Age-related differences in breast cancer mortality according to race/ethnicity, insurance, and socioeconomic status.

BackgroundWe assessed breast cancer mortality in older versus younger women according to race/ethnicity, neighborhood socioeconomic status (nSES), and health insurance status.MethodsThe study included female breast cancer cases 18 years of age and older, diagnosed between 2005 and 2015 in the California Cancer Registry. Multivariable Cox proportional hazards modeling was used to generate hazard ratios (HR) of breast cancer specific deaths and 95% confidence intervals (CI) for older (60+ years) versus younger (< 60 years) patients separately by race/ethnicity, nSES, and health insurance status.ResultsRisk of dying from breast cancer was higher in older than younger patients after multivariable adjustment, which varied in magnitude by race/ethnicity (P-interaction< 0.0001). Comparing older to younger patients, higher mortality differences were shown for non-Hispanic White (HR = 1.43; 95% CI, 1.36-1.51) and Hispanic women (HR = 1.37; 95% CI, 1.26-1.50) and lower differences for non-Hispanic Blacks (HR = 1.17; 95% CI, 1.04-1.31) and Asians/Pacific Islanders (HR = 1.15; 95% CI, 1.02-1.31). HRs comparing older to younger patients varied by insurance status (P-interaction< 0.0001), with largest mortality differences observed for privately insured women (HR = 1.51; 95% CI, 1.43-1.59) and lowest in Medicaid/military/other public insurance (HR = 1.18; 95% CI, 1.10-1.26). No age differences were shown for uninsured women. HRs comparing older to younger patients were similar across nSES strata.ConclusionOur results provide evidence for the continued disparity in Black-White breast cancer mortality, which is magnified in younger women. Moreover, insurance status continues to play a role in breast cancer mortality, with uninsured women having the highest risk for breast cancer death, regardless of age

Hyperkyphosis and incident falls among community-dwelling older adults

Background: Falls are a common cause of morbidity among older adults. Although many fall risk factors are well understood, it is unknown whether a common geriatric condition, hyperkyphosis, increases fall risk. Objectives: This dissertation research sought to determine whether older persons with worse degrees of kyphosis may be at increased risk of falls. Methods: Three longitudinal cohorts of older adults (aged ≥65) were used, each with different kyphosis measures, to examine the association between degree of kyphosis and fall risk. Study 1 examined whether four measures of kyphosis (Debrunner kyphometer, flexicurve ruler, Cobb angle, and block method) increased the odds of an incident fall over one year of monthly falls follow-up in a mixed-gender sample of 72 individuals (mean age=78). Studies 2 and 3 each prospectively examined two different measures of kyphosis and incident falls over three years of tri-annual follow-up through multivariable modeling with GEEs. Study 2 included 2,346 men with the Cobb angle measure of kyphosis (mean age=74) and 2,929 men with block-measured kyphosis (mean age=79) from the Osteoporotic Fractures in Men Study (MrOS). Study 3 used data from 1,162 women with the Cobb angle measure (mean age=69) and 610 women with the flexicurve measure of kyphosis (mean age=73) from the Study of Osteoporotic Fractures in Women (SOF). Results: In Study 1, all four measures of kyphosis conferred a 2-3 fold increase per SD in the odds of a fall over the following year (64% of participants fell over one year). In Studies 2 and 3, Cobb angle was not associated with fall risk in either MrOS or SOF. The blocks method was predictive of fall risk in MrOS (RR=1.11 per SD; 95% CI=1.06, 1.17) and KI was predictive of fall risk in SOF (RR=1.22 per SD; 95% CI=1.07, 1.40).Conclusion: All three studies provide evidence that increased kyphosis predicts greater fall risk in older persons. The Cobb angle measure, however, appears to be least related to falls, possibly because it is a measure limited to the mid to lower thoracic spine whereas the block and flexicurve methods include curvature in the lower cervical and entire thoracic spine

