bluuebunny/crossref_metadata_2025 huggingface dataset:
Improving participation of under-represented minorities in breast cancer therapeutic trials in a safety-net system.
Authors: Qureshi Nasir , Robles Fabian E. , Unni Nisha , Syed Samira K. , Li Hsiao Ching , Sadeghi Navid
Published: September 2022

90

Background: Racial and ethnic minorities remain under-represented in cancer clinical trials. Strategies to improve access and participation of diverse populations in clinical trials is therefore a key step to improve outcomes and eliminate disparities. Methods: Parkland Health (PH) is the safety-net system for Dallas County, Texas, and is affiliated with the UT Southwestern/Harold C. Simmons Comprehensive Cancer Center (SCCC). Trial operations at PH is mainly supported by a dedicated team of SCCC research coordinators. Interventions employed to increase minority access and accruals were focused on optimizing the portfolio, increasing provider awareness, and enhanced screening. A bilingual research patient navigator was also added to the research team to improve patient education and engagement. Transportation and childcare assistance are routinely provided for patients at PH. Accrual data for 2021, compared to 2017-2020, is presented here. Results: The majority (73%) of breast cancer patients at PH are uninsured and 88% belong to racial/ethnic minorities (57% Hispanics, 31% Blacks). Of the 15 therapeutic breast cancer trials open at SCCC in 2021, 12 (80%) were open at PH. The PH breast cancer trial portfolio included 4 cooperative group, 5 industry-sponsored (ISTs), and 3 investigator-initiated studies (IITs). Four trials were in metastatic setting and 8 were in curative intent setting. Four trials required a genomic biomarker. Forty-three patients were enrolled in therapeutic trials at PH in 2021. This represents 10.3% (43/418) of new cases during the same time period. Thirty-two were enrolled in cooperative group studies, 10 in IITs, and 1 in ISTs. The majority (93%) of the trial participants belonged to under-represented minorities. Number of trial participants in 2021 increased by 48% compared to the best year in the past 5 years (29 patients enrolled in 2018). Conclusions: Collaboration between academic institutions and safety-net systems presents a unique opportunity to provide clinical trial options to under-represented minorities. In this setting, interventions to improve trial portfolio, provider awareness, screening process, and patient education, as well as addition of a patient research navigator resulted in a significant increase in the number of minority participants in breast cancer trials at our safety-net hospital.
Diversity, equity, and inclusion in cancer clinical trial enrollment: Laying the groundwork for a cancer center collaborative intervention through key informant interviews.
Authors: Goel Pakhi , Edmonds Megan C. , Lin Sylvia , Goodman Karyn A. , Smith Cardinale B. , Hillyer Grace C. , Bickell Nina A.
Published: September 2022

98

Background: Clinical trial (CT) participation rates in the US are about 8% overall. Although, Black, Indigenous and People of Color (BIPOC) are as willing to join CTs as Whites, they remain underrepresented. We will implement a multi-level intervention across 3 cancer centers in New York City by creating a collaborative pool of CTs for breast, prostate, and liver cancer, thereby increasing availability of trials for all, especially BIPOC populations. To lay the groundwork, we conducted a formative evaluation to identify constructs that can influence implementation of this intervention. Methods: We designed a semi-structured interview guide for key informants to ascertain barriers and facilitators of enrollment at 1 cancer center and its 2 community affiliates. 23 key informants including oncologists, research staff, informatics, nurses, and cancer center leadership were identified using a targeted approach, followed by snowball sampling. Interviews were recorded, transcribed, and analyzed using thematic analysis approach. Results: Facilitators of accrual include patient referrals from physician-investigators and their teams, and oncologists’ knowledge of open trials through tumor boards, disease focus groups, and research meetings. Major barriers to CT enrollment are gaps in trial portfolio, inadequate infrastructure (e.g., staffing, space, and time), and incentives (e.g., RVU-based reimbursements). Informants felt that for patients, financial toxicity, medical mistrust, inadequate health literacy, comorbidities, poor performance status, and language are reasons for low accrual. Physicians emphasized their willingness to refer patients out-of-institution for CTs but lacked knowledge of outside trials. Care coordination across sites and loss of revenue for home institution are system-level barriers to referral. Additionally, informants believed that patients’ willingness to seek trials at other institutions is influenced by their commute, unfamiliarity with a new system, insurance coverage, rapport with oncologist, and motivation. Conclusions: Involving key stakeholders, increasing physician awareness of open CTs, educating patients and addressing their concerns about CTs, improving access to bilingual materials and interpreters, standardizing care coordination and ensuring similar rates of referrals across institutions are key facilitators to implement a multi-level intervention to increase CT enrollment across a cancer center collaboration.
Evaluating factors contributing to low rates of breast cancer clinical trial accrual in a diverse patient population.
Authors: Podany Emily L , Bulsara Shaun , Sanchez Katherine , Badr Hoda , Jibaja-Weiss Maria , Nemati Shafaee Maryam
Published: September 2022

