with pre-frailty/frailty. This study provides valuable information for creating interventions using neighborhood-level factors to mitigate frailty and improve health outcomes in survivors. See related commentary by Bhandari and Armenian, p. 997.

Critical interactions between race and the highly granular area deprivation index in liver transplant evaluation.

Neighborhood socioeconomic deprivation may have important implications on disparities in liver transplant (LT) evaluation. In this retrospective cohort study, we constructed a novel dataset by linking individual patient-level data with the highly granular Area Deprivation Index (ADI), which is advantageous over other neighborhood measures due to: specificity of Census Block-Group (versus Census Tract, Zip code), scoring, and robust variables. Our cohort included 1377 adults referred to our center for LT evaluation 8/1/2016-12/31/2019. Using modified Poisson regression, we tested for effect measure modification of the association between neighborhood socioeconomic status (nSES) and LT evaluation outcomes (listing, initiating evaluation, and death) by race and ethnicity. Compared to patients with high nSES, those with low nSES were at higher risk of not being listed (aRR=1.14; 95%CI 1.05-1.22; p<.001), of not initiating evaluation post-referral (aRR=1.20; 95%CI 1.01-1.42; p=.03) and of dying without initiating evaluation (aRR=1.55; 95%CI 1.09-2.2; p=.01). While White patients with low nSES had similar rates of listing compared to White patients with high nSES (aRR=1.06; 95%CI .96-1.17; p=.25), Underrepresented patients from neighborhoods with low nSES incurred 31% higher risk of not being listed compared to Underrepresented patients from neighborhoods with high nSES (aRR=1.31; 95%CI 1.12-1.5; p<.001). Interventions addressing neighborhood deprivation may not only benefit patients with low nSES but may address racial and ethnic inequities.

Utilization of Autologous HCT in Multiple Myeloma: A Novel Linkage of CIBMTR, Cancer Registry and Hospitalization Data in California

Introduction: Autologous hematopoietic cell transplant (autoHCT) is associated with improved overall survival for patients with multiple myeloma (MM), but utilization remains low. While MM disease characteristics and patient comorbidities inform the complex decision to proceed with autoHCT, race/ethnicity, neighborhood socioeconomic status (nSES) and health insurance have also been shown to strongly associate with use of autoHCT. Using a novel data linkage, we assess autoHCT utilization patterns over time and attempt to confirm previously seen associations between sociodemographics and access to transplant. Methods: This retrospective cohort study used linked data between the California Cancer Registry (CCR), the Center for International Blood and Marrow Transplant Research (CIBMTR) and the California Patient Discharge Database (PDD). From the CCR, we identified patients ages 18-79 diagnosed with first primary MM between 1991 and 2016 that were linked to the CIBMTR or PDD (95.5% of eligible CCR patients). Use of autoHCT was ascertained from all three sources. We estimated the cumulative incidence of autoHCT after MM diagnosis and determined the association of sociodemographic factors with receipt of autoHCT using multivariable Cox proportional hazards regression. Secondary analyses assessed interactions of race/ethnicity, nSES, and health insurance by year of diagnosis. All analyses accounted for death as a competing risk. Results: The cohort consisted of 29,109 MM patients with a median follow-up time of 10.2 years. Non-Hispanic White (NHW), Black/African American (B/AA), Hispanic, and Asian patients comprised 57%, 14%, 20% and 9% of the cohort, respectively. Overall, 18.9% of patients (n=5500) underwent an autoHCT. Median time from diagnosis to transplant was 9.7 months (interquartile range: 6.9-16.2). The CIBMTR captured 70.8% of autoHCTs (17.8% all three sources, 36.7% CIBMTR and PDD, 10.2% CIBMTR and CCR, and 6.1% CIBMTR only); the remaining autoHCTs were captured from PDD only (19.0%), CCR only (4.7%) or PDD and CCR (5.5%). The cumulative incidence of autoHCT at 12 months increased in recent time periods (Figure 1). During 1991-2016, compared with NHW patients B/AA patients were less likely to undergo autoHCT (adjusted Hazard Ratio [HR] and 95% confidence interval [CI] (HR: 0.79, CI: 0.72 - 0.86) while Hispanic and Asian patients had similar utilization of autoHCT. Those residing in low nSES (HR 0.77, CI: 0.72 - 0.82)) or intermediate nSES ((HR 0.86, CI: 0.80 - 0.92)) versus highest nSES and those covered by Medicaid (HR 0.69, CI: 0.64 - 0.76) or Medicare (HR 0.83, CI: 0.78 - 0.89) compared to private insurance were also less likely to undergo autoHCT. Furthermore, findings indicate interactions of year of diagnosis with race/ethnicity (p for interaction <0.001), nSES (p <0.001) and health insurance (p =0.001). In models stratified by time period, Hispanic (HR 0.63, CI: 0.41 - 0.97) patients were less likely to have an autoHCT than NHW patients in 1991-1995, but less so in later years. B/AA patients had lower utilization throughout the study period, particularly after 2005. The differences for patients residing in the lowest versus highest nSES became less pronounced over time, with the strongest association observed in 1991-1995 (HR 0.38, CI: 0.26 - 0.56). Patients with Medicare were less likely to undergo autoHCT after 2006, while patients with Medicaid were less likely to undergo autoHCT over the entire study period. Multivariable models restricted to the 2011-2016 time period are presented in Table 1. Conclusion: This is the first study to evaluate autoHCT utilization and sociodemographic factors in MM over time. Despite increased overall utilization, we found that B/AA patients were less likely than NHW patients to receive autoHCT with no change over time. Contrary to prior studies, Hispanic patients were less likely to undergo autoHCT only in the earliest era. We also observed that patients residing in the lowest nSES neighborhoods were less likely to utilize autoHCT, but differences decreased over time. Finally, those with public funded health insurance were less likely to undergo autoHCT. Additional studies are needed to further identify barriers to autoHCT utilization, particularly in B/AA patients and those with public health insurance. Identifying and mitigating these barriers is essential to ensuring greater and more equitable access to this highly effective therapy. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Impact of Patient Demographics and Neighborhood Socioeconomic Variables on Clinical Trial Participation Patterns for Non-Hodgkin Lymphoma at a Major Academic Institution

