Cancer Disparities: Unmet Challenges in the Elimination of Disparities

http://dx.doi.org/10.1158/1055-9965.EPI-11-062

Systems intervention to promote colon cancer screening in safety net settings: Protocol for a community-based participatory randomized controlled trial

BACKGROUND: Colorectal cancer is a leading cause of cancer mortality. Screening can be effective but is underutilized. System- or multi-level interventions could be effective at increasing screening, but most have been implemented and evaluated in higher-resource settings such as health maintenance organizations. Given the disparities evident for colorectal cancer and the potential for screening to improve outcomes, there is a need to expand this work to include diverse settings, including those who treat economically disadvantaged patients. This paper describes the study protocol for a trial designed to increase colorectal cancer screening in those ‘safety-net’ health centers that serve underinsured and uninsured patients. This trial was designed and is being implemented using a community-based participatory approach. METHODS/DESIGN: We developed a practical clinical cluster-randomized controlled trial. We will recruit 16 community health centers to this trial. This systems-level intervention consists of a menu of evidence-based implementation strategies for increasing colorectal cancer screening. Health centers in the intervention arm then collaborate with the study team to tailor strategies to their own setting in order to maximize fit and acceptability. Data are collected at the organizational level through interviews, and at the provider and patient levels through surveys. Patients complete a survey about their healthcare and screening utilization at baseline, six months, and twelve months. OUTCOMES: The primary outcome is colorectal cancer screening by patient self-report, supplemented by a chart-audit in a subsample of patients. Implementation outcomes informed by the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) conceptual framework will be measured at patient, provider, and practice levels. DISCUSSION: Our study is one of the first to integrate community participatory strategies to a randomized controlled trial in a healthcare setting. The multi-level approach will support the ability of the intervention to affect screening through multiple avenues. The participatory approach will strengthen the chance that implementation strategies will be maintained after study completion and, supports external validity by increasing health center interest and willingness to participate. TRIAL REGISTRATION: NCT0129949

A systematic review of body fat distribution and mortality in older people

We conducted a systematic review investigating body fat distribution in older adults and its association with morbidity and mortality. Our search yielded 2,702 citations. Following three levels of screening, 25 studies were selected to evaluate the association between body fat distribution and comorbidity, and 17 studies were used in the mortality analysis. Most of the selected studies in our analyses used anthropometric measures, e.g., body mass index (BMI), waist circumference, and waist-hip ratio; relatively few studies used direct measures, such as body fat/lean mass, and percentage body fat. Studies reported inconsistent findings regarding the strongest predictor(s) of morbidity and mortality. However, the majority of studies suggested that BMI per se was not the most appropriate predictor of morbidity and mortality in the elderly because of its inability to discern or detect age-related body fat redistribution. In addition, studies using BMI found that the optimal BMI range for the lowest mortality in the elderly was overweight (25 kg/m(2) ≤ BMI < 30 kg/m(2)) or mildly obese (30 kg/m(2) ≤ BMI < 35 kg/m(2)). Our findings suggest that the current clinical guidelines, recommending that overweight and obesity are major risk factors for increased morbidity and mortality are not applicable to this population. Therefore, the central message of this review is to admonish the government to establish new guidelines specifically for this population, using a combination of body fat distribution measurements, and to certify that these guidelines will not be applied to inappropriate populations

Prospective Study of Bowel Movement, Laxative Use, and Risk of Colorectal Cancer among Women

The authors prospectively examined the association between bowel movement frequency, laxative use, and the risk of colorectal cancer in 84, 577 women of the Nurses' Health Study living in the United States, 36-61 years of age and free of cancer in 1982. Between 1984 and 1996, 611 incident cases of colorectal cancer were documented. After controlling for age, body mass index, fiber intake, postmenopausal status and hormone use, physical activity, and use of laxatives, the relative risks associated with having bowel movements every third day or less, compared with those with bowel movements once daily, were 0.94 (95% confidence interval (Cl): 0.69, 1.28) for colorectal cancer, 0.88 (95% Cl: 0.62, 1.26) for colon cancer, and 1.18 (95% Cl: 0.63, 2.20) for rectal cancer. Compared with women who never used laxatives, the multivariate relative risks associated with weekly to daily laxative use were 1.00 (95% Cl: 0.72, 1.40) for colorectal cancer, 1.09 (95% Cl: 0.76, 1.57) for colon cancer, and 0.68 (95% Cl: 0.29, 1.57) for rectal cancer. These findings do not support an association between infrequent bowel movement, laxative use, and risk of colorectal cancer and indicate that simple questions directed at bowel movement frequency are unlikely to enhance our ability to predict colorectal cancer risk. Am J Epidemiol2000; 151: 958-6

Racial and ethnic heterogeneity in self-reported diabetes prevalence trends across Hispanic subgroups, National Health Interview Survey, 1997–2012

