Native American Patients Research Articles

Improving Cancer Care Accessibility for Native American Patients

Improving Cancer Care Accessibility for Native American Patients

Abstract P143: Racial Disparities In Acute Renal Failure Incidence Amidst Hypertensive Emergencies

Introduction: Persons from diverse backgrounds are disproportionately affected by adverse outcomes related to hypertension. We aimed to examine the likelihood of requiring hemodialysis during hospitalization in patients admitted for hypertensive emergency by race. Methods: We analyzed the 2020 National Inpatient Sample data to evaluate patients primarily admitted for hypertensive emergencies and acutely required hemodialysis. Patients who were already on hemodialysis were excluded. To assess for correlations, we applied logistic and linear regression analyses, taking into account potential confounders. The threshold for statistical significance was established at a 2-tailed p-value <0.05. Results: In 2020, of 1,221,535 hypertensive emergency hospital admissions, 128,095 (10.5%) necessitated hemodialysis due to acute renal failure. After controlling for age, gender, hospital characteristics, insurance status, income, and Elixhauser comorbidities, we found that Black, Hispanic, Asian/Pacific Islander, and Native American patients had higher likelihoods of requiring hemodialysis compared to White patients, with aORs of 1.88 (95% CI 1.79-1.96), 2.96 (95% CI 2.74-3.19), 3.29 (95% CI 2.99-3.62), and 2.57 (95% CI 2.18-3.04) respectively (Figure 1). Conclusion: This analysis was unable to account for the degree of hypertension control prior to admission, a significant limitation. Further investigation is needed to discern what factors preceding or during hospital admission increase the risk of acute renal failure, in order to address these observed racial disparities in outcomes for patients with hypertensive emergencies.

Racial Disparities in Atrial Fibrillation After Coronary Artery Bypass: Impact of Left Atrial Volume

BackgroundPrior studies have demonstrated a lower prevalence of postoperative atrial fibrillation (POAF) in Black, Hispanic, Asian, and Native American patients compared with White cohorts after coronary artery bypass grafting. We hypothesized that preoperative differences in left atrial size may explain this disparity. MethodsWe assessed the incidence of new POAF in 1218 patients (215 minority patients and 1003 White patients) undergoing isolated, first-time coronary artery bypass grafting from January 2017 through September 2022. Preoperative left atrial volume index (LAVi) was assessed by transthoracic echocardiography. ResultsMinority patients were younger and more likely to be female, with more comorbidities, including diabetes, prior stroke, and dialysis. There was no difference in postoperative mortality, stroke, renal failure, or reoperation for bleeding between minority and White patients. Whereas minority patients had higher blood product use and longer intensive care unit and postoperative lengths of stay, they experienced a lower incidence of new POAF (19.5% [42/215] vs 29.5% [292/1003]; P = 0.02). Mean LAVi was similar between minority and White patients (30.3 ± 12.6 mL/m2 vs 29.9 ± 10.1 mL/m2; P = .64). However, for White patients, LAVi was higher for patients with POAF than for patients without POAF (31.3 ± 10.9 mL/m2 vs 29.3 ± 9.7 mL/m2; P = .007), whereas for minority patients, LAVi was similar for patients with and without POAF (30.7 ± 26.0 mL/m2 vs 30.3 ± 11.7 mL/m2; P = .84). ConclusionsDespite more comorbidities, higher transfusion rates, and longer length of stay, minority patients had a significantly lower incidence of POAF compared with White patients but no difference in preoperative LAVi. Larger LAVi may be predictive of POAF in White patients but not in minority patients.

Race and Sex Disparities in Lower Extremity Total Joint Arthroplasty: A Retrospective Database Study.