100

Background: In an ideal world, the populations studied in cancer clinical trials (CCT) would be representative of the patients seen in clinic. Unfortunately, significant disparities exist in trial enrollment. Patients who are white, male, insured, or of high socioeconomic status (SES) are overrepresented in NCI-sponsored CCT. Despite data indicating equal willingness for participation in CCT across all racial groups, lack of access, cultural barriers, and social determinants of health contribute to poor accrual rates among racial and ethnic minority patients. The Dan L. Duncan Comprehensive Cancer Center (DLDCCC) provides equal access to breast CCT at Smith Clinic (SC) within the safety-net Harris Health system and Baylor St. Luke’s Medical Center (BSLMC). The patient populations differ greatly at these two sites, with BSLMC serving > 95% insured, largely Caucasian patients, and SC serving 60% uninsured, mostly low SES patients, with > 80% racial and ethnic minorities. Despite equal access, patients at SC have a significantly higher CCT refusal rate. Methods: We performed a retrospective review of a prospectively maintained database of new patients seen at DLDCCC dating from 5/2015 to 9/2021, which included 3043 patients screened for breast CCT. 366 patients were found to be eligible for CCT. Some patients were eligible for multiple CCT, so there were 431 total offers of CCT. We performed logistic regression to evaluate whether differences in age, clinic, race, trial type, and primary language may be underlying the observed differences in CCT enrollment rates. Results: In the BSLMC cohort, 61% (116/204) of eligible patients enrolled in a CCT, while in the SC cohort only 39% (74/227) of eligible patients elected to enroll in CCT. This difference was significant on univariate but not multivariate analysis. There were significant differences when comparing race and trial type in the overall patient set. On univariate analysis, SC patients, African American (AA) patients, Hispanic/Latino patients, and Spanish speaking patients were significantly more likely to decline CCT participation. However, on multivariate analysis, only the AA patient category was associated with enrollment refusal (odds ratio 0.261, 95% CI 0.116-0.563, p < 0.001). On both univariate and multivariate analyses, patients were significantly more likely to accept biobanking trials (multivariate: odds ratio 12.799, 95% CI 3.777-61.403, p < 0.001). Conclusions: Based on these findings, it is likely an oversimplification to assume that equal access will lead to a complete elimination of CCT disparities. Our AA patients were significantly less likely to agree to participate in clinical trials, challenging the commonly held view that lack of access is a major barrier. We are exploring interventions designed to improve our AA patient population’s views of trial enrollment.
Saturday pap smear clinic: Addressing barriers to women’s health.
Authors: Strelow Brittany Ann , O'Laughlin Danielle , Fellows Nicole , Stevens Joy , Fink Stephanie , Stolp Anne , Peters Sonya , Tweedy Johanna , Anderson Jordan Ann , Francis Mollie , Abdi Deqa , Abuhadid Kholood , Gertner Gabrielle , Olson Rachel
Published: September 2022

105

Background: Screening for cervical cancer with pap smears and HPV testing can improve patient outcomes by allowing for early identification of cervical cancer. The Minnesota Community Measure and Mayo Clinic's goal is to have a cervical cancer screening rate of 82% (Detailed Report-Cervical Cancer Screening, 2020). Healthy People 2030 aims to have a cervical cancer screening rate of 83.4% (Increase the proportion of females who get screened for cervical cancer -C-09, 2021). Community Internal Medicine cervical cancer screening rates are below this level at 63.09% compliance, with 5,239 patients non-compliant, who are eligible for cervical cancer screenings. Olmsted County only offers acute services on the weekends with no primary care services, which leaves women who work during the week or have childcare/caregiver issues with no options on the weekend or evenings when they have availability to attend appointments. Methods: Based on guidelines for pap smear screening (women ages 21-65), 14,195 women were identified within CIM to be eligible for screening. Of those, 5,239 were due for screening. The Saturday Pap Smear Clinic had 88 available spots. We aimed to improve cervical cancer screening rates among non-compliant women within Community Internal Medicine by 1% (52 women, total noncompliant women = 5,239) by January 2021 without adversely impacting coverage of existing clinic hours. Results: The electronic medical record (EMR), EPIC, was utilized to identify all patients who were eligible for a pap smear based on current guidelines (Total eligible = 14,195; Sample size/non-compliant: 5,239 patients) within Community Internal Medicine (CIM) of the Baldwin Building in Rochester, MN. Interventions included: surveys that were sent to patients via the Patient Portal. Advertising for the Saturday Clinic included Primary Care News, E-boards, Posters, Social Media, SCOPE, Mayo News, and Providers. The Saturday clinic allowed time outside the traditional hours. One unique feature of the clinic is that all females staffed it during clinic hours in an attempt to alleviate some of the fear/anxiety. After completion of the pilot Saturday Pap Clinic, pap smear compliance from the Saturday Pap Clinic alone arose 1.2% (62 patients) within CIM. Conclusions: Post-intervention, cervical screening rates among non-compliant women within Baldwin CIM improved by 1.2% (62 women total).
What’s missing? Diagnostic workup for breast cancer in Sudan.
Authors: Eltoum Noon , Caston Nicole E. , Gutnik Lily , Alfardous Alazm Mahmoud A. , Mohamed Feras Omer , Abdalkarem Lama Mahjoub , Saad Saad Ahmed , Badawi Abrar Z. , Henderson Nicole , Azuero Andres , Rocque Gabrielle Betty
Published: September 2022