Hyperkyphosis and incident falls among community-dwelling older adults

Background: Falls are a common cause of morbidity among older adults. Although many fall risk factors are well understood, it is unknown whether a common geriatric condition, hyperkyphosis, increases fall risk. Objectives: This dissertation research sought to determine whether older persons with worse degrees of kyphosis may be at increased risk of falls. Methods: Three longitudinal cohorts of older adults (aged ≥65) were used, each with different kyphosis measures, to examine the association between degree of kyphosis and fall risk. Study 1 examined whether four measures of kyphosis (Debrunner kyphometer, flexicurve ruler, Cobb angle, and block method) increased the odds of an incident fall over one year of monthly falls follow-up in a mixed-gender sample of 72 individuals (mean age=78). Studies 2 and 3 each prospectively examined two different measures of kyphosis and incident falls over three years of tri-annual follow-up through multivariable modeling with GEEs. Study 2 included 2,346 men with the Cobb angle measure of kyphosis (mean age=74) and 2,929 men with block-measured kyphosis (mean age=79) from the Osteoporotic Fractures in Men Study (MrOS). Study 3 used data from 1,162 women with the Cobb angle measure (mean age=69) and 610 women with the flexicurve measure of kyphosis (mean age=73) from the Study of Osteoporotic Fractures in Women (SOF). Results: In Study 1, all four measures of kyphosis conferred a 2-3 fold increase per SD in the odds of a fall over the following year (64% of participants fell over one year). In Studies 2 and 3, Cobb angle was not associated with fall risk in either MrOS or SOF. The blocks method was predictive of fall risk in MrOS (RR=1.11 per SD; 95% CI=1.06, 1.17) and KI was predictive of fall risk in SOF (RR=1.22 per SD; 95% CI=1.07, 1.40).Conclusion: All three studies provide evidence that increased kyphosis predicts greater fall risk in older persons. The Cobb angle measure, however, appears to be least related to falls, possibly because it is a measure limited to the mid to lower thoracic spine whereas the block and flexicurve methods include curvature in the lower cervical and entire thoracic spine

Brachytherapy utilization for cervical cancer in Western United States border counties: seeking to understand referral patterns for outcome improvement.

Purpose: Standard of care for definitive treatment of locally advanced cervical cancer (LACC) is concurrent chemoradiation followed by a brachytherapy boost. Only 55.8% of women in the United States receive brachytherapy, with even lower proportions in San Diego and Imperial Counties. The purpose of this study was to investigate brachytherapy practice and referral patterns in Western United States border region. Material and methods: A short survey was sent to 28 radiation oncologists in San Diego and Imperial Counties, who treat patients with gynecologic malignancies. Descriptive statistics were used for analysis. Results: Seventeen (61%) physicians responded to the survey. All physicians reported some training in cervical cancer brachytherapy during residency, with median 6 months. Only two physicians reported personally treating all cervical cancer patients with brachytherapy; however, 92% of remaining physicians would recommend brachytherapy for patients if given time and access. The most common reason for referral (78%) was patients deemed to require hybrid or interstitial brachytherapy implants. Barriers to referral included patients preference, insurance status, their resources, or logistics. No changes were reported for brachytherapy practices during the COVID-19 pandemic, except the addition of pre-procedural testing for SARS-CoV-2. Ninety-two percent of physicians identified inadequate maintenance of skills as a barrier to performing brachytherapy, but 77% were not interested in additional training. External beam radiation therapy boosts were rarely recommended in case scenarios describing potentially curable patients. Conclusions: The importance of brachytherapy is widely recognized for conferring a survival benefit, but barriers to implementation include inadequate training or maintenance of skills, and larger systematic issues related to reimbursement policy, social support, and financial hardship. As most established providers were uninterested in additional brachytherapy training, future approaches to improve patients access should be multidimensional and reflect the value of brachytherapy in definitive treatment of patients with LACC

Equitable COVID-19 Vaccination for Hispanics in the United States: A Success Story from California Border Communities

The ongoing 2019 novel coronavirus disease (COVID-19) pandemic continues to impact the health of individuals worldwide, including causing pauses in lifesaving cancer screening and prevention measures. From time to time, elective medical procedures, such as those used for cancer screening and early detection, were deferred due to concerns regarding the spread of the infection. The short- and long-term consequences of these temporary measures are concerning, particularly for medically underserved populations, who already experience inequities and disparities related to timely cancer care. Clearly, the way out of this pandemic is by increasing COVID-19 vaccination rates and doing so in an equitable manner so that communities most affected receive preferential access and administration. In this article, we provide a perspective on vaccine equity by featuring the experience of the California Hispanic community, who has been disproportionately impacted by the pandemic. We first compared vaccination rates in two United States–Mexico border counties in California (San Diego County and Imperial County) to counties elsewhere in California with a similar Hispanic population size. We show that the border counties have substantially lower unvaccinated proportions of Hispanics compared to other counties. We next looked at county vaccination rates according to the California Healthy Places Index, a health equity metric and found that San Diego and Imperial counties achieved more equitable access and distribution than the rest of the state. Finally, we detail strategies implemented to achieve high and equitable vaccination in this border region, including Imperial County, an agricultural region that was California’s epicenter of the COVID-19 crisis at the height of the pandemic. These United States–Mexico border county data show that equitable vaccine access and delivery is possible. Multiple strategies can be used to guide the delivery and access to other public health and cancer preventive services

HPV Vaccine Misperceptions Among Hispanics/Latinos in Southern California.