Total joint arthroplasty (TJA) is successful in improving health-related quality of life. However, outcomes vary in the literature due to modifiable and non-modifiable factors. Modifiable factors consist of body mass index (BMI), nutrition, and tobacco use. Non-modifiable risk factors include age, race, sex, and socioeconomic status. Prior literature has focused on racial disparities in terms of the utilization of lower extremity arthroplasty. The purpose of this study is to determine the effect of race and sex on the in-hospital complication rate, length of stay, and charges associated with primary TJA. This retrospective cohort utilized complex survey data from the National Inpatient Sample (NIS) between 2016 and 2019. The use of the International Classification of Disease-10 Procedure Codes (ICD-10 PCS) for right hip, left hip, right knee, and left knee TJA yielded a preliminary total of 2,660,280 patients. The exclusion criteria were bilateral arthroplasty and concomitant unilateral hip and knee arthritis. Major complications were defined as acute myocardial infarction, cardiac arrest, pulmonary embolism, adult respiratory distress syndrome, stroke, shock, and septicemia. Odds ratio (OR) and beta coefficients were adjusted for age, sex, primary payer, hospital region, hospital teaching status, and year. Total charges were adjusted for inflation using the Consumer Price Index data reported by the US Bureau of Labor Statistics. A total of 2,589,510 patients met our inclusion criteria; 87.6%, 5.9%, 4.8%, 1.4%, and 0.3% of people were 'White', 'Black', 'Hispanic', 'Asian, or Pacific Islander', and 'Native American', as defined by the National (Nationwide) Inpatient Sample (NIS) Variable 'RACE'. Black individuals experienced a significantly greater major complication rate compared to White individuals (0.87% vs. 0.74%, OR 1.25, p-value = 0.0004). Black and Hispanic individuals experienced a significantly greater minor complication rate compared to White individuals (6.39% vs. 4.12%, odds ratio (OR) 1.61, p-value < 0.0001; 4.68% vs. 4.12%, OR 1.17, p-value < 0.0001). Black, Hispanic, Asian or Pacific Islander, and Native American individuals stayed, on average, 0.33, 0.19, 0.19, and 0.25 days longer than White individuals (2.78, 2.54, 2.55, 2.56 vs. 2.37 days, p<0.0001). None of these statistically significant differences exceeded the established minimal clinically important difference of two days. Black, Hispanic, and Asian or Pacific Islander patients were charged $5,751, $18,656, and $12,119 more than White patients ($72,122, $85,027, $78,490, and $59,297 vs. $66,371, p ≤ 0.0165). Native American patients were charged $7,074 less than White patients ($59,297 vs. $66,371, p < 0.0001). Black and Hispanic TJA patients may have higher complication rates than White TJA patients. The differences in length of stay between race groups may not affect outcomes. Hispanic patients received significantly more charges than White patients, and Native American patients received significantly fewer charges than White patients after controlling for non-modifiable risk factors. Addressing the charge disparities may reduce the total national cost burden associated with TJA. The present study highlights the need for further studies on healthcare outcomes related to race and sex.

Confidentiality and Contraception: Protecting Adolescent Care in Response to One State's “Parents' Bill of Rights”

PurposeThis study aims to analyze parent responses to current strict Oklahoma confidentiality and consent laws in an outpatient subspecialty setting. MethodsA consent for treatment form including an explanation of the benefits of qualified confidential care for adolescents was given to parents of patients under 18 years of age. The form asked parents to waive the right to access confidential portions of the medical record, be present for the physical exam, be present for risk behavior discussions, and consent for hormonal contraception including a subdermal implant. Demographic information was collected using patient medical records. Data were analyzed using frequencies, chi-square, and t tests. ResultsOf the 507 parent forms, 95% of total parents gave permission for providers to have confidential conversations with the patients, 86% allowed providers to examine the patient alone, 84% of parents allowed providers to prescribe contraception, and 66% gave permission for subdermal implant. New patient status, race, ethnicity, assigned sex at birth, and insurance type did not correlate with parents’ willingness to provide permissions. There was a statistically significant difference between patient gender identity and percentage of parents who granted permission for a confidential physical exam. Groups more likely to discuss questions about confidential care with the health care provider included parents of new patients, Native American and Black patients, and cisgender female patients. DiscussionDespite laws that limit adolescent ability to access confidential care in Oklahoma, the majority of parents who were provided an explanatory document allowed their children the right to access this care.

Access to National Cancer Institute (NCI)–designated cancer centers among Native American patients with cancer.

e18646 Background: Native Americans (NA) have some of the highest mortality rates from cancer in the US. Despite that, they face significant geographic barriers to access to cancer care. However, little study addresses disparities in accessibility in NA population. This study aims to estimate the travel distance to National Cancer Institute (NCI)-designated cancer center for NA patients in Utah and the continental US. Methods: We first retrospectively collected geographic information of patients with genitourinary cancer (NA vs. white) from Feb 1, 2013, to Jan 31, 2023. The travel distance from patients’ home zip code to Huntsman Cancer Institute (HCI) at the University of Utah was calculated using GeoData ZIP Code Distance Calculations Matrix Template. Then, the shapefile was downloaded from the NCI website. Area Deprivation Index (ADI) state decile was used to match between NA reservations and the control block groups within the same state. The travel time was calculated using Google map. Locations were mapped in ArcGIS 10.7 using coordinates and a 5-digit zip code tabulation area (ZCTA). Results: During the ten-year period of time, a total of 468 NA patients were seen in our cancer clinic. The median travel distance for NA patients vs. white patients to HCI is 190.6 mi (range: 1.1-596.4 mi) vs. 21.6 mi (range: 1.1-269 mi, p&lt; 0.0001). In the continental US, the median travel distance from NA reservations vs. ADI-matched block groups to the nearest NCI-designated cancer centers is 186.5 mi (range 77.8-629 mi) vs. 159 miles (range 1.9-671.3 mi, p&lt; 0.01) (Table). Map data and travel time will be presented at the meeting. Conclusions: The travel distance to HCI for NA cancer patients in Utah was almost nine times longer than that of white cancer patients. It is also significantly longer from most NA reservations to the nearest NCI-designated cancer centers compared to ADI-matched block groups. This study highlights the significant disparity in cancer care accessibility faced by Native American communities and the urgent need for action to address this issue. [Table: see text]

Pan tumor outcomes to immune checkpoint inhibitors in patients of Native American origin in the United States: The multicenter POINT-US study.