INTRODUCTION: We examined racial/ethnic heterogeneity in self-reported diabetes prevalence over 15 years. METHODS: We used National Health Interview Survey data for 1997 through 2012 on 452,845 adults aged 18 years or older. Annual self-reported diabetes prevalence was estimated by race/ethnicity and education. We tested for trends over time by education and race/ethnicity. We also analyzed racial/ethnic and education trends in average annual prevalence. RESULTS: During the 15 years studied, diabetes prevalence differed significantly by race/ethnicity (P < .001) and by Hispanic subgroup (P < .001). Among participants with less than a high school education, the 5-year trend in diabetes prevalence was highest among Cubans and Cuban Americans (β(5YR) = 4.8, P = .002), Puerto Ricans (β(5YR) = 2.2, P = .06), non-Hispanic blacks (β(5YR) = 2.2, P < .001), and non-Hispanic whites (β(5YR) = 2.1, P < .001). Among participants with more than a high school education, non-Hispanic blacks had the highest average annual prevalence (5.5%) and Puerto Ricans had the highest 5-year trend in annual diabetes prevalence (β(5YR) = 2.6, P = .001). CONCLUSIONS: In this representative sample of US adults, results show ethnic variations in diabetes prevalence. The prevalence of diabetes is higher among Hispanics than among non-Hispanic whites, unevenly distributed across Hispanic subgroups, and more pronounced over time and by education. Findings support disaggregation of data for racial/ethnic populations in the United States to monitor trends in diabetes disparities and the use of targeted, culturally appropriate interventions to prevent diabetes

Is the biology of breast cancer changing? A study of hormone receptor status 1984-1986 and 1996-1997

Using archived tumours, those from 1984-1986 and 1996-1997 underwent immunohistochemistry for hormone receptors and grade analysis. A significant shift towards more ER-positive and low-grade disease was found; this appears to reflect screening practices, but could still influence survival

Urban-rural disparities in access to low-dose computed tomography lung cancer screening in Missouri and Illinois

INTRODUCTION: Low-dose computed tomography (LDCT) lung cancer screening is recommended for current and former smokers who meet eligibility criteria. Few studies have quantitatively examined disparities in access to LDCT screening. The objective of this study was to examine relationships between 1) rurality, sociodemographic characteristics, and access to LDCT lung cancer screening and 2) screening access and lung cancer mortality. METHODS: We used census block group and county-level data from Missouri and Illinois. We defined access to screening as presence of an accredited screening center within 30 miles of residence as of May 2019. We used mixed-effects logistic models for screening access and county-level multiple linear regression models for lung cancer mortality. RESULTS: Approximately 97.6% of metropolitan residents had access to screening, compared with 41.0% of nonmetropolitan residents. After controlling for sociodemographic characteristics, the odds of having access to screening in rural areas were 17% of the odds in metropolitan areas (95% CI, 12%-26%). We observed no association between screening access and lung cancer mortality. Southeastern Missouri, a rural and impoverished area, had low levels of screening access, high smoking prevalence, and high lung cancer mortality. CONCLUSION: Although access to LDCT is lower in rural areas than in urban areas, lung cancer mortality in rural residents is multifactorial and cannot be explained by access alone. Targeted efforts to implement rural LDCT screening could reduce geographic disparities in access, although further research is needed to understand how increased access to screening could affect uptake and rural disparities in lung cancer mortality

Causes of variation in BCG vaccine efficacy: examining evidence from the BCG REVAC cluster randomized trial to explore the masking and the blocking hypotheses.

BCG protection varies and in some places (nearest the equator) is low or absent. Understanding this variation can inform the efforts to develop new vaccines against tuberculosis. Two main hypotheses are used to explain this variation: under masking, new vaccines are unlikely to increase protection; under blocking new vaccines have a greater potential to be effective when BCG is not. We conducted a cluster randomized trial to explored the masking and blocking hypotheses by studying BCG vaccine efficacy of neonatal vaccination and when administered for the first or a second (revaccination) time at school age in two sites (Manaus close and Salvador further south from the equator). Seven hundred and sixty three state schools were matched on socio economic characteristics of the neighborhood and 239,934 children were randomized to vaccine (BCG vaccination at school age) or control group. Protection by first BCG vaccination at school age was high in Salvador (34%, 95% CI 7-53%, p=0.017) but low in Manaus (8%, 95% CI t0 39-40%, p=0.686). For revaccination at school age, protection was modest in Salvador (19%, 95% CI 3-33%, p=0.022) and absent in Manaus (1%, 95% CI to 27-23%, p=0.932). Vaccine efficacy for neonatal vaccination was similar in Salvador (40%, 95% CI 22-54%, p<0.001) and Manaus (36%, 95% CI 11-53%, p=0.008). Variation in BCG efficacy was marked when vaccine was given at school age but absent at birth, which points towards blocking as the dominant mechanism. New tuberculosis vaccines that overcome or by pass this blocking effect could confer protection in situations where BCG is not protective