110

Background: In Sudan, healthcare access may limit diagnostic workup for breast cancer. This study evaluates the relationship between geography and ethnicity and completeness of documentation of diagnostic workup (staging and receptor testing) in Sudan. Methods: This retrospective study used data abstracted from patients with breast cancer receiving cancer care at Sudan’s largest cancer center (Radiation and Isotopes Center Khartoum [RICK]) in 2017. The patient’s age at diagnosis, sex, breast cancer stage, ethnic subgroup (further categorized as Arab and non-Arab), regions of origin and residence (Central, Northeastern, Western, and Khartoum [where RICK is located]), and receptor status from pathology reports were abstracted from paper medical records. Complete diagnostic workup was defined as having both receptor testing and staging. Descriptive statistics were calculated using frequencies and percentages for categorical variables and median and interquartile range (IQR) for continuous variables. Odds ratios (OR) and 95% confidence intervals (CI) were estimated to evaluate complete diagnostic workup on ethnic group, origin, and residence using binomial logistic regression models (excluding non-Sudanese patients and those with missing demographics). Results: Of 240 patients included, 237 were female, median age was 53 (IQR 43-62). Most often patients were Arab (68%), originated from Northeastern and Khartoum regions (both 28%) and lived in the Khartoum region (53%). Overall, 49% patients were missing receptor testing and/or staging, with modest differences by geographic region and ethnicity (Table). In adjusted analyses, non-Arab patients had similar odds of having complete diagnostic workup when compared to Arab patients (OR 1.22; 95% CI 0.70-2.10). Patients originating from and residing in regions outside the Khartoum region had similar odds of complete diagnostic workup when compared to patients originating from and residing in the Khartoum region. Conclusions: Almost half of breast cancer patients had incomplete diagnostic workup, regardless of region of origin, region of residence, and ethnic group. This highlights a substantial systems-based quality gap in care delivery, warranting efforts to improve completeness in diagnostic workup for all patients with breast cancer in Sudan.[Table: see text]
Promoting prostate cancer screening equity: Findings from a quality improvement education initiative implemented in 3 sites.
Authors: Jacobs Ginny , Stevens Hobbs Kristen , Crawford Keith , Hussain Waseem , Jean-Simon Claire , Leiba Lawrence Roxanne , Lazure Patrice , Hall Laura Lee , McFadden Pam
Published: September 2022

112

Background: Prostate cancer (PC) screening guidelines differ in recommended age at screening and varying emphasis on risk factors (e.g., race, family history), leading to lack of clarity among healthcare providers (HCPs). Research has highlighted a higher risk for Black patients, and the importance for at-risk patients to undergo screening at an earlier age and receive appropriate follow-up. A system-based Quality Improvement Education (QIE) intervention was developed to increase screening and referrals for PC especially among higher risk subgroups. The QIE aimed to increase awareness of the burden and consequences of racial disparities while mobilizing a team-focused approach. Methods: QIE intervention was deployed at 3 practice sites that provide community-based primary care services to Black populations (72% Black patients). The sites differed in patient capacity, staff, challenges faced, and pre-intervention screening practices. Practice assessments were completed pre-intervention by site representatives (n = 3) and individual baseline surveys were filled out by HCPs (n = 24). The 12-week intervention included educational materials from Prostate Health Education Network (PHEN) and deployment of an updated screening protocol within each clinic to raise PC awareness to staff and patients. Post-intervention evaluation was based on qualitative interviews (n = 5) and feedback from the QIE coaches. Patient data from electronic health records (EHR) on PC screening and referrals was collected post-initiative and divided a posteriori into 3 sub-groups, pre, during and post-intervention (n = 6662). Results: QIE led to increased awareness of barriers to access faced by patients from diverse communities. The QIE also led to increased awareness among team members regarding the need for screening at-risk groups at an earlier age and the importance of follow-up with patients. Online education materials made available to HCPs raised patient awareness. Table highlights an increase in PC screening during the intervention, but limited sustainability post-intervention. Interviewees reported increases in patient education, referrals and follow-up action. Conclusions: Increase in percentage of patients screened during the intervention phase was potentially due to added attention during the initiative, while limited sustainability post-intervention might be due to the brief intervention period, reliance on retrospective data and inability to fully leverage EHR data. Based on this projects learnings, similar initiatives should seek organizational support for data analytics and process documentation to ensure consistent data standards and overall success.[Table: see text]
ReUnidos: Farmworker Skin Cancer Health Navigation Program.
Authors: Savage David James , Tushla Lisa A. , Guenin Katie , Gross Isabel , Kanakarajavelu Nina , Young Rebecca , Merino-Gonzalez Deysi , Stamm Nannette , Swetter Susan M. , Boiko Susan , Mofid Mona Z , Guild Samantha , Quandt Sara A , Arcury Thomas
Published: September 2022

