Racial Disparities In Survival Research Articles

PD21-07 RACIAL IMPACT (ASIAN VS. WHITE) ON THE PROGNOSIS OF PATIENTS WITH DE NOVO MCSPC: AN ANALYSIS ON LATITUDE, SEER AND NCDB

You have accessJournal of UrologyCME1 Apr 2023PD21-07 RACIAL IMPACT (ASIAN VS. WHITE) ON THE PROGNOSIS OF PATIENTS WITH DE NOVO MCSPC: AN ANALYSIS ON LATITUDE, SEER AND NCDB XuDong Ni, Michael Luu, Weiwei Ma, Stephen Freedland, Timothy J. Daskivich, and Yao Zhu XuDong NiXuDong Ni More articles by this author , Michael LuuMichael Luu More articles by this author , Weiwei MaWeiwei Ma More articles by this author , Stephen FreedlandStephen Freedland More articles by this author , Timothy J. DaskivichTimothy J. Daskivich More articles by this author , and Yao ZhuYao Zhu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003287.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Little is known about the impact of race (Asian or White) on the long-term survival outcomes of men with de novo mCSPC treated with different methods. Understanding racial disparities in survival is critical for accurate prognostic risk stratification and for informing the design of multiregional clinical trials. METHODS: This multiple-cohort study included individual patient-level data of men with de novo mCSPC from the following 3 cohorts: LATITUDE clinical trial data (LATITUDE [n = 1199]); Surveillance, Epidemiology, and End Results (SEER [n = 5496]); and the National Cancer Database (NCDB [n = 10366]). Key efficacy outcomes were overall survival (OS) in LATTITUDE and NCDB as well as OS and cancer-specific survival (CSS) in SEER. Kaplan-Meier analysis with propensity score matching (PSM) was used for survival analysis. Hazard ratios were calculated using a multivariate Cox proportional-hazard model. RESULTS: Across all three cohorts, Asian patients diagnosed with de novo mCSPC had better OS and CSS than White patients. In LATITUDE, median OS was significantly longer in Asian than in White men in the ADT+Abiraterone+Prednisone group (not reached vs. 43.8 months, HR0.47, 95% CI 0.28–0.77, P = 0.003 for cox analysis) as well as in the ADT+placebo group (57.6 months vs. 32.7 months, HR0.49, 95% CI 0.32–0.75, P = 0.001 for cox analysis). In SEER, among all patients diagnosed with de novo mCSPC, median OS was significantly longer in Asian than in White men (53 months vs. 42 months, HR0.76, 95% CI 0.68–0.85, p<0.001 for cox analysis). When analyses were restricted to patients who received chemotherapy, Asian men again had longer OS (67 months vs. 41 months, HR0.70 95% CI 0.51–0.95, p=0.02 for cox analysis). Using CSS data in SEER resulted in similar conclusions as OS. In NCDB, Asians also had longer OS than White men (whole cohort: 38 months vs. 26 months, HR0.73, 95%CI 0.63–0.84, P = 0.02 for cox analysis; ADT subgroup: 41 months vs. 26 months, HR0.75, 95% CI 0.63–0.89, p<0.001 for cox analysis; Chemotherapy subgroup: 34 months vs. 27 months, HR0.80, 95% CI 0.69–0.94, p=0.005 for cox analysis). CONCLUSIONS: Asian men had better OS and CSS than White men with mCSPC across different treatment regimens in all datasets examined and should be considered as an independent prognostic factor. This racial difference should also be considered when designing multiregional clinical trials. Further studies including biological analyses are needed to understand the etiology of the apparent survival advantage for Asian men. Source of Funding: NSFC 81972375, 81802528 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e592 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information XuDong Ni More articles by this author Michael Luu More articles by this author Weiwei Ma More articles by this author Stephen Freedland More articles by this author Timothy J. Daskivich More articles by this author Yao Zhu More articles by this author Expand All Advertisement PDF downloadLoading ...

Socioeconomic and racial disparities in survival for patients with stage IV cancer

BackgroundDisparities in cancer outcomes for minoritized people and groups experiencing disadvantages with Stage IV cancer is largely unknown. MethodsPatients with Stage IV pancreatic, colorectal, lung, breast, and prostate cancer were identified from 2004 to 2015 in the National Cancer Database. Cox proportional hazard models were used to quantify how demographics and treatments received were associated with overall survival. Results903,151 patients were included. Patients who were younger, non-Hispanic White, had private insurance, higher income, or received care at an academic center were more likely to receive surgery, chemotherapy, and/or radiation therapy (p < 0.001). Black patients, those with Medicare, Medicaid, no insurance, and lower income had lower survival rates across all five cancer types (p < 0.001). On multivariable analysis, receipt of surgery, radiation, and chemotherapy attenuated but did not eliminate this worse survival (p < 0.001). ConclusionsSurvival for patients with Stage IV cancer differs by socioeconomic and self-reported racial classifications.

Health Insurance Coverage and Racial/Ethnic Disparities in US Childhood and Adolescent Cancer Survival

To evaluate potential effect modification by health insurance coverage on racial and ethnic disparities in cancer survival among US children and adolescents. Data from 54 558 individuals diagnosed with cancer at ≤ 19years between 2004 and 2010 were obtained from the National Cancer Database. Cox proportional hazards regression was used for analyses. An interaction term between race/ethnicity and health insurance type was included to examine racial/ethnic disparities in survival by each insurance status category. Racial/ethnic minorities experienced a 14%-42% higher hazard of death compared with non-Hispanic Whites (NHWs) with magnitudes varying by health insurance type (Pinteraction < .001). Specifically, among those reported as privately insured, the hazard of death was higher for non-Hispanic Blacks (NHBs) (hazard ratio [HR]=1.48, 95% CI: 1.36-1.62), non-Hispanic American Indian/Alaskan Natives (HR=1.99, 95% CI: 1.36-2.90), non-Hispanic Asians or Pacific Islanders (HR=1.30, 95% CI: 1.13-1.50), and Hispanics (HR=1.28, 95% CI: 1.17-1.40) vs NHWs. Racial/ethnic disparities in survival among those reported as covered by Medicaid were present for NHBs (HR=1.30, 95% CI: 1.19-1.43) but no other racial/ethnic minorities (HR ranges: 0.98∼1.00) vs NHWs. In the uninsured group, the hazard of death for NHBs (HR=1.68, 95% CI: 1.26-2.23) and Hispanics (HR=1.27, 95% CI: 1.01-1.61) was higher vs NHWs. Disparities in survival exist across insurance types, particularly for NHB childhood and adolescent cancer patients vs NHWs with private insurance. These findings provide insights for research and policy, and point to the need for more efforts on promoting health equity while improving health insurance coverage.