2654 Background: Despite receiving identical standard-of-care therapies, epidemiological data indicate that Native American (NA) patients (pts) with cancer have worse outcomes vs. White pts. ICIs have revolutionized the treatment of certain tumors, however pts from certain racial and ethnic groups, including NA pts, are underrepresented in ICI trials. Methods: This is an ongoing multi-center retrospective study across four U.S. academic cancer centers that serve a high volume of NA pts. We included pts with self-reported race as NA in electronic medical records. We evaluated clinical outcomes and immune-related adverse events (irAEs) of 71 NA pts age ≥18 years with various solid tumors treated with ICI-based therapies between 2015 to 2021. IrAEs were defined based on the Common Terminology Criteria for Adverse Events (version 5.0) or RECIST 1.1. as available, was used to determine objective response rate (ORR). Kaplan Meier log-rank method was used to generate median progression free survival (mPFS) and median overall survival (mOS). Results: Median age (range) at ICI initiation was 62 (24 -81) years; 43 (60%) were males, with 26 (37%) females, 2 pts with missing gender data. 55 (77%) of pts had ECOG performance status 0. The distribution of top six tumor types included (number of pts [%]): non-small cell lung cancer (NSCLC) 22 (31%), renal cell carcinoma (RCC) 16 (23%), melanoma 7 (10%), small cell lung cancer (SCLC) 4 (6%), hepatocellular carcinoma 4(6%); colorectal adenocarcinoma, head and neck squamous cell carcinoma, cervical squamous cell carcinoma each had 3 pts (4%). Most pts (51 [72%]) received single agent ICI, 12 (17%) had dual ICI, 4 (6%) had chemotherapy+ ICI, and remaining had either ICI + tyrosine kinase inhibitor or ICI + study drug (4 [6%]). 55% of pts with NSCLC underwent tumor next-generation sequencing (NGS) while &lt;30% of patients with renal cell carcinoma or melanoma had tumor NGS performed. Among 71 pts, 17 (24%) had any grade (G) irAE, 4 (6%) were reported to be ≥G3. The median time to irAE onset was 18 weeks and 3 (4%) pts discontinued ICI due to irAEs. The mPFS, mOS and ORR for the most frequent tumors (N ≥5) are shown. Conclusions: Although limited by sample size, our emerging data provides new insights into ICI efficacy and irAEs in NA pts that have been unknown to date. To our knowledge, this is the first and only attempt to date evaluating ICI outcomes in NA pts. Updated clinical data and tumor genomics will be presented at the meeting. [Table: see text]

Trends of Concomitant Diabetes and Peripheral Artery Disease and Lower Extremity Amputation in US Medicare Patients, 2007 to 2019.

Previous studies demonstrate geographic and racial/ethnic variation in diagnosis and complications of diabetes and peripheral artery disease (PAD). However, recent trends for patients diagnosed with both PAD and diabetes are lacking. We assessed the period prevalence of concurrent diabetes and PAD across the United States from 2007 to 2019 and regional and racial/ethnic variation in amputations among Medicare patients. Using Medicare claims from 2007 to 2019, we identified patients with both diabetes and PAD. We calculated period prevalence of concomitant diabetes and PAD and incident cases of diabetes and PAD for every year. Patients were followed to identify amputations, and results were stratified by race/ethnicity and hospital referral region. 9 410 785 patients with diabetes and PAD were identified (mean age, 72.8 [SD, 10.94] years; 58.6% women, 74.7% White, 13.2% Black, 7.3% Hispanic, 2.8% Asian/API, and 0.6% Native American). Period prevalence of diabetes and PAD was 23 per 1000 beneficiaries. We observed a 33% relative decrease in annual new diagnoses throughout the study. All racial/ethnic groups experienced a similar decline in new diagnoses. Black and Hispanic patients had on average a 50% greater rate of disease compared with White patients. One- and 5-year amputation rates remained stable at ≈1.5% and 3%, respectively. Native American, Black, and Hispanic patients were at greater risk of amputation compared with White patients at 1- and 5-year time points (5-year rate ratio range, 1.22-3.17). Across US regions, we observed differential amputation rates, with an inverse relationship between the prevalence of concomitant diabetes and PAD and overall amputation rates. Significant regional and racial/ethnic variation exists in the incidence of concomitant diabetes and PAD among Medicare patients. Black patients in areas with the lowest rates of PAD and diabetes are at disproportionally higher risk for amputation. Furthermore, areas with higher prevalence of PAD and diabetes have the lowest rates of amputation.

Evaluating racial disparities in central-line–associated bloodstream infections for Tennessee hospitals, 2018–2021