113

Background: Farmworkers are at increased risk for skin cancer because of occupational exposure to sun and pesticides. In 2017/2018, Farmworker Justice conducted the Unidos community mobilization project to raise skin-cancer awareness and promote skin-cancer care access in farmworker communities. Unmet needs were identified in follow-up care coordination for patients who screened positive for a suspicious skin lesion. We undertook this ReUnidos study to document the incidence of skin cancer in the farmworker community and to evaluate the benefits of a health-navigator program to facilitate follow-up care. Methods: Participants (primarily Latinx) are screened in the community setting by volunteer dermatologists. Those who screen positive for suspected skin cancer are invited to participate in the study. They are assigned a trained navigator who addresses the importance of evaluating the lesion, the details of the diagnostic process, and any questions the subjects have. The navigators also help arrange travel, scheduling of appointments, interpretation services, and any other supports needed during the care journey. Data are collected on the number of biopsies performed, diagnoses, time from screening to diagnosis, skin cancer staging, time to treatment, as well as satisfaction with and perceived effectiveness of the navigator program. Outcome measures are extracted from chart review and final semi-structured interviews of both subjects and navigators. The project seeks to screen 1,000 community members. Approximately 2% are expected to screen positive for a suspicious lesion and require follow-up care. Results: To date, 16 health navigators have been trained and 6 screening events have been conducted in Northern San Diego County by Vista Community Clinic. A total of 126 adult participants have been screened, with 47% identifying as farmworkers. One participant screened positive for a potential skin cancer and has consented to the study. Conclusions: Community-based screenings linked to health-navigation programs may be effective tools to increase access to skin-cancer care among farmworkers. A telemedicine screening model is also being investigated for a second site in upstate New York to expand rural skin screening access. This model may also be useful in care coordination for other malignancies in farmworker communities such as lung cancer and lymphoma, which have also been linked to occupational pesticide exposure.[Table: see text]
Quality of care of Asian and White patients with lung cancer: Single-institution study.
Authors: Hu Xiao , Melson John , Pan Stacey , Salei Yana , Cao Yu
Published: September 2022

115

Background: Cancer is the leading cause of death in Asian Americans (AA), the fastest growing racial/ethnic group in the US. Lung cancer is a leading cancer diagnosis and cause of cancer death in AA. Yet data on the quality of lung cancer care in AA are limited. This retrospective study examines racial disparities in lung cancer care at an urban academic medical center serving a large proportion of Asian patients. Methods: Newly diagnosed patients with lung cancer from 01/01/2014 to 12/31/2019 were identified in the Tufts Medical Center cancer registry; clinical data were collected through 05/31/2022. Patient demographics, smoking status, utilization of screening low dose CT (LDCT), disease characteristics (diagnosis stage, histology, driver mutation presence), and treatment history were compared between Asian and White patients. The influence of race on presenting stage was evaluated via ordinal logistic regression. Time to treatment initiation (TTI) and overall survival (OS) in Asian and White patients were analyzed via log-rank tests. Multivariable Cox regression adjusting for baseline patient characteristics, tumor histology and stage was performed to evaluate the impact of race on OS. Results: Of 145 Asian and 476 White patients, the Asian cohort had significantly (p < 0.001) older age (72 vs 68 years), more male representation (74.5% vs 43.9%) and never-smokers (31.0% vs 9.7%). Of 45 Asian never-smokers, women comprised 75.6%. Of 216 patients eligible for lung cancer screening by the 2013 USPSTF criteria, the Asian cohort had relatively lower LDCT utilization (11.9% vs 21.3%, p = 0.198). Asians were 2.13 times (p = 0.003) more likely to be diagnosed with lung cancer at a later stage than White patients, adjusting for age, sex, income, smoking status, and histology. No difference was found in presence of CNS metastasis at diagnosis. Driver mutations were more often found in Asians (45.5% vs 29.4%). Of 206 patients with detected oncogenic mutations, EGFR alterations comprised 62.1% vs 15.0% in Asian and White cohorts, respectively. Asian patients had longer median TTI (1.13 vs 0.83 months, p = 0.005) and more often did not receive cancer directed therapy (12.6% vs 6.1%, p = 0.016). Of 536 patients who received cancer directed therapy, Asians more often received upfront targeted therapy (16.1% vs 2.2%, p < 0.001). No difference was seen in median OS between Asian and White (not reached vs 78.43 months, p = 0.410). Multivariable Cox regression suggested that Asians tended toward better OS (hazard ratio = 0.66, p = 0.091). Conclusions: This study done in Boston shows that Asian patients are diagnosed with lung cancer at more advanced stages and experience longer delays prior to treatment initiation, compared to White patients. Racial disparities persist in lung cancer care, particularly in detection/diagnosis and early management. Yet Asian patients, in aggregate, do not have inferior survival, warranting further research.
Association of disability with long-term noncompliance of breast cancer screening.
Authors: Tak Hyo Jung , Lee Min Sok , Shih Ya-Chen Tina
Published: September 2022