BackgroundCervical and other vaccine-preventable HPV-associated cancers disproportionately impact Hispanic/Latinos in the USA. HPV vaccine uptake may be impacted by community agreement with common HPV vaccine misperceptions. It is unknown whether Hispanics/Latinos have a greater agreement with these misperceptions relative to non-Hispanic whites.MethodsHPV vaccine misperceptions were assessed through a 12-item Likert scale included in a population health assessment mailed to households in the southwest United States. Linear regression models assessed the association between identifying as Hispanic/Latino and summed misperception score.ResultsAmong the 407 individuals in the analytic sample, 111 (27.3%) were Hispanic/Latino and 296 (72.7%) were non-Hispanic white. On average, Hispanics/Latinos had a 3.03-point higher HPV vaccine misperception sum score relative to non-Hispanic whites, indicating greater agreement with misperceptions (95% confidence interval: 1.16-4.88; p < 0.01).DiscussionCulturally relevant interventions are needed to address HPV vaccine misperceptions among Hispanics/Latinos as part of efforts toward HPV-associated cancer health equity

The association between bone turnover markers and kyphosis in community-dwelling older adults

Purpose: Hyperkyphosis, accentuated curvature of the thoracic spine, is often attributed to osteoporosis, yet its underlying pathophysiology is not well understood. Bone turnover markers (BTM) reflect the dynamic process of bone formation and resorption. This study examined the association between serum BTM levels and kyphosis in community-dwelling older adults. Methods: Between 2003 and 2006, 760 men and women in the Rancho Bernardo Study age 60 and older had blood drawn and kyphosis measured. Fasting serum was assayed for N-telopeptide (NTX) and procollagen type 1 n-terminal propeptide (P1NP), markers of bone resorption and formation, respectively. Participants requiring two or more 1.7 cm blocks under their head to achieve a neutral supine position were classified as having accentuated kyphosis. Analyses were stratified by sex and use of estrogen therapy (ET). Odds of accentuated kyphosis were calculated for each standard deviation increase in log-transformed BTM. Results: Mean age was 75 years. Overall, 51% of 341 non-ET using women, 41% of 111 ET-using women, and 75% of 308 men had accentuated kyphosis. In adjusted models, higher P1NP and NTX were associated with decreased odds of accentuated kyphosis in non-ET using women (P1NP: OR = 0.78 [95% CI, 0.58–0.92]; NTX: OR = 0.68 [95% CI, 0.54–0.86]), but not in men or ET-using women (p > 0.05). Conclusions: The selective association of higher bone turnover with reduced odds of accentuated kyphosis in non-ET using women suggests that elevated BTM were associated with a lower likelihood of hyperkyphosis only in the low estrogen/high BTM environment characteristic of postmenopausal women who are not using ET. Keywords: Kyphosis, Hyperkyphosis, Bone turnover, Bone remodeling, P1NP, NT

Age-related differences in breast cancer mortality according to race/ethnicity, insurance, and socioeconomic status.

BackgroundWe assessed breast cancer mortality in older versus younger women according to race/ethnicity, neighborhood socioeconomic status (nSES), and health insurance status.MethodsThe study included female breast cancer cases 18 years of age and older, diagnosed between 2005 and 2015 in the California Cancer Registry. Multivariable Cox proportional hazards modeling was used to generate hazard ratios (HR) of breast cancer specific deaths and 95% confidence intervals (CI) for older (60+ years) versus younger (< 60 years) patients separately by race/ethnicity, nSES, and health insurance status.ResultsRisk of dying from breast cancer was higher in older than younger patients after multivariable adjustment, which varied in magnitude by race/ethnicity (P-interaction< 0.0001). Comparing older to younger patients, higher mortality differences were shown for non-Hispanic White (HR = 1.43; 95% CI, 1.36-1.51) and Hispanic women (HR = 1.37; 95% CI, 1.26-1.50) and lower differences for non-Hispanic Blacks (HR = 1.17; 95% CI, 1.04-1.31) and Asians/Pacific Islanders (HR = 1.15; 95% CI, 1.02-1.31). HRs comparing older to younger patients varied by insurance status (P-interaction< 0.0001), with largest mortality differences observed for privately insured women (HR = 1.51; 95% CI, 1.43-1.59) and lowest in Medicaid/military/other public insurance (HR = 1.18; 95% CI, 1.10-1.26). No age differences were shown for uninsured women. HRs comparing older to younger patients were similar across nSES strata.ConclusionOur results provide evidence for the continued disparity in Black-White breast cancer mortality, which is magnified in younger women. Moreover, insurance status continues to play a role in breast cancer mortality, with uninsured women having the highest risk for breast cancer death, regardless of age