Background: Central-line–associated bloodstream infections (CLABSIs) significantly burden the US population and healthcare system. Reporting facilities in Tennessee consistently omit race and ethnicity data in the NHSN despite having the option to enter. Racial and ethnic disparities are well documented across many health outcomes, including patient safety. CLABSIs were compared among 3 racial groups to better understand the impact of race on CLABSI incidence in Tennessee. Methods: CLABSI data from NHSN were linked with records from the TN Hospital Discharge Data System (HDDS) for 2018–2021. A multivariable linear regression model was used to determine relative risk (RR) between racial groups for contracting a CLABSI after controlling for confounding variables including Charlson comorbidity index (CCI) and social vulnerability index (SVI) scores. Statistical significance was set at P &lt; .05. Data linkage and statistical analyses were performed in SAS version 9.4 software. Results: In Tennessee between 2018 and 2021, 342 (17.2%) of the 1,980 CLABSI events had race documented, and no ethnicity variables exist in the NHSN. The data linkage process yielded a 72% match (1,426 CLABSIs). The remaining 28% were excluded from the analysis. Per 1,000 central-line days (CL days) for all races, white patients had the highest CLABSI rate (17.5), followed by Black patients (1.36), and Native American or Alaskan Native patients (0.68). Per 1,000 admissions by race, Black patients had a higher CLABSI rate (1.26) than Native American/Alaskan Native patients (0.85) and white patients (0.75). The risk of contracting a CLABSI was 79% higher in Black patients than in white patients (RR, 1.79; 95% CI, 1.55–2.07; P &lt; .0001) when controlling for CCI, age group, and SVI. Conclusions: These results suggest that racial disparities between Black and white patients are present in Tennessee hospitals regarding CLABSIs. Although most CLABSI events were linked to HDDS patients, there were limitations in the ability to match all cases and calculate CL days by race. This study highlights the need for complete race and ethnicity data in the NHSN. Further studies should examine infection types at the regional and facility levels to target interventions for reducing HAI inequities in Tennessee.Disclosures: None

Does race influence the attainment of the principles of oncologic surgical resection in colon adenocarcinoma? A retrospective cohort analysis from the national cancer database.

The authors performed a retrospective cohort study of all cases of resectable colon adenocarcinoma who underwent surgical resection in the National Cancer Database between 2004 and 2018. The postoperative lymph node count and margins were grouped as 'principles of oncologic surgical resection'. A multivariate logistic regression analysis was performed to assess race and other demographic variables as independent factors influencing the attainment of the principles of oncologic resection. A total of 456746 cases were included. From this cohort, 377344 (82.6%) achieved an adequate oncologic resection and 79402 (17.4%) did not. On logistic regression, African American and Native American patients were less likely to attain an adequate oncologic resection. Similarly, patients with an elevated Charlson-Deyo score (2 or above), stage I cancer, and patients who underwent extended resection were less likely to achieve adequate oncologic resection. Resections performed in metropolitan areas, patients with private insurance, high-income quartiles, and patients diagnosed in more recent years were more likely to achieve adequate oncologic resection. There are significant racial disparities regarding the attainment of the principles of oncologic resection in colon cancer, which could be explained by unconscious biases, social discrepancies, and inadequate healthcare access. Early introduction and conscientization of unconscious biases are required in surgical training.

Abstract 754: Exploring racial and ethnic disparities in pain medication use in patients with colorectal cancer

Abstract Background: Pain management is a substantial component of treating patients with colorectal cancer (CRC). CRC-related pain occurs in over 70% of patients and is among the most frequently reported adverse events in this patient population. CRC-related pain is multifactorial and includes nociceptive, neuropathic, and psychogenic origins. CRC-related pain is primarily managed by medications, including opioid and non-opioid analgesics, corticosteroids, and antiepileptics. Among these, opioids are by far the most utilized treatment. Prior literature suggests racial and ethnic differences in the use of some pain medications, including opioids, in patients with cancer, but there is no research confirming these findings in patients with CRC. Methods: Utilizing the National Cancer Institute Surveillance Epidemiology and End Results (NCI SEER)- Medicare-linked database, our analysis included all patients with a CRC diagnosis and a newly initiated outpatient prescription claim for pain medications from 2009-2018. Patients on pain medications before CRC diagnosis or of unspecified race or ethnicity were excluded from the analysis. We assessed three classes of pain medications, including opioids, non-opioid analgesics, and neuropathic analgesics. Prescription claims were specific to patients diagnosed with CRC and stratified by self-identified race and ethnicity. Our objective was to characterize the relationship between race and receipt of pain medications in the first year following the diagnosis of CRC. Results: After the application of the inclusion/exclusion criteria, 136,014 patients with CRC were identified and included in the analysis (White: 81.6%; Black/African American: 11.2%; Asian/Pacific Islander: 4.3%; Hispanic: 2.6%; Native American 0.29%). As compared to White patients, Black/African American (Odds Ratio [OR] 0.96; 95% Confidence Interval [CI]: 0.92-0.99) and Asian/Pacific Islander patients (OR 0.75; 95% CI: 0.71-0.79) were less likely to be prescribed an opioid analgesic, while Native American patients were more likely (OR 1.42; 95% CI: 1.16-1.73). Asian/Pacific Islander (OR 1.60; 95% CI: 1.48-1.73) and Hispanic (OR 1.57; 95% CI: 1.42-1.73) patients were more likely to be prescribed a non-opioid analgesic as compared to White patients. Black/African American (OR 1.06; 95% CI: 1.01-1.12) and Native American (OR 1.57; 95% CI: 1.22- 2.03) patients were more likely to be prescribed a neuropathic analgesic compared to White patients. No other differences were noted in pain medication use by race or ethnicity. Conclusion: Our study findings suggest that pain medication usage in patients with CRC varies for patients from historically minoritized racial and ethnic groups compared to White patients. Future research should explore the barriers and facilitators of pain medication usage patterns in patients from historically minoritized racial and ethnic groups with CRC. Citation Format: John M. Allen, MegCholack Awunti, Yi Guo, Sherise C. Rogers, Lisa Scarton, Diana J. Wilkie. Exploring racial and ethnic disparities in pain medication use in patients with colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 754.