118

Background: Although the U.S. Preventive Services Task Force (USPSTF) recommends a biennial screening mammography for women aged 50 to 74 years at average risk for breast cancer, 24.6% of screening-eligible women do not follow the recommendation. Very little is known regarding the association between various types of disabilities and subsequent breast cancer screening behaviors following the initiation of screening mammography. This study examines the association of disability with short-term vs. long-term noncompliance of having a mammogram. Methods: Using data from 2016, 2018, and 2020 Behavioral Risk Factor Surveillance System annual surveys, we constructed the study cohort of women aged 55 to 74 years who did not have a cancer history and who received a mammogram at least once in the past. Outcomes are short-term (2 years) and long-term (5 years) noncompliance of USPSTF recommendations. Key independent variables are six binary variables of standard functional disability conditions (hearing, vision, cognition, ambulation, self-care, and independent living) in the first model and a categorized total number of disabilities (0, 1, 2, ≥3) in the second model. We employed a multivariable logistic regression model, adjusting individuals’ socio-demographics, general health status, chronic conditions, health risk factors, and metropolitan statistical areas (MSA), and accounting for complex survey design. Results: Among the study cohort (n = 232,143; weighted n = 29,358,431), 18.1% and 7.1% of women reported not having mammography in the past two and five years, respectively, representing short- vs. long-term noncompliance. Of the study cohort, 32.8% had any type of disability (ambulation 22.7%, cognition 11.0%, independent living 8.8%). Notably, the long-term noncompliance rate was highest among women with a disability and residing in non-MSA (10.2%). In multivariable analysis, while only disability in independent living was associated with short-term noncompliance (odds ratio [OR] 1.28; 95% confidence interval [CI] 1.15-1.42), disability in independent living (OR 1.34; 95% CI 1.18-1.52), vision (OR 1.15; 95% CI 1.01-1.32) and ambulation (OR 1.12; 95% CI 1.01-1.24) were all significantly associated with long-term noncompliance. Women with ≥3 disabilities were 1.64 times more likely to be non-compliant in the long term, and the association of disability with noncompliance was more pronounced in non-MSA. Conclusions: This study provides the first empirical evidence on the positive association between disability and screening noncompliance, especially in the long term. It suggests disability could aggravate disparities in timely access to cancer screening, particularly in non-MSA. Understanding how various types of disabilities affect screening behavior is a critical step for public health efforts in cancer prevention and control through identifying vulnerable subgroups for targeted interventions.
Rural-urban disparities in uptake of lung cancer screening.
Authors: Niranjan Soumya J. , Rivers Desiree , Ramchandran Rekha , Murrell Edward , Bae Sejong , Dransfield Mark T. , Scarinci Isabel C.
Published: September 2022

119

Background: In Alabama, lung cancer is the leading cause of cancer death. High lung cancer incidence and mortality rates are attributed to high smoking rates among underserved, low-income, and rural populations. Residents in rural Alabama tend to be older, engage in risky health behaviors, and have lower adherence to preventive care than their urban and suburban counterparts. Disparities in mortality rates between rural and urban areas are substantial for lung cancer. It can be explained by increased tobacco use and the preponderance of late-stage diagnoses following the lack of uptake of lung cancer screening (LCS). Therefore, we examined factors associated with LCS uptake among patients referred for screening at the University of Alabama at Birmingham (UAB). Methods: A retrospective cohort of patients at UAB who were eligible for lung cancer screening between 01/01/2015 and 12/31/2020 was used to define the cohort. Eligibility was defined as individuals between 55-80 years old, without diagnostic codes for lung cancer (ICD-9 162.9 or ICD-10 C34.90 within the past ten years), and had a smoking history. Patient demographic variables included Age, Sex, Race/Ethnicity, RUCA codes, and distance from UAB. Chi-square tests and Student t-tests were used to compare screening uptake across patient demographic and clinical variables. Bivariate analyses were used to determine significant predictors of lung cancer screening uptake at UAB. Results: Of the 67,355 identified as eligible for LCS, only 1147 (0.017%)were screened. Sixteen individuals were not AL residents and therefore were not included in further analysis. Of those 1129 individuals screened, the mean age was 67.02, male (54.92%) and Non-Hispanic White (57.77%). Compared to those not screened (97.86%), those screened (2.14%) were more likely to live in an urbanized area. Additionally, compared to those not screened (50.52 mi), those screened were more likely to live closer to UAB (22.06 mi). Conclusions: Findings show a substantial disparity between adults living in rural areas and those living in more urbanized areas regarding LCS use. Furthermore, the study provides evidence that LCS has not reached all subgroups and that additional targeted efforts are needed to increase lung cancer screening uptake.
Advancing equity in prostate cancer outcomes using community-facing navigation in the cancer continuum of care.
Authors: Stevens Hobbs Kristen , Hall Laura Lee , Farrington Thomas , Moore Angelo , Barnett LaSonia , Aguilera-Funez Nadia , Crawford Keith , George Jerry
Published: September 2022