Abstract PD1-07: Racial disparities in neoadjuvant chemosensitivity and survival in early breast cancer: A national database study

Abstract Background: Neoadjuvant chemotherapy (NAC) is the standard of care for locally advanced breast cancer (BC). Patients (pts) who attained pathological complete response (pCR) with NAC have a better prognosis when compared to those who have residual disease (RD). We analyzed the association of race with neoadjuvant chemosensitivity in early BC and the overall survival (OS) based on the chemosensitivity. Methods: We queried the National Cancer Database for early BC pts who received NAC from 2010-2016. Preoperative chemosensitivity was defined as very sensitive (VS) (ypT0/TisN0), sensitive (S) (pathological TNM stage less than clinical, excluding ypT0N0), and refractory (R) (pathological greater than or equal to clinical). Demographic, clinical, treatment, and survival rates were summarized by race focusing on neoadjuvant chemosensitivity. All associations were compared using Kruskal-Wallis, Pearson’s Chi-Squared, and Fisher’s Exact Tests. Multivariate cox models were generated for the OS. All analyses were conducted in RStudio v4.0.2 at a significance level of 0.05. Results: A total of 103,605 pts who received NAC were analyzed. 43.2% (n= 44,796) were R, 34.4% (n= 35,638) were S and 22.4% (n= 23,171) pts were VS. The 3-year (yr) OS rates for R, S, VS groups were 81%, 88%, 95% respectively (rsp) (p&amp;lt; 0.001). The 5-yr OS rates were 73%, 82%, 92% rsp (p &amp;lt; 0.001). In the hormone-receptor positive HER2 negative (HR+) subtype, only 8.9% (n= 3,837) were VS, while among triple negative breast cancer (TNBC) subtype, 28.4% (n= 9,224) pts were VS, among HER2 positive (HER2+) subtype, 36.7% (n=9,665) pts were VS and in both subtypes around 28-36% were R as opposed to 58.4% with R disease among HR+ subtype. Among HR+ group, pts had more R disease regardless of race (all races R: 54-57%, p &amp;lt; 0.001). Among HER2+ disease, Blacks had lower percentage of VS disease compared to other races (32% vs 37-40%, p&amp;lt; 0.001). Among TNBC, more R disease was seen among Blacks compared to other races (38% vs 30-35%, p&amp;lt; 0.001). In whole cohort, as expected, compared to pts with R disease, pts with S and VS disease had lower overall mortality risk (HR= 0.45, 95% CI= 0.43 – 0.46, P&amp;lt; 0.001, HR= 0.20, 95% CI = 0.19- 0.21, p &amp;lt; 0.001 rsp). In TNBC subgroup among pts with R disease, the median OS of Blacks was significantly lower compared to whites (71.9 vs 101.8 months, p &amp;lt; 0.001). Among BC subtypes, the 3-yr and 5-yr OS for R (65%, 56%) and S groups (83%, 76%) were significantly lower in TNBC when compared to other subtypes (HR+ R: 3-yr- 88%, 5-yr- 79% and S: 3-yr- 90%, 5-yr- 83%; HER2+ R: 3-yr- 85%, 5-yr- 77% and S: 3-yr- 92%, 5-yr- 86%, p&amp;lt; 0.001). In the whole cohort, Blacks with R, S, VS disease had significantly lower 3yr (73%, 85%, 94% rsp) and 5yr OS (63%, 78%, 91% rsp) compared to all other races and this was more prominent in the R and S groups (Table 1). Conclusion: Blacks diagnosed with TNBC were more resistant while other races were more sensitive to NAC. In all BC subtypes, Blacks had lower 3-yr and 5-yr OS regardless of chemosensitivity (including those who attained pCR), though this disparity was more predominant among those with residual disease after NAC (resistant and sensitive group). Since Blacks who do not attain pCR have worse survival compared to other races, it highlights the need to design more effective and personalized treatment strategies for Blacks to help them attain pCR, especially in the TNBC subtype. Table 1: Racial Disparities in Survival in Different Chemosensitivity Groups Citation Format: Arya Mariam Roy, Kayla Catalfamo, Kristopher Attwood, Shipra Gandhi. Racial disparities in neoadjuvant chemosensitivity and survival in early breast cancer: A national database study. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD1-07.

Abstract PD1-01: The Impact of Structural Racism on Breast Cancer Stage at Presentation