Abstract 4258: Racial and ethnic differences in the mutational landscape of low-grade serous ovarian cancer

Abstract Objective To characterize the mutational landscape of low grade serous ovarian cancer (LGSOC) with racial/ethnic stratification. Methods The AACR Project GENIE database version 12.0 was queried via cBioPortal (http://genie.cbioportal.org) for low-grade serous ovarian cancer (LGSOC) samples. This is a publicly available, de-identified, multi-institutional database of next-generation sequencing genomic profiling results for tumor samples. Mutation frequencies for 9 homologous recombination deficiency (HRD) genes, 4 MAP-Kinase (MAP-K) pathway genes and 6 mismatch-repair (MMR) deficiency genes were reported and compared between racial/ethnic groups using chi-squared or Fischer’s exact tests. The threshold used for statistical significance was a two-sided alpha of 0.05. Results Among 317 tumor samples of LGSOC, there were high rates of MAP-K pathway gene mutations but low rates of HRD, MMR and TP53 gene mutations (Table 1). Non-Hispanic Black patients had significantly higher rates of KRAS mutations compared to non-Hispanic White patients (6/7, 86% vs 48/178, 27%, p&amp;lt;0.01). There was no difference in KRAS mutation frequency among Asian (6/17, 35%), Hispanic (7/24, 29%) and Native American (2/2, 100%) patients when compared to non-Hispanic White patients. BRAF mutations were less common compared to KRAS mutations (32/317, 10%), with no racial/ethnic differences in mutation frequency. Conclusion High rates of MAP-K pathway mutations in LGSOC support development and trials of drugs targeting this pathway, such as MEK protein inhibitors. Furthermore, prior literature has demonstrated the prognostic advantage of KRAS and BRAF mutations in LGSOC as well as the association of KRAS mutations with progression of serous borderline tumors to LGSOC. These racial/ethnic differences in frequencies of these mutations are thus hypothesis generating for clinical research to evaluate the impact of race/ethnicity on the development and prognosis of this rare ovarian cancer. Mutation frequencies of HR, MAP-kinase, MMR and TP53 genes in low-grade serous ovarian cancer Gene No. of samples with ≥1 mutation No. of samples profiled for mutation Mutation frequency BRCA1 3 287 1.05 BRCA2 7 287 2.44 BRIP1 5 271 1.85 CHEK2 2 278 0.72 BARD1 2 239 0.84 RAD51B - - - RAD51C - - - RAD51D 2 246 0.81 PALB2 2 279 0.72 KRAS 93 317 29.34 NRAS 29 317 9.15 BRAF 32 317 10.09 EIF1AX 14 144 9.72 MSH2 3 275 1.09 MSH3 1 113 0.88 MSH6 6 286 2.10 MLH1 1 317 0.32 MLH3 3 96 3.13 PMS2 1 270 0.37 TP53 12 317 3.79 Citation Format: Muhammad Danyal Ahsan, Emily M. Webster, Sarah R. Levi, Natalie T. Nguyen, Juan R. Cubillos-Ruiz, Evelyn Cantillo, Eloise Chapman-Davis, Melissa K. Frey, Kevin Holcomb. Racial and ethnic differences in the mutational landscape of low-grade serous ovarian cancer. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4258.

Abstract 5530: A community led approach to addressing disparities in pancreatic cancer care for Native Americans in Oregon

Abstract Pancreatic adenocarcinoma (PDAC) is the third leading cause of cancer-related deaths in the United States (US). Due to unique barriers facing Native Americans (NA) patients, this underrepresented population has worse outcomes and increased mortality. In Oregon, NAs have nearly double the PDAC incidence rate compared to the general US population. Oregon Health &amp; Science University (OHSU) is a leader in PDAC care and research, yet NAs remain underrepresented in pancreatic cancer research at OHSU, and across the country. This highlights the need for a focused and comprehensive research program that collaborates with local tribal communities to identify specific issues and barriers that can be addressed to improve patient care in the NA population. We hypothesize that if we establish a workflow that strengthens existing relationships with tribal communities and leverages established OHSU infrastructure and expertise, we can directly address the unmet need of understanding, preventing and treating PDAC for NA individuals in our local communities. This includes increasing enrollment of NAs in PDAC clinical trials and developing a genetic registry that could help both depict genetic underpinnings that predispose NA individuals to PDAC and potentially guide therapeutic approaches. To build trust within NA communities, we initiated collaborations with Oregon tribes to develop culturally appropriate programs guided by NA community members. Through OHSU’s Northwest Native American Center of Excellence, we developed a close relationship with the Confederated Tribes of Warm Springs. Together with our institution’s Community Outreach, Research, and Engagement (CORE) team, we are working with the Confederated Tribes of Warm Springs to better understand provider and NA community member attitudes towards and barriers to clinical trial participation. We will incorporate these perceptions into a tribe-specific program that describes the multi-faceted facilitators and barriers that inform decision-making. Moreover, we are implementing a patient navigator program to help NA patients overcome clinical trial barriers by providing culturally appropriate patient education, reimbursement for travel-associated expenses, local administration of chemotherapy, and telehealth capabilities. Future work includes co-implementing strategies for tribes to review incoming research requests with the goal of implementing a system to promote awareness and enrollment of NAs in PDAC clinical research. This system will be then be utilized to establish the first NA PDAC tissue registry to identifying gene-environment interactions and unique genetic alterations that may predispose NA individuals to PDAC. Overall, this collaborative work will create a roadmap for engagement and a conscientious process to provide awareness and the best in class treatment for NA individuals with PDAC. Citation Format: Claymore Kills First, Grace A. McCarthy, Charles D. Lopez, Brett C. Sheppard, Jackilen Shannon, Jonathan R. Brody. A community led approach to addressing disparities in pancreatic cancer care for Native Americans in Oregon. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5530.

Identifying disparities in brachytherapy delivery for locally advanced cervical cancer

IntroductionThe standard of care for locally advanced cervical cancer is concurrent chemotherapy and external beam radiation therapy (EBRT) followed by a brachytherapy boost. Some studies show a decreased usage of brachytherapy in cervical cancer patients despite the standard of care and known survival advantage. This study aims to characterize the utilization of brachytherapy in Oregon and identify where disparities in treatment may exist. MethodsThe Oregon State Cancer Registry database was used to identify patients diagnosed with FIGO Stage IB2-IVB cervical cancer between 2007 and 2016. Patients who received initial EBRT were categorized by whether they received brachytherapy boost or not. Age at diagnosis, county of patient residence, rural-urban status of the county, race/ethnicity, and insurance payer were studied using multivariable logistic regression to identify possible underserved populations. Survival data was compared using a Cox proportional hazard survival model. Results401 patients who received primary EBRT for FIGO stage IB2-IVB cervical cancer were identified in the 10-year span. Breakdown by stage is: 16% stage IB2, 23.9% stage II, 37.4% stage III, and 22.7% stage IV. Of those, 154 (38.4%) received brachytherapy boost treatment, 75 (18.7%) received a different boost modality, and 42.9% received no boost. Stage IV (p = 0.001) and uninsured patients (p = 0.04) were significantly less likely to receive brachytherapy. Older age was also associated with decreased brachytherapy usage, as each additional year of life decreased brachytherapy receipt by 1.8% (p = 0.04). Native American and Pacific Islander patients were the only group significantly more likely to receive brachytherapy (p=0.003). There was no significant difference in the rate of brachytherapy boost identified based on urban/rural status of the county (p = 0.63 to 0.69), other racial/ethnic categories (p = 0.66 to 0.80), or among the other stages (p=0.45 to 0.63). In Cox proportional hazard survival analysis, patients that received brachytherapy showed a 42% reduction in risk of cancer specific mortality, though this did not reach the predetermined level of statistical significance (p = 0.057). ConclusionsThe brachytherapy boost rate among locally advanced cervical cancer patients was 38.4%. The data also indicated a likely reduction in cancer specific mortality in patients receiving brachytherapy. Older patients, stage IV patients, and uninsured patients were less likely to receive brachytherapy. Given the low overall brachytherapy usage, these data indicate access and delivery of brachytherapy care needs to be improved across the state. The increased brachytherapy use in the American Indian and Pacific Islander patient population should be further studied to identify facilitators to treatment completion and potentially extrapolate to other groups.

Sociodemographic and Geographic Variation in Access to Neuro-Ophthalmologists in the United States.

Neuro-ophthalmologists have expertise in rare and complex disorders, but the ability of patients to access neuro-ophthalmic care has not been examined at a nationwide level. Using the 2020 directory of all 502 members of the North American Neuro-Ophthalmology Society as a reference, we found the practice locations of 461 confirmed practicing members and converted each street address to latitude and longitude coordinates. We calculated the travel distance and time from each census tract to the nearest practice location and calculated population-weighted averages by state, region, and other prespecified factors. Choropleth maps were used to visualize the distribution of travel distances and times across the United States. California had the most practicing neuro-ophthalmologists out of any state (50), whereas 4 states (DE, MT, SD, and WY) had none. Washington, DC and MA had the most neuro-ophthalmologists per capita. The average travel distance and time to the nearest neuro-ophthalmologists were found to be 40.90 miles and 46.50 minutes, respectively, although a large portion of western plains and mountain regions had travel times of over 120 minutes. Patients in rural areas had longer travel times than those in urban areas, and Native American patients had the longest travel times of any racial or ethnic group. The travel time to see a neuro-ophthalmologist varies widely by state, region, and rurality, with Native American patients and rural patients being disproportionately affected. By identifying the areas with the greatest travel burdens, future policies can work to alleviate these potential barriers to care.

Allergic Contact Dermatitis and Patch Testing in Skin of Color Patients.

Objective: Skin of color patients face important health issues relevant to dermatologists, such as allergic contact dermatitis; however, there is a lack of information surrounding common allergens causing contact dermatitis that disproportionately affect skin of color patients, as well as interpreting patch testing in this population. Methods: Covidence, Embase, MEDLINE, PubMed, Web of Science, and Google Scholar were searched to identify relevant articles studying allergic and irritant contact dermatitis in skin of color patients. Results: The most common positive reactions in African American patients included PPD, balsam of Peru, bacitracin, fragrance mix, and nickel. The most common positive reactions in Hispanic patients included Carba mix, nickel sulfate, and thiuram mix. The most common positive reactions in Asian patients included nickel sulfate, fragrance mix, and potassium dichromate. When interpreting patch test results in patients with higher Fitzpatrick skin types, positive patch tests presented with lichenification and hyperpigmentation, rather than erythema and vesicles. Furthermore, characteristic bright red or pink hues for positive results may appear violaceous or faint pink. Conclusions: Awareness of the common allergens associated with allergic contact dermatitis in patients of skin of color can help guide patch testing as an important diagnostic tool. Further research must be conducted regarding contact dermatitis in this patient population, especially given the relative lack of data surrounding Hispanic, Asian and Pacific Islander, and Native American patients.

Predictors of inpatient admission likelihood and prolonged length of stay among cerebrovascular disease patients: A nationwide emergency department sample analysis

PurposeTo examine the hospital- and patient-related factors associated with increased likelihood of inpatient admission and extended hospitalization. MethodsWe applied multivariate logistic regression to a subset of ED hospital and patient characteristics linearly extrapolated from the 2019 National Emergency Department Sample database (n=626,508). Patient characteristics with 10 or fewer ED visits after national extrapolation were not reported in the current study to maintain patient confidentiality, in accordance with the HCUP Data Use Agreement. All selected ED visits represented a primary diagnosis of CVD (ICD-10 codes 160-168). All reported hospital and patient characteristics were subject to adjustment for covariates. P-values < 0.05 were considered statistically significant. Main findingsMedicare beneficiaries report higher inpatient admission rates than uninsured OR 0.81 (0.73-0.91) and privately insured OR 0.86 (0.79-0.94) individuals. Black and Native-American patients were 37% and 55% more likely to be hospitalized long (>75th percentile) (OR 1.37 [1.25-1.50], OR 1.55 [1.14-2.10]). Northeast emergency departments reported an increased odds of admission compared to the Midwest OR (0.40-0.62), South OR 0.79 (0.63-0.98) and West OR 0.52 (0.39-0.69). Patients with multiple comorbidities (mCCI = 3+) were 226% more likely to have a longer stay OR 3.26 (3.09-3.45) than patients presenting with zero or few comorbidities. Level I, II, and III trauma centers report distinctly high odds of inpatient admission (OR 3.54 [2.84-4.42], OR 2.68 [2.14-3.35], OR 1.51 [1.25-1.84]). Principal conclusionsLikelihoods of inpatient admission and long hospital stays were observably stratified through multiple, independently acting hospital and patient characteristics. Significant associations were stratified by race/ethnicity, location, and clinical presentation, among others. Attention to the factors reported here may serve well to mitigate emergency department crowding and its sobering impact on United States healthcare systems and patients.

Hospital-Level Segregation Among Medicare Beneficiaries Undergoing Lung Cancer Resection

BackgroundRecent research has raised concern that health care segregation, the high concentration of racial groups within a subset of hospitals, is a key contributor to persistent disparities in surgical care. However, to date the extent and effect of hospital level segregation among patients undergoing resection for lung cancer remains unclear. MethodsWe used 100% Medicare fee-for-service claims to evaluate the degree of hospital-level racial segregation for patients undergoing resection for lung cancer between 2014 and 2018. Hospitals serving a high volume of minority patients were defined as the top decile of hospitals by volume of racial and ethnic minority beneficiaries served. Multivariable logistic regression analysis was used to compare surgical outcomes between hospitals serving high vs low volumes of minority patients. ResultsA total of 122,943 patients were included, with racial/ethnic composition of 360 American Indian or Native American (0.3%), 2077 Asian or Pacific Islander (1.7%), 1146 Hispanic or Latino (0.9%), 8707 non-Hispanic Black (7.1%), and 108,665 non-Hispanic White patients. Overall, 31.6%, 15.9%, 15.0%, and 7.8% of all hospitals performed 90% of lung cancer resection for Black, Asian, Hispanic, and Native American patients, respectively. Hospitals performing higher volumes of operations for racial and ethnic minorities had higher mortality (3.9% vs 3.1%; odds ratio [OR], 1.19; 95% CI, 1.15-1.23; P < .001), complications (18.1% vs 15.9%; OR, 1.17; 95% CI, 1.14-1.19; P < .001), and readmissions (11.7% vs 11.2%; OR, 1.04; 95% CI, 1.02-1.05; P < .001) for resections for lung cancer. ConclusionsOur findings suggest that a small proportion of hospitals provide a disproportionate amount of surgical care for racial and ethnic minorities with lung cancer with inferior surgical outcomes.

Abstract B095: Financial hardship screening among Native American patients with cancer: A qualitative analysis

Abstract Introduction: Cancer-related financial hardship is an increasingly recognized problem for patients, families and caregivers. Many Native American patients, including persons of American Indian or Alaska Native descent, may be at increased risk for cancer-related financial hardship due to highly prevalent factors, such as low income, medical comorbidity, and lack of private health insurance coverage. Methods: We conducted key informant interviews with Native American patients with cancer and clinical staff at a single cancer center. Eligible patients included those who had a confirmed diagnosis of cancer and were referred to the cancer center through the Indian Health Service Purchased and Referred Care Program, Tribal health program, or Urban Indian health program. Eligible clinical staff included physicians, advanced practice providers, and social workers. Patient interviews included questions about current financial hardship, experiences in discussing financial hardship with the cancer care and primary care team, and acceptability of completing a financial hardship screening tool at the cancer center. Clinician interviews focused on confidence, comfort, and experience in discussing financial hardship with patients. Recorded interviews were transcribed and thematically analyzed using MAXQDA® software. Results: A total of seven patients and four clinicians participated in the interviews. Patients expressed many financial challenges to receiving cancer care. The most frequently stated challenges related to transportation from rural parts of the state to the cancer center. Most patients discussed reliance on caregivers for transportation. Some patients also experienced financial challenges related to lodging during treatment, food insecurity, and utility expenses. Patients were willing to complete a financial hardship screening tool, but indicated this tool should be short and not overly intrusive of the patient’s finances. Clinical staff described discomfort in discussing financial hardship with patients, primarily due to a lack of training and knowledge about resources to support patients. There were also differing perspectives on which staff type (social work, Native American patient navigators, or others) were responsible for addressing financial hardship. Conclusions: We identified facilitators and barriers at both the patient and clinician levels to complete a financial hardship screening tool. These preliminary findings suggest that cancer centers need to develop clear organizational structures and processes in order for financial hardship to be addressed effectively. We are currently implementing a screening tool in a pilot study and conducting additional interviews among patients and clinical staff to identify methods to address financial hardship among Native American cancer patients. Citation Format: Amber Anderson Buettner, Amanda Janitz, Stefani Madison, Mark Doescher, Keri Harjo, Stephnie Dartez, Marvin Bear, Michaela Khoussine, Dorothy Rhoades. Financial hardship screening among Native American patients with cancer: A qualitative analysis [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr B095.

Abstract A101: Exploring facilitators and barriers to low-dose CT screening for lung cancer among Native American patients: The TEALS study

Abstract Purpose: Lung cancer screening (LCS) with low dose CT scanning reduces mortality but uptake of LCS is poor. Lung cancer mortality in Oklahoma’s Native American population is 45% higher than for the non-Hispanic White population. The Tribally Engaged Approaches to Lung Screening (TEALS) study is a collaboration between the University of Oklahoma Health Sciences Center and the Choctaw Nation of Oklahoma Health Services Authority (CNHSA). The goals of TEALS are to implement a systematic LCS program within Choctaw Nation and to understand LCS decision-making processes, barriers and facilitators. Procedures: Using purposive sampling from 2 of 8 CNHSA clinics in Oklahoma in 2021, we conducted a pilot study using phone interviews with patients who had completed LCS and those who had not. Using a semi-structured interview guide, we asked patients about their experience with the LCS program, factors that influenced their decision, and suggestions for improving the program. Conventional inductive content analysis was used to identify major themes. Multiple coders and peer debriefing enhanced scientific rigor. Results: Completers (4 men and 5 women) and non-completers (3 men and 3 women) were included. Major themes included: (1) Contextual factors influencing the decision-making process; (2) Individual characteristics influencing the decision-making process; and (3) Barriers to screening. Contextual factors included the provider raising the discussion of LCS, which was most frequently cited by completers but not the non-completers. Other contextual factors included the use of handouts and pamphlets during clinic visits. Patient suggestions included brochures/posters in waiting rooms and creating an information video to run on TVs in waiting areas. Individual characteristics included motivation to ‘be there’ for family/children, previous cancer in family/friends, and ease of arranging appointments. Non-completers preferred not to know or were scared to know the results of screening. Barriers included long distance travel to LCS sites, missing work, access to transportation or assistance, confusion about the appointment leading to missed appointments. Interviews highlighted the need to clarify eligibility criteria. Notably, some patients who were classified as ‘non-completers’ had already had a diagnostic CT for respiratory symptoms or as follow-up for prior cancer, indicating a gap in correctly identifying LCS eligibility. Conclusions: Findings from this pilot have guided implementation of the TEALS clinical trial. Large banners are now available in participating clinics. Academic detailing ensures the decision aid pamphlet is available and used in waiting rooms. Providers are reminded of the critical role they play in informing patients about LCS. Appointment reminders and assistance with transportation (e.g., tribal transportation) are in place. Eligibility criteria for the clinical trial have been clarified. Gathering this information from pilot study participants has enabled the team to refine the LCS intervention as it expands to other sites. Citation Format: Kathleen Dwyer, Dorothy A. Rhoades, Mark Doescher, Brook McCann, Michele Gibson, Zsolt Nagykaldi. Exploring facilitators and barriers to low-dose CT screening for lung cancer among Native American patients: The TEALS study [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A101.