120

Background: According to the American Cancer Society, prostate cancer is the second most common cause of cancer death in Black men. Between 2014–2018, the prostate cancer incidence rate among Black men was 73% higher than that in white men. Approximately 6,040 Black men are projected to die of prostate cancer in 2022. Many disparities contribute to prostate cancer mortality in Black men, including missed genitourinary (GU) referral appointments. Research has shown that patient navigation can be an effective, evidence-based intervention to improve health outcomes. Improving completion of GU referrals through navigation may advance equity in continuity of care. Methods: An algorithm was integrated into electronic medical records (EMR) to identify Black men eligible for prostate cancer screening in primary care practices of a health system North Carolina. An assessment was adapted for community-facing navigators using existing literature on patient navigation practices. Navigators were trained on culturally responsive prostate cancer education and a plan-do-study-act quality improvement (QI) model. A notice to navigate alert was implemented into the navigation workflow to alert staff of Black men with prostate-specific antigen (PSA) levels of 10 or greater. Results: At baseline, perceived barriers to entering the continuum of care were related to the social determinants of health, as noted by navigators. During the intervention, navigators were alerted of 25 Black men 49 – 74 years of age with PSA levels of 10 and above. Initial PSA results ranged from 10.55 to 101.61 (ng/ml). Twenty-three of them agreed to accept navigation services and were scheduled appointments to follow up with GU. Of the completed appointments, 15 were diagnosed with prostate cancer. Post-intervention, navigators noted barriers to completing GU appointments included health literacy/education, work schedules, transportation, lack of responsiveness to female navigators, the digital divide, social support, and denial of prognosis. Conclusions: Providing Black men with navigation services allowed common barriers to be eliminated, increased GU appointment completion, identified men with prostate cancer at earlier stages, and assisted with earlier initiation of treatment by conducting a warm handoff to clinical navigators. Future studies may seek to understand implementation of the EMR algorithm across all primary care practices, integrating the use of navigators as an intervention, and supplementing culturally—tailored patient education materials to include a digital component.
Patient-reported outcomes: Completion, access, and equity.
Authors: McGuire Jessica , Hubbell Harrison Taylor , Hochberg Ephraim P. , Foley Cara , Ryan David P. , Mulvey Therese Marie
Published: September 2022

141

Background: Patient Reported Outcomes CTCAE (PROM) completion has demonstrated improvements in survival for patients with advanced cancer. Little is known about completion rates by race and gender for questionnaires assigned to all patients receiving IV infusions. Methods: Beginning in 2019 all patients who had a visit associated with an IV infusion were assigned a PROM PRO-CTCAE questionnaire through the EHR portal 72 hours prior to the visit and again using an in- clinic tablet if not completed upon check-in. The PROMs questionnaires are available in 6 languages via both electronic platforms. At registration, all patients self- identify as White, Black/African American, Asian or other (multiple, do not prefer to answer) by race. We collected 2021 data on all eligible patients who were assigned a questionnaire and cross referenced that by completion and self-assigned race and gender at registration. Data from breast, thoracic and GI clinics are presented. Results: 1715 patients were eligible and self-identified as White, Black or Asian for a PROM CTCAE questionnaire across the three clinics (519 breast clinic, 390 thoracic, 806 GI). 3872 questionnaires were completed (average 2.26 questionnaires per eligible patient). 2875 (73%) were completed by EHR portal and 1027 (27%) were completed in clinic on the tablet. White patients completed questionnaires 67% when assigned, Asian 68% and Black/African American 52% of the time. 81% of breast clinic patients completed questionnaires, 62% of thoracic patients and 54% of GI patients. Overall, in thoracic and GI clinics White women completed questionnaires 58%, Black women 41% and Asian women 70% compared to White men 59%, Asian men 56% and Black men 57%. All patients who completed questionnaires in breast clinic identified as women. Conclusions: We assigned PROM CTCAE questionnaires to all eligible patients who had an IV infusion encounter associated with their visits in the breast, thoracic and GI clinics by both the electronic chart portal and again in clinic by tablet, if not completed prior to the in person visit. PROM questionnaires are available in 6 languages through both methods. We identified differences in completion rates by race with fewer African American/Black patient completion rates compared to White or Asian self-identification, (52% vs 67.5%). The largest differences were between White or Asian women, 58% and 70% completion rates compared to Black women 41%. Differences in gender may explain differences across disease groups as all breast clinic patients were self-identified as female, 81% completion rate compared to 62% thoracic and 54% GI.
Pathologic complete responses and overall survival after neoadjuvant chemotherapy for muscle-invasive bladder cancer: Analyzing the impact of race.
Authors: Roy Arya Mariam , Jiang Changchuan , Perimbeti Stuthi , Jatwani Karan , Chatta Gurkamal S. , Gopalakrishnan Dharmesh
Published: September 2022

146

Background: Neoadjuvant chemotherapy (NAC) has been demonstrated to improve overall survival (OS) after radical cystectomy (RC) in patients with muscle-invasive bladder cancer (MIBC). We compared pathologic complete response (PCR) rates and OS after NAC between African American (AA) and Caucasian patients with MIBC. Methods: We queried the National Cancer Database for Caucasian and AA patients with localized MIBC (cT2-T4aN0M0) with urothelial histology who received NAC + RC between 2007 and 2018. We excluded patients who belonged to other races, had nodal or distant metastases, non-urothelial histology, did not receive NAC, or had missing pathological data. Logistic regression was used to analyze PCR and residual disease (RD) and Cox proportional hazards regression to analyze OS, with adjustment for age at diagnosis, race, stage, grade, insurance, treatments received, and comorbidities. STATA/IC 16.0 was used for analysis and a two-sided p-value < 0.05 was considered significant. Results: A total of 7008 Caucasians and 424 AAs with MIBC were identified. 75.6% were males and 24.4% were females. Among those who received NAC, only 12.6% (n = 933) attained PCR and 87.4% (n = 6499) had RD. Among Caucasians, 12.76% (n = 894) attained PCR and 87.24% (n = 6114) had RD. Among AAs, 9.2 % (n = 39) had PCR and 90.8% (n = 385) had RD. AA had more likelihood of attaining PCR when compared to Caucasians, but was not statistically significant (OR = 1.35, 95% CI = 0.966 – 1.90, p = 0.078). The median OS of patients with PCR and RD were 144 and 47 months respectively. Patients who had RD had significantly higher mortality risk when compared to those who attained PCR (HR = 3.67, 95% CI = 3.14-4.29, p < 0.01). In the PCR group and RD groups, AA vs Caucasian race was not associated with a statistically significant mortality benefit in univariate or multivariate analysis. Within PCR and RD groups, AAs were found to have mortality risk compared to Caucasians (PCR group: HR = 1.53, 95% CI = 0.2-1.43, p = 0.21 and RD group: HR = 1.07, 95% CI = 0.93- 1.2, p = 0.34). Conclusions: PCR with NAC in localized MIBC was associated with significantly improved overall survival. AA or Caucasian race was not independently predictive of PCR or OS after NAC in MIBC.
Persistent racial and ethnic inequities in cancer-specific mortality of head and neck cancers by human papillomavirus infection.
Authors: Abdelaziz Abdullah Islam , Calip Gregory Sampang
Published: September 2022

148

Background: Overlapping racial and ethnic disparities exist in the prevalence of risk factors that drive the prognosis of head and neck cancers in the US, including the use of tobacco products, socioeconomic status and human papillomavirus (HPV) infection. Our objective was to describe inequities in cancer-specific survival among patients diagnosed with head and neck cancers by HPV status and racial/ethnic group. Methods: We conducted a retrospective cohort study using the Surveillance, Epidemiology and End Results Head and Neck with HPV Status Database. Patients diagnosed with first primary cancers of the hypopharynx, nasopharynx, oropharynx, pharyngeal tonsil, other pharyngeal, soft palate and tongue base between 2010 and 2016 were included, and information on clinical and demographic characteristics including tumor information, cancer-directed treatment, area-level socioeconomic status and HPV status were collected from population-based cancer registry data. Estimates of 5-year cancer-specific survival were calculated using the Kaplan-Meier method, and multivariable Cox proportional hazards models were used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for racial/ethnic inequities in survival stratified by HPV status. Results: Among 15,393 patients diagnosed with head and neck cancer with documented HPV status, the median age was 59 years (interquartile range 53-66) and 10,457 (68%) were HPV+. Compared to patients diagnosed with HPV- head and neck cancers, a higher proportion of patients with HPV+ head and neck cancers were male (87% vs. 77%), diagnosed at stage IV (75% vs. 66%) and non-Hispanic White (84% vs. 68%%); and a lower proportion of HPV+ patients were non-Hispanic Black (6% vs. 13%) and uninsured or had Medicaid coverage (13% vs. 25%). Overall, 5-year cancer-specific survival was higher among HPV+ patients (82%) than among HPV- patients (62%), with a wider disparity observed among Black head and neck cancer patients (HPV+ 74%, HPV- 44%). In multivariable models, significant differences in cancer-specific survival were found across racial/ethnic groups and HPV status (P-interaction: 0.045). Compared to White patients, persistent inequities in cancer-specific survival were observed among Black HPV+ (HR 1.49, 95% CI 1.19-1.87) and HPV- (HR 1.42, 95% CI 1.21-1.66); and among Latinx HPV+ patients (HR 1.32, 95% CI 1.03-1.69). Conclusions: In this population-based study of patients with head and neck cancers, significant disparities in cancer-specific survival were observed that differed by both race/ethnicity and HPV status. The complex inequities in outcomes of head and cancers likely reflect the clinical impacts of socioeconomic and demographic risk factors in addition to HPV-related dysregulation of tumor metabolism and the immune microenvironment.
Socioeconomic factors and outcomes among patients with recurrent/metastatic head and neck cancer receiving immunotherapy.
Authors: Uy Natalie F. , Ng Kevin , Voutsinas Jenna M. , Wu Vicky , Merkhofer Cristina Maria , Tseng Diane , Giustini Nicholas Peter , Lee Sylvia , Baik Christina S , Santana-Davila Rafael , Eaton Keith D. , Rodriguez Cristina P.
Published: September 2022