Abstract Background: Despite advances in diagnosis and treatment, racial and economic disparities in breast cancer-specific survival persist and this is exacerbated by later stage at presentation. It is essential to assess the factors that contribute to later stage at presentation to target racial and socioeconomic disparities in breast cancer mortality. The objective of this study was to analyze the effect of neighborhood socioeconomic status (SES) and race/ethnicity, as measured by the Index of Concentration at the Extremes (ICE), on breast cancer stage at presentation in a diverse metropolitan area that mirrors the projected demographics of many US regions. Methods: Patients treated at our medical campus, comprised of a safety-net hospital and an academic cancer center, with stage I-IV breast cancer from 2005-2017 were identified from our tumor registry. Census tracts were used as neighborhood proxies. Using 5-year estimates from the American Community Survey, 5 ICE variables were computed: economic (high vs. low), race/ethnicity (non-Hispanic White (NHW) vs. non-Hispanic Black (NHB) and NHW vs. Hispanic) and racialized economic (low-income NHB vs high-income NHW and low-income Hispanics vs. high-income NHW) segregation. ICE uniquely captures spatial economic and racial/ethnic segregation by mapping social inequality not otherwise captured by evaluating a population of a specific socioeconomic level or belonging to a particular racial/ethnic group. We used five separate models based on each of the ICE variables to evaluate economic and racial/ethnic segregation. Model 1 captures economic segregation (high vs. low), Model 2 captures racial segregation (NHB vs. NHW), Model 3 evaluates racialized economic segregation (low-income NHB vs high-income NHW), Model 4 captures segregation by Hispanic ethnicity (Hispanic vs. Non-Hispanic), and Model 5 captures ethnic and economic segregation (low-income Hispanics vs. high-income NHW). Our main outcome was breast cancer stage at presentation categorized as early (Stage I and II) vs. late (Stage III and IV) disease. All models controlled for the following covariates: race/ethnicity, age, insurance status, tumor subtype, and comorbidities including hypertension, diabetes, coronary artery disease, and hyperlipidemia. Results: The study population included 6,145 breast cancer patients. 52.6% were Hispanic, 26.3% were NHW, and 17.2% were NHB. Those living in the most economically marginalized neighborhoods (Quartiles 1 and 2) had significantly increased odds of presenting with later stage disease [ORQ1 1.36 (1.13-1.64), ORQ2 1.43 (1.18-1.75); p&amp;lt; 0.05]. Those living in the most racial/ethnic and economically marginalized neighborhoods (Quartile 1 of Models 3 and 5) had statistically significantly increased odds of presenting with later stage after controlling for all covariates compared to a NHW living in more economically advantaged neighborhoods [ORModel3 1.55 (1.21-1.99), ORModel5 1.43 (1.11-1.85); p&amp;lt; 0.05]. Conclusions: This study is the first to evaluate stage at presentation by ICE, which allows us to uniquely evaluate how residential racial and economic segregation may influence breast cancer disparities. Our study shows that patients in the most economically and racial/ethnically marginalized neighborhoods were more likely to present with later stage disease. This suggests that structural racism is influencing stage at presentation, and therefore effecting racial and economic disparities in breast cancer, even when accounting for demographics and tumor characteristics. To address these disparities, effective interventions are needed that account for the social and environmental contexts in which cancer patients live and can access care. Table 1: Odds Ratios for Later Stage at Presentation with Breast Cancer by Different Types of Residential Segregation Model 1: Economic segregation (high-income vs low-income) Model 2: NHB vs NHW segregation Model 3: NHB and economic segregation (low-income NHB vs high-income NHW) Model 4: Hispanic vs NHW segregation Model 5: Hispanic and economic segregation (low-income Hispanics vs. high-income NHW) Q1: Most disadvantaged neighborhoods; Q4: Reference: most advantaged neighborhoods. *p &amp;lt; 0.05 Citation Format: Alexandra Hernandez, Brianna L Cohen, Ashly Westrick, Cheyenne Thompson, Susan Kesmodel, Neha Goel. The Impact of Structural Racism on Breast Cancer Stage at Presentation [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD1-01.

Racial impact (Asian vs. White) on the prognosis of patients with de novo mCSPC: An analysis on LATITUDE, SEER and NCDB.

27 Background: Little is known about the impact of race (Asian or White) on the long-term survival outcomes of men with de novo mCSPC treated with different methods. Understanding racial disparities in survival is critical for accurate prognostic risk stratification and for informing the design of multiregional clinical trials. Methods: This multiple-cohort study included individual patient-level data of men with de novo mCSPC from the following 3 cohorts: LATITUDE clinical trial data (LATITUDE [n=1199]); Surveillance, Epidemiology, and End Results (SEER [n=5496]); and the National Cancer Database (NCDB [n=10366]). Key efficacy outcomes were overall survival (OS) in LATTITUDE and NCDB as well as OS and cancer-specific survival (CSS) in SEER. Kaplan-Meier analysis with propensity score matching (PSM) was used for survival analysis. Hazard ratios were calculated using a multivariate Cox proportional-hazard model. Results: Across all three cohorts, Asian patients diagnosed with de novo mCSPC had better OS and CSS than White patients. In LATITUDE, median OS was significantly longer in Asian than in White men in the ADT+Abiraterone+Prednisone group (not reached vs. 43.8 months, HR 0.47, 95%CI 0.28–0.77, P=0.003 for Cox analysis) as well as in the ADT+placebo group (57.6 months vs. 32.7 months, HR 0.49, 95%CI 0.32–0.75, P=0.001 for cox analysis). In SEER, among all patients diagnosed with de novo mCSPC, median OS was significantly longer in Asian than in White men (53 months vs. 42 months, HR 0.76, 95%CI 0.68–0.85, P&lt;0.001 for Cox analysis). When analyses were restricted to patients who received chemotherapy, Asian men again had longer OS (67 months vs. 41 months, HR 0.70 95% CI 0.51–0.95, P=0.02 for Cox analysis). Using CSS data in SEER resulted in similar conclusions as OS. In NCDB, Asians also had longer OS than White men (whole cohort: 38 months vs. 26 months, HR 0.73, 95%CI 0.63–0.84, P=0.02 for Cox analysis; ADT subgroup: 41 months vs. 26 months, HR 0.75, 95%CI 0.63–0.89, P&lt;0.001 for Cox analysis; Chemotherapy subgroup: 34 months vs. 27 months, HR 0.80, 95%CI 0.69–0.94, P=0.005 for Cox analysis). Conclusions: Asian men had better OS and CSS than White men with mCSPC across different treatment regimens in all datasets examined and should be considered as an independent prognostic factor. This racial difference should also be considered when designing multiregional clinical trials. Further studies including biological analyses are needed to understand the etiology of the apparent survival advantage for Asian men. [Table: see text]

Association of Social Determinants and Tumor Biology With Racial Disparity in Survival From Early-Stage, Hormone-Dependent Breast Cancer

Black women with hormone receptor-positive breast cancer experience the greatest racial disparity in survival of all breast cancer subtypes. The relative contributions of social determinants of health and tumor biology to this disparity are uncertain. To determine the proportion of the Black-White disparity in breast cancer survival from estrogen receptor (ER)-positive, axillary node-negative breast cancer that is associated with adverse social determinants and high-risk tumor biology. A retrospective mediation analysis of factors associated with the racial disparity in breast cancer death for cases diagnosed between 2004 and 2015 with follow-up through 2016 was carried out using the Surveillance, Epidemiology, and End Results (SEER) Oncotype registry. The study included women in the SEER-18 registry who were aged 18 years or older at diagnosis of a first primary invasive breast cancer tumor that was axillary node-negative and ER-positive, who were Black (Black), non-Hispanic White (White), and for whom the 21-gene breast recurrence score was available. Data analysis took place between March 4, 2021, and November 15, 2022. Census tract socioeconomic disadvantage, insurance status, tumor characteristics including the recurrence score, and treatment variables. Death due to breast cancer. The analysis with 60 137 women (mean [IQR] age 58.1 [50-66] years) included 5648 (9.4%) Black women and 54 489 (90.6%) White women. With a median (IQR) follow-up time of 56 (32-86) months, the age-adjusted hazard ratio (HR) for breast cancer death among Black compared with White women was 1.82 (95% CI, 1.51-2.20). Neighborhood disadvantage and insurance status together mediated 19% of the disparity (mediated HR, 1.62; 95% CI, 1.31-2.00; P < .001) and tumor biological characteristics mediated 20% (mediated HR, 1.56; 95% CI, 1.28-1.90; P < .001). A fully adjusted model that included all covariates accounted for 44% of the racial disparity (mediated HR, 1.38; 95% CI, 1.11-1.71; P < .001). Neighborhood disadvantage mediated 8% of the racial difference in the probability of a high-risk recurrence score (P = .02). In this study, racial differences in social determinants of health and indicators of aggressive tumor biology including a genomic biomarker were equally associated with the survival disparity in early-stage, ER-positive breast cancer among US women. Future research should examine more comprehensive measures of socioecological disadvantage, molecular mechanisms underlying aggressive tumor biology among Black women, and the role of ancestry-related genetic variants.

Health-care access dimensions and ovarian cancer survival: SEER-Medicare analysis of the ORCHiD study.

Racial and ethnic disparities in ovarian cancer (OC) survival are well-documented. However, few studies have investigated how health-care access (HCA) contributes to these disparities. To evaluate the influence of HCA on OC mortality, we analyzed 2008-2015 Surveillance, Epidemiology, and End Results-Medicare data. Multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between HCA dimensions (affordability, availability, accessibility) and OC-specific and all-cause mortality, adjusting for patient characteristics and treatment receipt. The study cohort included 7590 OC patients: 454 (6.0%) Hispanic, 501 (6.6%) Non-Hispanic (NH) Black, and 6635 (87.4%) NH White. Higher affordability (HR = 0.90, 95% CI = 0.87 to 0.94), availability (HR = 0.95, 95% CI = 0.92 to 0.99), and accessibility scores (HR = 0.93, 95% CI = 0.87 to 0.99) were associated with lower risk of OC mortality after adjusting for demographic and clinical factors. Racial disparities were observed after additional adjustment for these HCA dimensions: NH Black patients experienced a 26% higher risk of OC mortality compared with NH White patients (HR = 1.26, 95% CI = 1.11 to 1.43) and a 45% higher risk among patients who survived at least 12 months (HR = 1.45, 95% CI = 1.16 to 1.81). HCA dimensions are statistically significantly associated with mortality after OC and explain some, but not all, of the observed racial disparity in survival of patients with OC. Although equalizing access to quality health care remains critical, research on other HCA dimensions is needed to determine additional factors contributing to disparate OC outcomes by race and ethnicity and advance the field toward health equity.

The Intersectionality between Race, Ethnicity, and Residential-Level Socioeconomic Status in Disparities of Head and Neck Cancer Outcomes: A SEER Study.

Head and neck cancer (HNC) mortality differs by race, ethnicity, and socioeconomic status (SES). However, it is unclear whether the relationship between race/ethnicity and HNC-specific mortality varies according to the residence-level SES. Data from the Surveillance Epidemiology and End Results database included participants with primary HNC between 2006 and 2017 (followed through 2018) to assess the joint association of race/ethnicity and census-tract level SES Yost-index groups (quintiles) with all-cause and HNC-specific mortalities. Relative survival rates at 1, 5, and 10 years were calculated. Multivariable Cox proportional hazard regression models estimated hazard-ratios and 95% confidence intervals for all-cause mortality, and Fine-Gray subdistribution hazard models for HNC-specific mortality. Cumulative incidence curves for HNC-specific deaths were estimated. 76,095 patients were included in the analysis: 63.2% were <65 years, 73.4% male, and 11.3% non-Hispanic (NH) Black. Most patients (58.3%) were diagnosed at regional or distant stages and 20.6% died of HNC. The five-year relative survival rate increased with SES group, with 51.6% in the lowest SES group, and 74.1% in the highest SES group. NH-Black patients had higher risk of all-cause and HNC-specific mortality than NH-White patients, regardless of the SES group. NH-Asian/Pacific Islander and Hispanic patients had higher risk of HNC-specific mortality in some SES groups. NH-Black patients of all SES strata had significantly worse outcomes. Other factors, such as healthcare quality, may be associated with persistent disparities. The study highlights the persistence of significant racial disparities in HNC survival across socioeconomic categories. There is need to consider additional factors underlying these disparities.

Impact of Patient Navigation on Reducing Breast Imaging Disparities and Applications in the COVID-19 Era.

The coronavirus (COVID-19) pandemic has impacted breast cancer screening with concerns that this may lead to increased overall breast cancer mortality and worsened racial and ethnic disparities in breast cancer survival. As pandemic recovery efforts are underway, we must be prepared to address barriers to timely access of breast imaging services, including those that existed prior to the pandemic, as well as any new barriers that may arise as a result of the pandemic. Patient navigation is an important tool that has been shown to address barriers to timely breast imaging access and help reduce disparities. Patient navigation programs can serve as a key part of the strategy to mitigate the impact of the COVID-19 pandemic on timely breast cancer diagnosis. These programs have been shown to be successful in promoting adherence to breast cancer screening guidelines as well as encouraging timely diagnostic follow-up, particularly in underserved communities. Further research is needed to explore the role of using a telehealth platform for patient navigation and evaluate the cost-effectiveness of patient navigator programs as well as more randomized controlled trials to further explore the impact of patient navigation programs.

Partially Recursively Induced Structured Moderation (PRISM) for modeling racial differences in endometrial cancer survival.

Health disparities are driven by a complex interplay of determinants operating across multiple levels of influence. However, while recognized conceptually, much disparities research fails to capture this inherent complexity in study focus and/or design; little of such work accounts for the interplay across the multiple levels of influence from structural (contextual) to biological or clinical. We developed a novel modeling framework that addresses these challenges and provides new insights. We used data from the Florida Cancer Data System on endometrial cancer patients and geocoded-derived social determinants of health to demonstrate the applicability of a new modeling paradigm we term PRISM regression. PRISM is a new highly interpretable tree-based modeling framework that allows for automatic discovery of potentially non-linear hierarchical interactions between health determinants at multiple levels and differences in survival outcomes between groups of interest, including through a new specific area-level disparity estimate (SPADE) incorporating these multilevel influences. PRISM demonstrates that hierarchical influences on racial disparity in endometrial cancer survival appear to be statistically relevant and that these better predict survival differences than only using individual level determinants. The interpretability of the models allows more careful inspection of the nature of these hierarchical effects on disparity. Additionally, SPADE estimates show distinct geographical patterns across census tracts in Florida. PRISM can provide a powerful new modeling framework with which to better understand racial disparities in cancer survival.

Racial and ethnic disparities in childhood and young adult acute lymphocytic leukaemia: secondary analyses of eight Children's Oncology Group cohort trials

Previous studies have identified racial and ethnic disparities in childhood acute lymphocytic leukaemia survival. We aimed to establish whether disparities persist in contemporaneous cohorts and, if present, are attributable to differences in leukaemia biology or insurance status. Patients with newly diagnosed acute lymphocytic leukaemia in inpatient and outpatient centres in the USA, Canada, Australia, and New Zealand, aged 0-30 years, who had race or ethnicity data available, enrolled on eight completed Children's Oncology Group trials (NCT00103285, NCT00075725, NCT00408005, NCT01190930, NCT02883049, NCT02112916, NCT02828358, and NCT00557193) were included in this secondary analysis. Race and ethnicity were categorised as non-Hispanic White, Hispanic, non-Hispanic Black, non-Hispanic Asian, and non-Hispanic other. Event-free survival and overall survival were compared across race and ethnicity groups. The relative contribution of clinical and biological disease prognosticators and insurance status was examined through multivariable regression models, both among the entire cohort and among those with B-cell lineage versus T-cell lineage disease. Between Jan 1, 2004, and Dec 31, 2019, 24 979 eligible children, adolescents, and young adults with acute lymphocytic leukaemia were enrolled, of which 21 152 had race or ethnicity data available. 11 849 (56·0%) were male and 9303 (44·0%) were female. Non-Hispanic White patients comprised the largest racial or ethnic group (13 872 [65·6%]), followed by Hispanic patients (4354 [20·6%]), non-Hispanic Black patients (1517 [7·2%]), non-Hispanic Asian (n=1071 [5·1%]), and non-Hispanic other (n=338 [1·6%]). 5-year event-free survival was 87·4% (95% CI 86·7-88·0%) among non-Hispanic White patients compared with 82·8% (81·4-84·1%; hazard ratio [HR] 1·37, 95% CI 1·26-1·49; p<0·0001) among Hispanic patients and 81·8% (79·3-84·0; HR 1·45, 1·28-1·65; p<0·0001) among non-Hispanic Black patients. Non-hispanic Asian patients had a 5-year event-free survival of 88·1% (95% CI 85·5-90·3%) and non-Hispanic other patients had a survival of 82·8% (76·4-87·6%). Inferior event-free survival among Hispanic patients was substantially attenuated by disease prognosticators and insurance status (HR decreased from 1·37 [1·26-1·49; p<0·0001] to 1·11 [1·00-1·22; p=0·045]). The increased risk among non-Hispanic Black patients was minimally attenuated (HR 1·45 [1·28-1·65; p<0·0001] to 1·32 [1·14-1·52; p<0·0001]). 5-year overall survival was 93·6% (91·5-95·1%) in non-Hispanic Asian patients, 93·3% (92·8-93·7%) in non-Hispanic White patients, 89·9% (88·7-90·9%) in Hispanic, 89·7% (87·6-91·4%) in non-Hispanic Black patients, 88·9% (83·2-92·7%) in non-Hispanic other patients. Disparities in overall survival were wider than event-free survival (eg, among non-Hispanic other patients, the HR for event-free survival was 1·43 [1·10-1·85] compared with 1·74 [1·27-2·40] for overall survival). Disparities were restricted to patients with B-cell acute lymphocytic leukaemia, no differences in event-free survival or overall survival were seen in the T-cell acute lymphocytic leukaemia group. Substantial disparities in outcome for B-cell acute lymphocytic leukaemia persist by race and ethnicity, but are not observed in T-cell acute lymphocytic leukaemia. Future studies of relapsed patients, access to and quality of care, and other potential aspects of structural racism are warranted to inform interventions aimed at dismantling racial and ethnic disparities. National Cancer Institute and St Baldrick's Foundation.

Investigation of racial differences in survival from non-small cell lung cancer with immunotherapy use: A Texas study.

The use of immunotherapy is associated with improved survival among patients with Non-Small Cell Lung Cancer (NSCLC) and has gained widespread use in its management. However, there is limited information on whether the survival benefits associated with immunotherapy differ among races and ethnicities. This study aimed to investigate racial differences in survival amongst patients with NSCLC who received immunotherapy as the first-line treatment in Texas. Patients with NSCLC who received immunotherapy between October 2015 to December 2018 were identified from the Texas Cancer Registry (TCR). Disease-specific survival was evaluated and compared among patients across racial/ethnic categories using the Kaplan-Meier survival analysis, log-rank test, and a multivariable Cox proportional hazard regression model following an inverse probability treatment weighting (IPTW) propensity score analysis. A total of 1453 patients were included in the analysis. Median survival (in months) was longest among Asians (34, 95% CI: 15-Not Estimable), followed by African Americans (AAs) (23, 95% CI: 15-34), Hispanics (22, 95% CI: 16-26), and Whites (19, 95% CI: 17-22). The adjusted regression estimates had no statistically significant differences in survival among AAs (aHR = 0.97; 95% CI = 0.78-1.20; P =0.77) and Hispanics (aHR = 0.96; 95% CI = 0.77-1.19, P =0.73) when compared to White patients. Asians on the other hand, had 40% reduction in mortality risk compared to Whites (aHR = 0.60; 95% CI = 0.39-0.94, P = 0.03). Our study indicated that African Americans and Hispanics do not have poorer survival compared to White patients when receiving immunotherapy as first-line treatment. Asians however had longer survival compared to Whites. Our findings suggest that existing racial disparity in NSCLC survival might be mitigated with the use of immunotherapy and should be considered in providing care to these minority groups.

Abstract A009: Survival disparities in lung squamous cell carcinoma: Clinical and genomic correlates with genetic ancestry

Abstract Many studies show racial and ethnic survival disparities in lung squamous cell carcinoma (LSCC), and self-identified African-Americans have significantly lower overall survival and progression-free survival than self-identified Caucasians. However, survival models based on genetic ancestry, rather than self-identified race, are needed to assess whether genetic ancestry influences this survival disparity or whether the cause of the disparity is largely socioeconomic. Using clinically annotated genomic data from 501 LSCC tumor samples in the Cancer Genome Atlas (TCGA), we compared clinical data, gene expression profiles, mutations, and copy number changes of tumors across ancestral groups to identify significantly differential events. We then applied the Cox Proportional Hazards model to predict overall survival as a function of genetic ancestry alongside other genetic, molecular, and clinical variables. We found a significant difference in metastatic stage between tumors from patients of African (AFR) and European (EUR) ancestry, which was significant in predicting survival. We identified increased copy number of chromosome arm 8q and locus chr8q24, as well as increased expression of MYC targets in AFR samples relative to EUR samples, all of which suggest a role for the MYC pathway in differential cancer progression. In addition, we found enrichment of amplifications at chr22q11 and chr16p11 in AFR samples compared to EUR samples. We identified top differentially mutated genes between groups, of which mutant SPRR3, PDGFA, FRS3, and C21orf62 correlate with survival. Notably, when survival was modeled as a function of both genetic ancestry and SPRR3 mutation, genetic ancestry was no longer significant as a predictor of survival. The PDGFRA receptor is also significantly differentially expressed between groups, suggesting a possible role of the PDGF axis in differential tumor growth. These results suggest potential genetic and clinical factors implicated in racial survival disparities. Further studies and more diverse sampling of cancer patient populations would allow validation of these differences and future elucidation of patient-specific treatment modalities. Citation Format: Sejal Jain, Alexandria Yao, Diane Allen-Gipson, Fatemeh Momen-Heravi, Alison M. Taylor. Survival disparities in lung squamous cell carcinoma: Clinical and genomic correlates with genetic ancestry [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 A009.

Abstract IA039: The breast cancer biomarkers as predictors of survival: Do they vary by race and ethnicity?

Abstract Introduction: Racial/ethnic disparities in cancer survival in the United States are well documented, but the underlying biology is not well understood. Compared with European American (EA) counterparts, African American (AA) women are more likely to die from breast cancer in the United States. Our recent studies were aimed to evaluate trends in survival, by race-ethnicity, for women diagnosed with breast cancer. We uncovered some biological factors underlying this disparity by comparing functional expression and prognostic significance of several biomarkers including master transcriptional regulators of luminal differentiation. Materials &amp; Methods: We used a ML approach to assess a cohort of racially diverse 555 primary BC patients who underwent surgery in Greenville, NC and develop proteomics-based genomics (PbG) signatures. We apply quantitative automated image processing and computational methods to profile the subcellular distribution of the multi-functional transcriptional regulator, Kaiso (ZBTB33), and GP78. The cross-validated models were developed on a BC pooled dataset of (N= 845) samples (primarily taxane and anthracycline based) and chemotherapy cohort (N=415) including racial disparities. Results: Multiplex multivariate analysis of the association of Kaiso’s subcellular distribution with other breast cancer biomarkers reveals novel functional and predictive linkages between Kaiso and the autophagy-related proteins, LC3A/B, that are associated with features of the tumor immune microenvironment, survival, and race. Univariate or multivariate HRs for overall survival, estimated from digital IHC scoring of nuclear antigen, show distinct differences in the magnitude and significance of these biomarkers to predict survival based on race: ESR1 [EA HR 0.47; 95% confidence interval (CI), 0.31–0.72 and AA HR 0.77; 95% CI, 0.48–1.18]; FOXA1 (EA HR 0.38; 95% CI, 0.23–0.63 and AA HR 0.53; 95% CI, 0.31–0.88), and GATA3 (EA HR 0.36; 95% CI, 0.23–0.56; AA HR 0.57; CI, 0.56–1.4). In addition, elevated levels of gp78 in patient breast cancer cells predict poor survival. Moreover, high levels of gp78 are associated with poor outcomes in both ER+ and ER– tumors, and breast cancers expressing elevated amounts of gp78 protein are enriched in gene expression pathways that influence cell cycle, metabolism, receptor-mediated signaling, and cell stress response pathways. Conclusion: Understanding these biomarkers and their downstream regulons will elucidate the intrinsic mechanisms that drive racial disparities in breast cancer survival. These findings identify effective modalities of Kaiso biomarker assessment and uncover unanticipated insights into Kaiso’s role in breast cancer progression. Even within clinically homogeneous tumor groups, regulatory networks that drive mammary luminal differentiation reveal race-specific differences in their association with clinical out- come. Our findings implicate a prominent role for gp78 in tumor progression and offer insights into our understanding of racial differences in breast cancer outcomes. Citation Format: Sandeep K. Singhal, Kevin L. Gardner. The breast cancer biomarkers as predictors of survival: Do they vary by race and ethnicity? [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 IA039.

Abstract A023: Racial differences in lung cancer burden: A retrospective analysis of TriNetX data

Abstract Background. Lung cancer is the number one cause of cancer-related deaths in the U.S. and many other countries. Lung cancer incidence and mortality rates have decreased for all races over the past 20 years, in part because of decreased tobacco use. Yet, there have been few clinical studies of lung cancer morbidity and mortality by race. The purpose of this study is to examine racial differences in lung cancer mortality in the U.S. using the electronic health records (EHR) database, TriNetX. Method. This retrospective cohort study was conducted based on the data from US Collaborative Network in TriNetX, a real-time, EHR database providing 42.7-million patient data from 49 health care organizations (HCOs). The cohort of interest was lung cancer patients in the U.S., which were identified using the ICD-10 code of C34 with an index diagnosis date of January 1, 2010. Kaplan-Meier curves, log-rank chi-square statistics, and hazard ratio (HR) were compared among different racial groups in the EHR data. Results. Of 42.7-million patients in the U.S., the majority (60.3%) were people who are non-Hispanic white (NHW) followed by people who are Black/African American (15.4%), Hispanic (7.2%), Asian (4.6%), and others (Native Hawaiian/Pacific Islander, 0.5%). 394,560 lung cancer patients were identified. Kaplan-Meier survival curves showed that Asians had the highest survival probability with median overall survival (OS) from the initial lung cancer diagnosis of 127.3 months, compared to 92.1 months for Hispanic, 69.1 months for African American/Black, 61.4 months for others, and 53.8 months for NHW. The HR was highest among NHW (HR=1.71, 95% CI=1.62-1.81), others (HR=1.62, 95% CI=1.41-1.85), African American/Black (HR=1.52, 95% CI=1.43-1.61), and Hispanic patients (HR=1.40, 95% CI=1.30-1.52) compared to Asian patients Conclusion. These findings suggest racial disparities in lung cancer survival, with NHW having the lowest and Asians having the highest median survival. These findings are inconsistent with the results from the Multiethnic Cohort study (prospective population based study), which reported blacks having the lowest median survival. It indicates that there are different racial burdens of lung cancer from clinical data and population data. Further analyses are needed to adjust potential confounders such as smoking status and stage of diagnosis. Citation Format: SoHye Park, Zachary Urdang, Julie Barta, Kuang-Yi Wen, Joseph Curry, Hee-Soon Juon. Racial differences in lung cancer burden: A retrospective analysis of TriNetX data [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 A023.

Abstract A070: Association between socioeconomic and clinical factors on timely access to care among young Black women with breast cancer

Abstract Background: Young-onset breast cancer is associated with higher mortality due to multiple factors including tumor biology and delayed presentation. Young women with breast cancer with longer treatment delays have decreased survival time, with the impact on survival being more prominent in Black women. The factors contributing to the racial survival disparity are complex and are likely an interplay between tumor biology, genomics, patterns of care and socioeconomic factors. This study looked at socioeconomic and clinical factors that may affect timely access to care for breast cancer in young Black women, and thus impact survival. Methods: Data from the Black Women Etiology and Survival of Triple-negative Breast Cancers (BEST) Study, a population-based cohort of Black women diagnosed with breast cancer ≤ 50 years old between 2009 and 2015 from the Florida and Tennessee State Cancer Registries was used. The time to treatment (in days) was used as the exposure variable and defined as the time from breast cancer diagnosis to the date of first treatment. The primary outcome was determined by distant or local recurrence or death. Pearson chi-square test was conducted to assess the association between clinical and socioeconomic factors with time to treatment. The socioeconomic variables studied were insurance, income and education. Clinical factors evaluated were the stage of breast cancer at diagnosis, hormone subtype, neoadjuvant chemotherapy and type of surgery. Survival analysis and Cox proportional hazard model were performed to analyze the 10-year overall survival and recurrence rate while adjusting for income, breast cancer stage and hormone subtype. Results: There was a statistically significant association between time to treatment and hormone receptor subtype (p=0.04). More than 60% of women with triple-negative breast cancer (TNBC), and 57% of women with HER2+ breast cancer received treatment within a month of their breast cancer diagnosis. There was also a significant association between the time to treatment and type of surgery received (p=0.03). 64% of patients who had lumpectomies received treatment in ≤30 days, compared to 54% of patients who had a mastectomy. Survival analysis showed the highest mortality in patients with time to treatment &amp;gt;90 days, followed by patients who received treatment in ≤30 days. The study did not find a statistically significant association between insurance, income, or education on the timeliness of treatment for breast cancer. Conclusion: In our study of young Black women, delayed breast cancer treatment resulted in lower survival. While those with TNBC and HER2+ disease were more likely to receive treatment ≤30 days, i.e. neoadjuvant chemotherapy to assess response to chemotherapy and the amount of residual disease at the time of the surgery, the enrichment for aggressive disease is likely the reason for the low survival observed in this group. Timely access to treatment for breast cancer impacts survival and strategies to decrease treatment delays are crucial to reducing breast cancer mortality. Citation Format: Kikelola Oyeleye, Rebecca Lee, Sonya Reid, Tuya Pal, Anne Weidner, Lindsay Venton. Association between socioeconomic and clinical factors on timely access to care among young Black women with breast cancer [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 A070.

Racial disparities in overall survival after the introduction of cyclin-dependent kinase 4/6 inhibitors for patients with hormone receptor-positive, HER2-negative metastatic breast cancer.

CDK4/6 inhibitors (CDK4/6i) combined with endocrine therapy have improved HR + /HER2- metastatic breast cancer (MBC) outcomes. However, it is still unclear whether the response to CDK4/6i is similar for all races. Therefore, we aimed to assess overall survival (OS) trends stratified by race in patients with HR + /HER2- MBC after the approval of CDK4/6i, as part of the standard of care, in 2015. We performed a population-based study using the SEER database. Patients with HR + /HER2- MBC were divided into two time-based cohorts: 1) pre-CDK4/6i era (diagnosed in 2011-2013) and 2) post-CDK4/6i era (diagnosed in 2015-2017). We used propensity score matching and identified 2,684 patients in each cohort that matched in several characteristics. Kaplan-Meier methods were used to estimate 2-year OS. Association between cohort and OS was evaluated using marginal Cox proportional hazards models with robust sandwich variance estimator. We conducted competing risk analysis to estimate the risk of breast cancer death in both cohorts. The 2-year OS rate was 65% for the post-CDK4/6i era and 62% for the pre-CDK4/6i era (stratified log-rank p = 0.025). The 2-year OS for non-Hispanic White (NHW) patients improved in the post-CDK4/6i era compared to the pre-CDK4/6i era (67% vs. 63%, p = 0.033). However, OS did not improve for non-Hispanic Black (NHB) (54% vs. 54%, p = 0.876) or Hispanic (67% vs. 65%, p = 0.617) groups. The risk of breast cancer death decreased in the post-CDK4/6i era as compared to the pre-CDK4/6i era (2-year risk of breast cancer death: 33% vs. 30%, p = 0.015); however, this effect was observed only in NHW (sHR 0.84, p = 0.005) women, but not in NHB (sHR 0.94, p = 0.630) or Hispanic (sHR 0.91, p = 0.550) women. Our study confirms that outcomes for HR + /HER2- MBC have improved after CDK4/6i were introduced in 2015. However, this effect is primarily driven by the improved OS in NHW patients, without significant improvement in OS in NHB or Hispanics.

Reduction in Racial and Ethnic Disparity in Survival Following Liver Transplant for Hepatocellular Carcinoma in the Direct-acting Antiviral Era

Black patients with hepatocellular cancer (HCC), often attributed to hepatitis C virus (HCV) infection, have suboptimal survival following liver transplant (LT). We evaluated the impact of direct-acting antiviral (DAA) availability on racial and ethnic disparities in wait list burden post-LT survival for candidates with HCC. Using the United Network for Organ Sharing registry, we identified patients with HCC who were listed and/or underwent LT from 2009 to 2020. Based on date of LT, patients were categorized into 2 era-based cohorts: the pre-DAA era (LT between 2009 and 2011) and DAA era (LT between 2015 and 2017, with follow-up through 2020). Kaplan-Meier and Cox proportional hazards analyses were used to compare post-LT survival, stratified by era and race and ethnicity. Annual wait list additions for HCV-related HCC decreased significantly in White and Hispanic patients during the DAA era, with no change (P= .14) in Black patients. Black patients had lower 3-year survival than White patients in the pre-DAA era (70.6% vs 80.1%, respectively; P < .001) but comparable survival in the DAA era (82.1% vs 85.5%, respectively; P= .16). 0n multivariable analysis, Black patients in the pre-DAA era had a 53% higher risk (adjusted hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.28-1.84), for mortality than White patients, but mortality was comparable in the DAA era (adjusted HR, 1.23; 95% CI, 0.99-1.52). In a stratified analysis in Black patients, HCV-related HCC carried more than a 2-fold higher risk of mortality in the pre-DAA era (adjusted HR, 2.86; 95% CI, 1.50-5.43), which was reduced in the DAA era (adjusted HR, 1.34; 95% CI, 0.78-2.30). With the availability of DAA therapy, racial disparities in post-LT survival have improved.

Racial survival disparities in head and neck cancer clinical trials.

Survival disparities between Black and White head and neck cancer patients are well documented, with access to care and socioeconomic status as major contributors. We set out to assess the role of self-reported race in head and neck cancer by evaluating treatment outcomes of patients enrolled in clinical trials, where access to care and socioeconomic status confounders are minimized. Clinical trial data from the Radiation Therapy Oncology Group studies were obtained. Studies were included if they were therapeutic trials that employed survival as an endpoint. Studies that did not report survival as an endpoint were excluded; 7 Radiation Therapy Oncology Group Studies were included for study. For each Black patient enrolled in a clinical trial, a study arm-matched White patient was used as a control. A total of 468 Black participants were identified and matched with 468 White study arm-specific controls. White participants had better outcomes than Black participants in 60% of matched pairs (P < .001). Black participants were consistently more likely to have worse outcomes. When outcomes were measured by progression-free survival or disease-free survival, the failure rate was statistically significantly higher in Black participants (hazard ratio [HR] = 1.50, P < .001). Failure was largely due to locoregional failure, and Black participants were at higher risk (subdistribution HR =1.51, P = .002). The development of distant metastasis within the paired cohorts was not statistically significantly different. In this study of clinical trial participants using self-reported race, Black participants consistently had worse outcomes in comparison to study arm-specific White controls. Further study is needed to confirm these findings and to explore causes underlying this disparity.