Background: There have been tremendous advancements in Non-Hodgkin Lymphoma (NHL) therapies and outcomes in large part due to clinical trials. Prior studies have demonstrated that certain populations including the elderly, certain racial and/or ethnic minority groups, and women are underrepresented in cancer clinical trials. Better understanding of how social context impacts clinical trial enrollment will allow us to better design tailored interventions to address barriers to clinical trial participation. We performed a retrospective analysis of patients with NHL seen at MD Anderson Cancer Center (MDACC) to systematically investigate the association between clinical trial participation patterns and sociodemographic context measured by neighborhood socioeconomic factors based on place of residence. Examining our practice patterns may then inform strategies to enhance trial recruitment of underrepresented groups. Methods: We examined 3448 patients, age ≥18 years with a diagnosis of NHL seen at MDACC between January 2017 and December 2020. Using patient address, geolocation software and American Community Survey (2015 - 2020) and 2020 census data available through data.Census.gov we ascertained 35 neighborhood level socioeconomic status (nSES) variables corresponding to each census tract including the domains of educational attainment, neighborhood median income, poverty, crowding, race composition and home values. We performed descriptive analysis to understand the demographics of the total populations and those enrolled in clinical trials. We performed univariate analysis of clinical trial enrollment patterns by sex, race, age, histology type, insurance type and nSES variables using 2-sample t-test and Mann-Whitney tests (MHT). Using exhaustive variable selection based upon minimizing the Akaike Information Criteria, including 2-way interactions, we found the set of variables that generated an optimal generalized additive logistic regression model for incidence of participation in clinical trials. We repeated this procedure for the diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL) subgroups. We adjusted alpha 0.05/3=0.017 as the criteria for significance in these models to address multiple testing. Results: We excluded 130 patients with international patient addresses and 427 patients without complete address information. and found no significant difference in baseline characteristic or clinical trial enrollment between the 572 excluded patients and the study cohort of 2943 patients. The study population was 59% male, 74.6% Non-Hispanic white (NHW), 13.2% Hispanic, 6.1% black, 3.7% Asian; 29.5% had DLBCL, 22% FL, 13.2% mantle cell, 9% marginal zone, 8.3% T-cell, and 6.5% high grade B cell lymphoma. The most common insurance was managed care 47% and Medicare 45.7%; 2.5% of patients were self-pay, 1.2% had Medicaid, and 2.1% had other government insurance. There was a high overall clinical trial participation rate of 30.5% with 20.9% enrolled in therapeutic trials and participation differed by diagnosis (Table). In univariate analyses, lower participation rates were associated with lower nSES including: increasing % of populations living below poverty level, increasing % living in crowded households, increasing % above age 25 years with less than high school diploma, and decreasing median household income. Racial composition of census tract was not associated with differences in clinical trial participation. Participation did not differ by insurance type. In multivariable analysis, incidence of participation declined nonlinearly with age in the overall, FL, and DLBCL models. In the DLBCL subset Hispanic patients had lower odds of participation than Whites (odds ratio 0.34, p=0.0003). No nSES variable predicted clinical trial participation in these models. Conclusion: In a large academic cohort, age and diagnosis not race, gender, insurance type, or nSES were independent predictors of trial participation. One major limitation to the generalizability of these results is the select patient population seen at our institution are relatively well insured. Examination of multi-center datasets including community practices when underinsured patients received care and evaluation of interventions to influence access to clinical trials are needed. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal