Nonwhite Patients Research Articles

Impact of Race and Neighborhood Socioeconomic Characteristics on Liver Cancer Diagnosis in Patients with Viral Hepatitis and Cirrhosis

Concerning data have revealed that viral hepatitis and hepatocellular carcinoma (HCC) disproportionally impact non-White patients and those from lower socioeconomic status. A recent study found that HCC clusters were more likely to be in high poverty areas in New York City. We aim to investigate the impacts of neighborhood characteristics on those with viral hepatitis and cirrhosis, particularly with advanced HCC diagnosis. Patients with cirrhosis and viral hepatitis admitted to a New York City health system between 2012 and 2019 were included. Those with prior liver transplants were excluded. Neighborhood characteristics were obtained from US Census. Our primary outcome was HCC and advanced HCC diagnosis. This study included 348 patients; 209 without history of HCC, 20 with early HCC, 98 with advanced HCC, and 21 patients with HCC but no staging information. Patients with advanced HCC were more likely to be older, male, Asian, history of HBV, and increased mortality. They were more likely to live in areas with more foreign-born, limited English speakers, and less than high school education. After adjusting for age, sex, and payor type, Asian race and low income were independent risk factors for advanced HCC. Neighborhood factors were not associated with mortality or readmissions. We observed that in addition to age and sex, Asian race, lower household income, lower education, and lower English proficiency were associated with increased risk of advanced HCC. These disparities likely reflect suboptimal screening programs and linkage to care among vulnerable populations. Further efforts are crucial to validate and address these concerning disparities.

Black and hispanic women have less support during cancer evaluation and treatment: results from a prospective patient reported outcomes program in gynecologic malignancy

ObjectiveRace remains a significant predictor of poor outcomes in women with gynecologic cancer and minority patients consistently report worse quality of life during cancer treatment. Disparities between patients in strength...

Research Silos in Cancer Disparities: Obstacles to Improving Clinical Outcomes for Underserved Patient Populations.

Despite much vaunted progress in cancer therapeutics and diagnostics, outcomes for many groups of non-White patients with cancer remain worse than those for their White compatriots. One reason for this is the lack of inclusion and representation of non-White patients in clinical trials, preclinical datasets, and among researchers, a shortfall that is gaining wide recognition within the cancer research community and the lay public. Several reviews and editorials have commented on the negative impacts of the status quo on progress in cancer research toward medical breakthroughs that help all communities and not just White patients with cancer. In this perspective, we describe the existence of research silos focused either on the impact of socioeconomic factors proceeding from systemic racism on cancer outcomes, or on genetic ancestry as it affects the molecular biology of cancer developing in specific patient populations. While both these research areas are critical for progress toward precision medicine equity, breaking down these silos will help us gain an integrated understanding of how race and racism impact cancer development, progression, and patient outcomes. Bringing this comprehensive approach to cancer disparities research will undoubtedly improve our overall understanding of how stress and environmental factors affect the molecular biology of cancer, which will lead to the development of new diagnostics and therapeutics that are applicable across cancer patient demographics.

Racial/Ethnic Differences in Association Between Medicaid Expansion and Causes and Costs of Readmission After Acute Ischemic Stroke.

The purpose of this study was to examine whether the relative frequency of leading causes and total associated costs of readmission after acute ischemic stroke changed with Medicaid expansion, and how these changes differed by racial/ethnic group. We used a difference-in-differences approach to compare changes in the relative frequency of leading causes of unplanned 30-day readmission and to examine changes in the costs associated with unplanned readmission between expansion states (AR, MD, NM, and WA) and non-expansion states (FL and GA). To estimate the differential effect of Medicaid expansion by race/ethnicity on the causes and cost of readmission, we added a time*treatment*race interaction. Multinomial logistic regression was performed to analyze the changes in readmission cause. Gamma log-link modeling was used to study changes in readmission costs for expansion compared to non-expansion states. The final multinomial model showed an association between expanded Medicaid and the relative frequency of sepsis readmission for White patients. According to predictive margins, White patients in expansion states had an estimated increase of 3.3 percentage points in the share of readmissions for sepsis but not for White patients in non-expansion states. In contrast, non-White patients in expansion states had a decrease of 1.8 percentage points in the share of readmissions for sepsis. Overall, Medicaid expansion was associated with a net increase of 6.7 percentage points in the share of readmissions for sepsis among non-Hispanic Whites relative to all other groups. In the final gamma model, Medicaid expansion was associated with a decrease in readmission costs overall. According to predictive margins, the net cost reduction in expansion versus non-expansion states was an average of $2509. Medicaid expansion is associated with an overall decrease in unplanned readmission costs and an increase among readmitted White patients in the likelihood of readmission for sepsis.

The impact of youth-onset type 2 diabetes on postoperative wound healing complications.

Youth-onset type 2 diabetes mellitus is associated with a more rapid decline in β cells, and earlier onset of medical complications compared to adult-onset diabetes. However, its impact on surgical wounds remains less clear. Therefore, this study aimed to determine whether youth-onset diabetes is a risk factor for wound healing complications in the 30-day postoperative period. To do so, the National Surgical Quality Improvement Program Database years 2012-2019 was analysed. Patients aged 18-24 with non-insulin-dependent diabetes were included. Outcomes assessed included wound infections, wound dehiscence, readmissions, and reoperation. Univariate analysis identified differences between the diabetic and non-diabetic cohorts after which, multivariate logistic regression was employed to control for potential confounding. Analysis included 1589 diabetic and 196,902 non-diabetic patients ages 18-24. The diabetic cohort exhibited a higher proportion of female (83.8% vs. 55.2%, p< 0.001), non-white (22.7% vs. 19.5%, p= 0.001), and Hispanic patients (16.2% vs. 13.6%, p= 0.002). Diabetic patients were less likely to have dirty or contaminated wounds (16.2% vs. 25.2%, p< 0.001); however had increased ratesof superficial surgical site infections (SSSIs; 2.0% vs. 0.8%, p< 0.001) and readmission (4.0% vs. 3.0%, p= 0.026). After regression, diabetes remained a significant positive predictor of SSSI (odds ratio: 1.546, p= 0.022); however, it no longer significantly predicted 30-day readmission. Overall, this analysis of a large multicentresurgical outcomes database found that when compared to non-diabetics, youth-onset diabetic patients exhibited a higher proportion of SSSIs in the 30-day postoperative period. These infections were found, despite the diabetic cohort exhibiting lower rates of wound contamination. After controlling for confounding variables, youth-onset diabetes remained a significant predictor of SSSI. Clinically, prevention and treatment of diabetes along with judicious wound care is recommended.

Sex- and Race-Based Differences in the Treatment of Interstitial Lung Diseases in North America and Australasia

Biological sex, gender, and race are important considerations in patients with interstitial lung diseases (ILDs). Does a patient's sex assigned at birth, and race, influence ILD treatment initiation? Patients with ILD from three longitudinal prospective registries were compared in this observational study. ILD-related medications included antifibrotics and immunomodulating medications. Race was dichotomized as "White" vs"non-White." Time to treatment initiation was determined from the date of the initial ILD registry visit to the date of first medication initiation. Proportions of treated patients were compared between groups by χ2 test. Cox proportional analysis was used to determine how sex and race were associated with time to treatment initiation stratified by ILD diagnosis. A total of 4,572 patients were included across all cohorts. The proportion of men who received treatment was higher than for women in the Canadian cohort (47%vs40%; P< .001), and the proportion of White patients who received treatment was also higher compared with non-White patients (46%vs36%; P< .001). In contrast, the proportion of treated men in the Chicago cohort was lower compared with women (56%vs64%; P= .005), and that of White patients was lower compared with non-White patients (56%vs69%; P< .001). No sex- or race-based differences in proportions of patients treated were found in the Australasian cohort. White race was significantly associated with earlier treatment initiation compared with non-White race across diagnoses in the Canadian cohort, whereas the opposite association was found in the Australasian cohort. Sex- and race-based differences exist in the initiation of ILD treatment, with variability across different cohorts in different countries. Reasons for these differences need to be further explored in future studies.

Abstract C001: PIONEER: Computational Probing of dIfferences in symptOms and fuNction of divErsE brain and spine tumoR populations

Abstract Background: Cancer outcomes studies primarily enroll white patients, and symptom care standards are based overwhelmingly on white patients’ experiences, even though many analyses have shown ethno-racial disparities in symptom burden. This study seeks to better understand ethno-racial disparities in the symptom burden of brain and spine tumor patients using novel computational network analysis (NA) approaches. NA identifies complex symptom co-severity patterns across large patient cohorts. This is the first study to use NA to analyze ethno-racial disparities in cancer symptom burden. Methods: Symptom severity data reported using the MD Anderson Symptom Inventory from a two-institutional cohort of 1651 brain and spine tumor patients was analyzed. Symptom data from white (n = 1,382) and non-white patients (n = 269) were analyzed separately. All non-white patients were analyzed together due to sample size limitations. Gaussian Graphical Model networks were constructed for each group. Network characteristics were analyzed and compared using permutation-based statistical tests. Results: Networks for white and non-white patients were constructed with high and moderate accuracy, respectively. Assessment of strength centrality, a measure of how core a symptom is to overall symptom burden, and betweenness centrality, a measure of how much a symptom contributes to the severity of other symptoms, revealed several key symptoms for each group. For white patients, fatigue, nausea, and distress/feeling upset had the highest strength, whereas fatigue, nausea, and pain had the highest betweenness. For non-white patients, drowsiness, disturbed sleep, and sadness had the highest strength, whereas change in appetite, disturbed sleep, sadness, and pain had the highest betweenness. The two network architectures were statistically different from each other in the Network Comparison Test (p = 0.033). White patients had significantly higher strength for fatigue (p = 0.032) and betweenness for nausea (p = 0.005), whereas non-white patients had significantly higher strength for sleep disturbance (p = 0.005). Independent t-test analysis only identified drowsiness as being significantly different between the two groups (p = 0.032), emphasizing how NA can reveal differences in symptom burden undiscoverable by traditional analyses. Discussion: Our results demonstrate that white and non-white patients experience different symptom co-severity patterns, with symptoms such as sleep disturbance being more influential in non-white patients and symptoms such as fatigue and nausea more significant in white patients. These results underscore the importance of considering the differences (and similarities) in symptomatology of patients from different racial and ethnic backgrounds. This will help address disparities and provide more personalized and effective care for diverse brain and spine tumor patient populations. Citation Format: Brandon H. Bergsneider, Elizabeth Vera, Mark R. Gilbert, Terri S. Armstrong, Orieta Celiku. PIONEER: Computational Probing of dIfferences in symptOms and fuNction of divErsE brain and spine tumoR populations [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 C001.

Abstract A090: Overcoming racial and ethnic disparities in cancer clinical trial accrual during the COVID-19 pandemic: A partnership between a cancer center’s clinical trials office and community outreach and engagement

Abstract Background: Despite passage of the NIH Revitalization Act in 1993, enrollment in clinical trials remains low for Black and Hispanic adults. The novel coronavirus 2019 (COVID-19) pandemic resulted in substantial disruptions to patient care, including challenges for clinical trial accrual. The extent to which the pandemic has disrupted clinical trial enrollment continues to be investigated; data on enrollment disruptions for different racial and ethnic groups are scarce. Objective: We compared racial and ethnic patient accrual to intervention cancer clinical trials before, and during the COVID-19 pandemic. Methods: We assessed monthly and annual enrollment to all intervention and treatment-intervention-only clinical trials coordinated by the Moores Cancer Center Clinical Trials Office (MCC CTO) from January 1, 2019 to December 31, 2021. We considered monthly enrollment from January 1, 2019 to March 31, 2020 to include the period before the onset of the COVID-19 pandemic and from April 1, 2020 to December 31, 2021 for the pandemic phase. We assessed the annual percentage of individuals enrolled in trials (i.e., 2019, 2020, and 2021) according to race (White, African American/Black, and Asian) and ethnicity (Hispanic, non-Hispanic). Results: Enrollment to all intervention clinical trials dropped from 512 patients in 2019 (pre-pandemic period) to 455 in 2020 and 447 in 2021, during the pandemic. Monthly accrual data show a drop in treatment intervention trials with the onset of the pandemic, from 36 in March 2020 to 25 in April 2020. This drop was followed by a quick rebound in May (n=42) and June (n=40), similar to the 2019 pre-pandemic figures (n=44 for May and 39 for June). Accrual dropped sharply with the second wave of the pandemic, from 34 in November 2020 to 17 in January 2021 but rebounded to 43 in May 2021. Annual enrollment by race shows that the percent of non-White cancer patients increased each year after the onset of the pandemic, from 23.5% in 2019 to 26.2% in 2020, and 31.3% in 2021 (p=0.06 comparing White to non-White patients for 2019 versus 2020 and 2021 combined). Similarly, the proportion of Hispanic patients on treatment trials increased from 21% in 2019, to 24% in 2020, and 27% in 2021 (p=0.34 comparing 2019 to 2020 and 2021 combined). Conclusion: Our results, from a single NCI designated comprehensive cancer center, show that although a drop-in accrual to interventional trials occurred from 2019 to 2020 and extended into 2021, accrual for non-White and Hispanic patients increased over this time period. We hypothesize that this was due to existing strategies that were in place as part of a MCC CTO-Community Outreach and Engagement partnership that provided institutional-, provider-, and patient-level support for accrual of under-represented patients. Furthermore, COVID-adaptive contingency measures to overcome challenges due to the pandemic were also implemented including pre-infusion COVID19 testing, remote interpreter services, and per protocol flexibility in minimizing in-person study visits. Citation Format: Jesse Nodora. Overcoming racial and ethnic disparities in cancer clinical trial accrual during the COVID-19 pandemic: A partnership between a cancer center’s clinical trials office and community outreach and engagement [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 A090.

Abstract PR001: Assessing differences in miRNA profiles by race and ethnicity: Implications for creating an equitable ovarian cancer early detection test

Abstract Introduction: Assessing serum micro RNA (miRNA) profiles is an emerging technique for earlier detection of ovarian cancer. A panel of miRNAs for ovarian cancer prediction has been proposed, but it is unknown whether race and ethnicity may influence their expression. The goal of this study was to determine how race affects expression of miRNAs associated with ovarian cancer risk to ensure creation of an equitable test. Methods: Serum samples from 1586 women from the Mass General Brigham BioBank were analyzed for the presence of 179 different miRNAs. The Abcam Fireplex® assay was used to assess miRNA expression determined by flow cytometry, measured in mean fluorescence units (MFI) and log2 normalized prior to analysis. Demographic characteristics and medical histories were abstracted from linked electronic medical records. Patients with missing race/ethnicity were excluded. Differences in miRNA profiles by race/ethnicity (white, non-Hispanic vs non-white) were assessed using dimension reduction. The miRNA expression data was mapped to two-dimensions using constrained least-squares, then the reduced dimension data was used to train a simple neural network to predict race/ethnicity. In addition, pairwise t-test analyses were performed to analyze racial/ethnic differences among eight miRNAs previously reported to be informative for prediction of ovarian cancer. Results: The racial/ethnic composition of the study population was similar to the state population (76.9% white, 13.4% Hispanic, 5.2% black, 2.6% Asian, 1.9% Other). Non-white patients were on average younger (41.9 years ± 13.2 vs 51.3 years ± 15.1, p&amp;lt;0.01) and had fewer comorbid conditions compared to white patients (3.5 comorbidities ± 2.7 vs 4.6 comorbidities ± 2.8, p&amp;lt;0.01). The dimension reduction and classification analysis showed a significant effect of race on miRNA profiles, with miRNAs able to predict race at an AUC of 0.71 (95% CI 0.68-0.74) after 10-fold cross validation. The AUC remained consistent when stratified for age, menopausal status, and comorbidities. Among eight miRNAs highly predictive of ovarian cancer, seven significantly varied by race (hsa-mir-150-5p, hsa-mir-200c-3p, hsa-mir-23b-3p, has-mir-29a-3p, hsa-mir-320c, hsa-mir-320d, and hsa-mir-32-5p, p&amp;lt;0.01). Hsa-mir-200c-3p was the most significantly different by race (7.19 mean log2 MFI among non-white vs 6.94 mean log2 MFI among white patients, p&amp;lt;0.01). Upon analyzing each racial subtype and variation in hsa-mir-200c-3p, black and Hispanic patients had relatively similar mean values which were significantly different from values observed among white patients. Conclusions: miRNA expression is significantly influenced by race and ethnicity, with differences remaining largely consistent even after controlling for confounders. Understanding baseline differences in biomarker test characteristics prior to clinical implementation of novel diagnostic tools is essential to ensuring instruments perform comparably across diverse populations. Citation Format: Stephanie Alimena, James Webber, Laura Wollborn, Marta Williams, Chad B. Sussman, Joyce Y. Wang, Julia Spiegel, Kevin M. Elias. Assessing differences in miRNA profiles by race and ethnicity: Implications for creating an equitable ovarian cancer early detection test [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 PR001.

Abstract B020: “Access to these screenings have been a gift”: A mixed methods assessment of a community navigation program for breast and cervical in the era of COVID-19

Abstract Background: The COVID-19 pandemic exacerbated health inequities among systematically marginalized populations. At the onset of the pandemic, routine cancer screenings were effectively halted; from March to May 2021, there was a deficit of 9.3 million screens. Early evidence suggests that non-White patients, compared to White, have experienced even greater declines in breast and cervical cancer screenings. Consequences of missed or late screenings include later stage diagnosis and poor outcomes. Community navigation programs have been used to promote engagement in cancer screenings in under-resourced communities, but these too were interrupted as restrictions were put in place to mitigate the spread of COVID-19.Objective: To use a mixed methods approach to describe the challenges, strengths, and lessons learned of implementing a community navigation program for breast and cervical cancer screening during the COVID-19 pandemic. Methods: In 2019, The University of Illinois Cancer Screening, Access, Awareness, and Navigation (UI CAAN) intervention was established to address breast and cervical cancer disparities on Chicago’s West side, an area with large Black and Latinx populations. The intervention included community navigators who worked in partnership with community-based safety net hospitals and organizations. Participants were recruited at community events and through clinical referrals and were eligible if they were overdue for a guideline concordant breast or cervical cancer screening. Quantitative navigation and screening data were collected by the navigators in a REDCap database. Qualitative data, four focus groups with participants and partners, were also collected to broaden our understanding of impact of COVID-19 on the community navigation intervention. For these analyses, we describe participants’ navigation and screening outcomes and use content analysis methods for the focus groups. We then triangulate the findings to understand the challenges, strengths, and lessons learned of the UI CAAN. Results: From 2019-2022, a total of 366 individuals were navigated for breast and cervical cancer screenings. Of these, 68% (n = 248) received a breast and/or cervical cancer screening. Among those who were screened, 75% were Latinx and 23% were Black, 92% were uninsured, and 86% did not have a primary care provider. Concerning services received, 30% had a mammogram and a pap smear, 37% a pap smear only, and 33% a mammogram only. At the height of the pandemic, navigators coordinated with community and clinical partners to deliver 500 meals, held 9 PPE distribution events, distributed 3000 masks, and conducted 2 webinars about COVID-19. Conclusion: Despite the challenges of the COVID-19 pandemic, the UI CAAN community navigation program was able to shift its efforts at the height of the pandemic to assist its community and clinical partners. The continued collaboration allowed for a successful resumption of navigation and screening efforts once healthcare systems were able to re-engage patients in cancer screenings. Citation Format: Leslie R. Carnahan, Chibuzor Abalsalim, Jeanette Santana González, Mari Goudy, Hunter Holt, Jessica Madrigal, Thrishka McKinnor, Tigist Mersha, Theresa Mobley, Maria Olivero, Mary Rinder, Barbara Williams, Vida Henderson. “Access to these screenings have been a gift”: A mixed methods assessment of a community navigation program for breast and cervical in the era of COVID-19 [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 B020.

Sociodemographics of Chiari I Malformation.

Socioeconomic and demographic factors affect the care of patients with Chiari I malformations. This article describes the current cost of surgical treatment of Chiari I malformations and highlights how careful patient selection, treatment selection, postoperative protocols, and varying payment models may serve as cost-reducing measures. In addition, the article highlights racial disparities resulting in delayed diagnosis and greater disease progression in non-white patients, as well as the relative parity in the workup and treatment of Chiari I malformation based on insurance status. These findings illustrate the need for greater access to neurosurgical care and greater outreach to community physicians by the neurosurgical community.

Abstract A059: Facility-level disparities in the delivery of guideline-based treatment across genitourinary cancers

Abstract Objectives Disparities in guideline-based treatment (GBT) for genitourinary cancers are commonly presented individually, impeding comprehensive examinations of institutional drivers. In this study, we utilize the National Cancer Database to characterize the prevalence of disparities in GBT for prostate (PCa), bladder (BCa), and kidney (KCa) cancer within the same facility to evaluate whether disparities cluster at the institutional level. Methods Patients diagnosed with clinically localized (cT2-4aNX-1MX-0) bladder, (cT2b-4NX-0MX-0) prostate, or (cT2a-3cNX-1MX-0) kidney cancer between 2004-2017 within each National Cancer Database dataset were included. We collected clinicodemographics, treatment received, and facility data. GBT was defined according to NCCN Guidelines by TNM staging. We calculated rates of GBT by cancer type and race and compared rates between White and non-White patients (non-Hispanic Black, Hispanic, and Asian) using Chi-squared tests. Pairwise correlations in GBT rates between PCa, BCa, and KCa treated across the facilities were estimated using Pearson correlation coefficients, where the facilities with &amp;lt;10 cases of each cancer were excluded. Results We identified 86,845 BCa, 73,050 KCa, and 252,403 PCa cases. BCa GBT was highest for White and Asian patients (50.5% and 48.6%, respectively) versus 42.2% for Black patients. KCa GBT rates were equivalent for White, Hispanic, and Asian patients (~76%) but lowest for Black patients (74.8%). In PCa, the highest rate was 80.8% (White patients) and lowest was 76.5% (Black patients). Overall, GBT rates for BCa (41%, SD 18%) were significantly lower than for KCa (72%, SD 17%) and PCa (77%, SD 16%), all p&amp;lt;0.001. Intra-facility rates of GBT correlated poorly across cancer types (r=0.1 for prostate-kidney, 0.2 for prostate-bladder, and 0.31 for bladder-kidney; all p≤0.001). Correlation coefficients at academic medical centers were highest among the four facility types, though still low (r=0.31 prostate-bladder, 0.39 prostate-kidney, 0.39 bladder-kidney). Conclusions Overall rates of GBT for GU cancers vary significantly by cancer type and race, without clustering of high rates within the same facility. Restricting disparities-focused interventions to individual cancers disregards potential facility-level commonalities as actionable targets. Citation Format: Samuel L. Washington, Julie A. Szymaniak, Pedro Gallardo, Chengshi Jin, Li Zhang, Sima Porten, Maxwell V. Meng, Matthew R. Cooperberg, Peter R. Carroll. Facility-level disparities in the delivery of guideline-based treatment across genitourinary cancers [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 A059.

Epidemiological trends, prognostic factors, and survival outcomes of synchronous brain metastases from 2015 to 2019: a population-based study.

Brain metastases (BM) constitute a significant cause of oncological mortality. Statistics on the incidence of BM are limited because of the lack of systematic nationwide reporting. We report the incidence of synchronous brain metastases (sBM), defined as BM identified at the time of primary cancer diagnosis from 2015 to 2019 using National Cancer Institute's (NCI's) Surveillance, Epidemiology, and End Results Program database. We identified 1,872,057 patients with malignancies diagnosed between 2015 and 2019 from the SEER 17 Registries database, including 35,986 (1.9%) patients with sBM. Age-adjusted incidence rates were examined using the NCI Joinpoint software. Kaplan-Meier curves and a multivariate Cox regression model were used to investigate survival. The incidence rate of sBM from 2015 to 2019 was 7.1 persons per 100,000. Lung and bronchus cancers had the highest incidence of sBM (5.18 to 5.64 per 100,000), followed by melanoma (0.30 to 0.34 per 100,000) and breast cancers (0.24 to 0.30 per 100,000). In children, renal tumors had the highest sBM incidence. sBM were associated with poorer survival than extracranial metastases only (hazard ratio [HR]: 1.40 [95% CI: 1.39-1.42], P < .001). We observed better survival in white patients relative to nonwhite patients with sBM (HR: 0.91 [95% CI: 0.90-0.94], P < .001). The incidence rate of sBM has remained similar to rates reported over the last 9 years, with the majority associated with primary lung and bronchus cancers. sBM represent a national healthcare burden with tremendous mortality in pediatric and adult populations. This population may benefit from improved screening and treatment strategies.

Pancreatic cancer multidisciplinary program increases clinical trial enrollment of minority patients

Background: Historically, racial and ethnic minorities are underrepresented in cancer clinical trials. Despite the NIH Revitalization Act of 1993, enrollment of white patients in clinical trials continues to be disproportionately higher than that of non-white patients. We propose that implementation of a pancreas multidisciplinary clinic (PMDC) in a large multi-institutional health system improves clinical trial enrollment of minority patients.

Contralateral Prophylactic Mastectomy among Women with Pathogenic Variants in BRCA1/2: Overall Survival, Racial, and Ethnic Differences.

Patients with unilateral breast cancer carrying pathogenic variants in BRCA1/2 have the option to undergo contralateral prophylactic mastectomy (CPM). However, differences in CPM use and survival outcomes following CPM are poorly understood in this high-risk population, in part due to a lack of data from contemporary clinical cohorts. The objective of this study was to evaluate post-CPM overall survival (OS) and related racial/ethnic differences in a contemporary clinical cohort. We retrospectively reviewed the medical records of women with a personal history of unilateral breast cancer carrying pathogenic variants in BRCA1/2 who were diagnosed between 1996 and 2012. Genetic test results, self-reported demographic characteristics, and clinical factors were abstracted from electronic medical records. Of 144 BRCA-positive patients, the majority were White (79.2%, n = 114). Overall, 56.1% (n = 81) of all BRCA1/2 carriers chose to undergo CPM, with no racial/ethnic difference in CPM election (p = 0.78). Of 81 patients who underwent CPM, there is strong evidence of a difference in survival between the racial/ethnic groups, with White patients having the highest OS compared to non-White patients (p = 0.001). Of the 63 patients who did not undergo CPM, there is no racial/ethnic difference in overall survival (p = 0.61). In multivariable cox regression, adjusted for demographic and clinical characteristics, OS was significantly lower among non-Whites than in Whites (HR = 0.39, p = 0.04). Evaluation of a contemporary clinical cohort of BRCA-positive women with unilateral breast cancer showed no racial/ethnic difference in CPM use, but there was a significant difference in post-CPM overall survival.

Polymorphisms in ACE1, TMPRSS2, IFIH1, IFNAR2, and TYK2 Genes Are Associated with Worse Clinical Outcomes in COVID-19.

Although advanced age, male sex, and some comorbidities impact the clinical course of COVID-19, these factors only partially explain the inter-individual variability in disease severity. Some studies have shown that genetic polymorphisms contribute to COVID-19 severity; however, the results are inconclusive. Thus, we investigated the association between polymorphisms in ACE1, ACE2, DPP9, IFIH1, IFNAR2, IFNL4, TLR3, TMPRSS2, and TYK2 and the clinical course of COVID-19. A total of 694 patients with COVID-19 were categorized as: (1) ward inpatients (moderate symptoms) or patients admitted at the intensive care unit (ICU; severe symptoms); and (2) survivors or non-survivors. In females, the rs1990760/IFIH1 T/T genotype was associated with risk of ICU admission and death. Moreover, the rs1799752/ACE1 Ins and rs12329760/TMPRSS2 T alleles were associated with risk of ICU admission. In non-white patients, the rs2236757/IFNAR2 A/A genotype was associated with risk of ICU admission, while the rs1799752/ACE1 Ins/Ins genotype, rs2236757/IFNAR2 A/A genotype, and rs12329760/TMPRSS2 T allele were associated with risk of death. Moreover, some of the analyzed polymorphisms interact in the risk of worse COVID-19 outcomes. In conclusion, this study shows an association of rs1799752/ACE1, rs1990760/IFIH1, rs2236757/IFNAR2, rs12329760/TMPRSS2, and rs2304256/TYK2 polymorphisms with worse COVID-19 outcomes, especially among female and non-white patients.

Unintended Consequences? Medicare Commercial Partnerships Complicate Arthroplasty Care and Registry-Based Research: Commentary on an article by Jennifer C. Wang, BS, et al.: "The Rise of Medicare Advantage. Effects on Total Joint Arthroplasty Patient Care and Research".

Commentary The health-care environment has undergone major changes over the past 20 years, including the expansion of partnerships between commercial insurance carriers and the U.S. Department of Health and Human Services (HHS) through its subagency, the Centers for Medicare & Medicaid Services (CMS). Most orthopaedic surgeons performing arthroplasty procedures have probably observed the growing proportion of their patients with Medicare Advantage (commercially managed Medicare) plans. Few among us were likely aware of the full implication of this transition on clinical practice, patient outcomes, and the effectiveness of registry-based arthroplasty research. Wang and colleagues provide a thoughtful analysis of patient demographic characteristics, medical comorbidities, and 90-day postoperative adverse outcomes that were identified for 697,317 patients who underwent elective total hip or total knee arthroplasty in hospitals participating in the Premier Healthcare Database. The authors identified a 335% relative increase in patient participation in Medicare Advantage plans from 2004 to 2020, with increased enrollment of non-White patients, a propensity for increased Medicare Advantage enrollment in urban environments, and increased arthroplasty care engagement in teaching hospitals. While differences in medical comorbidities were not substantially different between patients enrolled in the 2 plan types, Medicare Advantage patients experienced an increased risk for stroke and acute kidney injury following surgery. The authors extrapolate their findings beyond the core data obtained to present their perspectives on the impact of CMS insurance privatization on the future of high-quality joint arthroplasty care. Increased administrative burdens, including pre-authorization coordination for appropriate and clinically indicated surgical treatment, have been encountered by most practicing surgeons and their support teams. The transition of quality reporting through qualified registries—including the American Joint Replacement Registry—has been built around traditional Medicare enrollment reporting mechanisms. At least 1 potentially unintended consequence of the transition toward Medicare Advantage plans is the shielding of patient-based procedural outcomes from these mechanisms—which may serve to undermine innovation and validation. There are some notable limitations of the study, which the authors have outlined. It is very challenging to use administrative databases to fully identify and investigate all factors that may influence adverse postoperative outcomes. While the database used by the authors identifies postoperative surgical and medical complications, it does not address the long-term performance of the implants and techniques. Moreover, the composite medical complexity of patients may not be fully represented in the analyzed data. The factors and conditions underlying patient decisions to select traditional Medicare or Medicare Advantage plans cannot be assessed, and the potential impact of selection bias on the study findings cannot be determined. The study highlights the unanticipated consequences that may arise when fiscally driven policy intersects with specialized medical care. Future studies will be valuable to determine whether the observations in this study are sustained as the growth of Medicare Advantage plans continues—especially with the trends suggesting that under-represented minority patients will potentially be the most adversely affected. With potential implications for arthroplasty care delivery and the future ability to utilize qualified registries to assess arthroplasty outcomes, it is crucial for advocacy efforts to guide policymakers toward ensuring the successful provision of arthroplasty care—including transparency of outcomes among patients who have elected to participate in Medicare Advantage programs.

Quantification of risk factors for diabetic retinopathy progression.

To determine the importance of blood sugar control, blood pressure, and other key systemic factors on the risk of progression from no retinopathy to various stages of diabetic retinopathy. Restrospective cohort analysis of patients (N = 99, 280) in the Kaiser Permanente Northern California healthcare system with a baseline retina photographic screening showing no evidence of retinopathy and a minimum follow-up surveillance period of 3 years from 2008 to 2019. We gathered longitudinal data on diabetic retinopathy progression provided by subsequent screening fundus photographs and data captured in the electronic medical record over a mean surveillance of 7.3 ± 2.2 (mean ± SD) years. Progression from an initial state of no diabetic retinopathy to any of four outcomes was determined: (1) any incident retinopathy, (2) referable (moderate or worse) retinopathy, (3) diabetic macular edema, and (4) proliferative diabetic retinopathy.Multiple predictors, including age, race, gender, glycosylated hemoglobin (HbA1c), systolic blood pressure (SBP), cholesterol, chronic renal disease, and type of diabetes were investigated. Among modifiable risk factors, the average HbA1c had the strongest impact on the progression of diabetic retinopathy, followed by average SBP control and total cholesterol. Patients with an average HbA1c of 10.0% or greater (≥ 97mmol/mol) had a risk ratio of 5.72 (95% CI 5.44-6.02) for progression to any retinopathy, 18.84 (95% CI 17.25-20.57) for referable retinopathy, 22.85 (95% CI 18.87-27.68) for diabetic macular edema, and 25.96 (95% CI 18.75-36.93) for proliferative diabetic retinopathy compared to those with an average HbA1c of 7.0% (53mmol/mol) or less. Non-white patients generally had a higher risk of progression to all forms of diabetic retinopathy, while Asian patients were less likely to develop diabetic macular edema (HR 0.76, 95% CI 0.66-0.87). We confirm the critical importance of glucose control as measured by HbA1c on the risk of development of diabetic retinopathy.

1739. An Exploratory Analysis to Examine Urgent Care Antibiotic Prescribing Inequities in a Vertically Integrated Healthcare System

Abstract Background Previous studies have shown antibiotic prescribing differences based on patient demographics which may represent inequitable care. Our objective was to perform an exploratory analysis of antibiotic prescribing rates for respiratory conditions to better understand possible inequities and identify disparities in our health system. Methods This was a retrospective cohort study of urgent care encounters for respiratory conditions in the Intermountain Healthcare (IH) network from July 1st 2018 – June 30th 2019. Individual respiratory encounters were identified using a validated methodology based on ICD10 codes. Overall antibiotic prescribing rates and rates for Tier 1 (antibiotics indicated), 2 (sometimes indicated), and 3 (not indicated, eg bronchitis) conditions were assessed. Prescribing rates for categories in which inequities might exist, including age, weight, patient race/ethnicity, preferred language, provider type, and provider/patient gender combinations, were examined. We considered an absolute percentage difference between groups within a category of ≥5.0% to represent a potential disparity. Results 93,588 (48.5%) of 193,107 respiratory urgent care encounters were associated with an antibiotic prescription. Overall antibiotic prescribing rates (Results Image 1) were higher in white compared to non-white patients (49.0% vs 38.2%) and in those reporting non-Hispanic ethnicity compared to Hispanics (49.1% vs 43.2%). Patients over 18 years-old were prescribed antibiotics more frequently than younger patients. Among Tier 3 encounters male providers prescribed antibiotics more frequently for male patients than female providers did for female patients (20.8% vs 15.6). Overweight and obese patients with Tier 3 diagnoses received antibiotic prescriptions more frequently than non-obese patients (22.8% vs 15.3%). Minimal differences between patients who preferred English and those who preferred non-English languages were observed. Results Image 1 - Table 1 Overall antibiotic prescribing rates and antibiotic prescribing rates for Tier 3 conditions for urgent care respiratory condition encounters July 1st, 2018 – June 30th, 2019*¥. *Tier 3 codes are those where antibiotics are not indicated (eg bronchitis). ¥Absolute differences of ≥5.0% between groups within each category are indicated in bold. Conclusion Antibiotic prescribing rates for respiratory conditions in urgent care encounters in our system differed based on race, ethnicity, age, obesity, and gender. These differences may represent biases contributing to inequities in care and may serve as potential targets for improved stewardship efforts. Disclosures All Authors: No reported disclosures.

Who Presents Where? A Population-Based Analysis of Socio-Demographic Inequalities in Head and Neck Cancer Patients' Referral Routes.

Head and neck cancers (HNC) are often late stage at diagnosis; stage is a major determinant of prognosis. The urgent cancer referral pathway (two week wait; 2WW) within England's National Health Service aims to reduce time to diagnosis. We investigated factors associated with HNC route to diagnosis. Data were obtained from the English population-based cancer registry on 66,411 primary invasive HNCs (ICD C01-14 and C31-32) diagnosed 2006-2014. Multivariable logistic regression determined the likelihood of different diagnosis routes by patients' demographic and clinical characteristics. Significant socio-demographic inequalities were observed. Emergency presentations declined over time and 2WW increased. Significant socio-demographic inequalities were observed. Non-white patients, aged over 65, residing in urban areas with advanced disease, were more likely to have emergency presentations. White males aged 55 and older with an oropharynx cancer were more likely to be diagnosed via 2WW. Higher levels of deprivation were associated with both emergency and 2WW routes. Dental referral was more likely in women, with oral cancers and lower stage disease. Despite the decline over time in emergency presentation and the increased use of 2WW, socio-demographic variation is evident in routes to diagnosis. Further work exploring the reasons for these inequalities, and the consequences for patients' care and outcomes, is urgently required.