153

Background: Immune checkpoint inhibitors (ICI) are now a therapeutic standard for recurrent/metastatic head and neck squamous cell cancer (R/M HNSCC). There is limited data on the impact of demographics and socioeconomic (SES) factors on outcomes in this population, and we sought to evaluate these in our single institution cohort. Methods: R/M HNSCC patients (pts) receiving ICI were retrospectively reviewed from an institutional database. SES factors included income, distance to center (dist), marital status, race, and insurance. Median household income by residence zip code was obtained from the US Census Bureau. Time to ICI initiation (TTI) was time from initial visit recommending ICI and first ICI dose. Opiate use was calculated using morphine equivalents prior to ICI initiation and either at best response or end of ICI if no response. Associations between SES factors with overall survival (OS) and TTI were assessed using Cox proportional hazards regression. Binary outcomes were assessed using logistic regression and included ER visits/unplanned hospitalizations (UH) and increase in opioid use. Analyses were adjusted for disease characteristics, smoking status, ECOG, and demographics. Results: Between 1/2012-12/2019, 152 pts received ICI; 124 (82%) were male, with median age of 64 years (range 23-90), and 103 (68%) were partnered/married. The most common races were 114 white (75%), 14 Asian (9%) and 6 Hispanic, any race (4%). Out of 149 (98%) insured pts, 27 (18%) were Medicaid and 69 (46%) Medicare. Median dist was 39 miles (Q1 21, Q3 100), and median income was $80,586 (Q1 $61,202, Q3 $103,059). The most common primary sites were oropharynx (36%), oral cavity (22%), and nasopharynx (7%); 29 (19%) had an ECOG ≥2. While on or within 100 days of ICI, 69 (45%) had ER visits, and 57 (38%) had UH. Increased dist was associated with improved OS (4th vs 1st quartile, p = 0.0002; HR 0.33; 95% CI [0.18,0.59]); we observed no other SES association with OS. Increased opioid use was associated with Medicaid/no insurance (p = 0.05; OR 2.89; 95% CI [1.02,8.77]). No SES association with TTI was found, although there was a nonsignificant trend of higher TTI with increasing dist. We saw no correlation with ER/UH and any SES variables. Conclusions: Among R/M HNSCC pts receiving ICI, insurance had an impact on opiate usage, suggesting more advance disease/higher burden of symptoms and indicating need for augmentation of supportive care in this group. Higher dist was associated with improved OS, even accounting for performance status, which may reflect increased resources in this group. Further studies should examine pt factors that may contribute to disparities in the setting of novel therapies for R/M HNSCC pts.
Evaluating healthcare system–level racial disparities in mortality following lung cancer resection among Medicare beneficiaries.
Authors: Bonner Sidra , Kunnath Nick , Dimick Justin , Griggs Jennifer J. , Ibrahim Andrew M
Published: September 2022

156

Background: Racial inequities in lung cancer surgical quality are well documented yet understanding the variation in racial inequities across healthcare systems remain limited. Therefore, in this study the variation in racial disparities mortality across healthcare systems was evaluated. Methods: Using 100% Medicare fee-for-service claims, we analyzed data on Medicare beneficiaries between the ages of 65- and 99-years old undergoing resection for lung cancer. All patients undergoing resection for lung cancer between 2014 and 2018 were included. Clinical risk-adjusted 30-day post-operative mortality rates for an overall health care systems as well as rates for non-Hispanic Black and non-Hispanic white patients within each of system were evaluated using multivariate logistic regression. The variation across all healthcare systems performing at least 5 operations for each racial group was performed. A total of 216 healthcare systems were included. Results: Overall, 82,978 patients were included with mean (SD) age of 73.7(5.5) years and racial composition of 7,124 Black patients (8.6%) and 75,854 White patients (91.7%). Of these 216 systems, 90 (41.7%) had significant disparities with the worst mortality in Black beneficiaries. Of these systems with significant worst mortality for Black patients undergoing resection for lung cancer, the odds of mortality of Black compared to White patients ranged from OR 1.04 (95% CI 1.01-1.08; P < 0.001) to OR 2.9 (95% CI 2.6-3.2; P < 0.001). There was weak but statistically significant association between system overall mortality and the Black-White difference in mortality (R = 0.14; P < 0.04). Conclusions: Our findings provide justification for system- level interventions to address disparities in surgical care for Black patients undergoing resection for lung cancer. Moreover, our findings suggest that quality improvement efforts to improve overall quality of surgical care that do not focus on the care of Black patients may be insufficient for reduction of disparities.[Table: see text]
Designing and implementing an evidence-based and longitudinal implicit bias training curriculum for school of medicine members and health care providers.
Authors: Hamel Lauren M. , Robinson Leah M. , Chamblee Marquita , Roy Donovan , Dougherty David W. , Sood Beena
Published: September 2022

159

Background: Implicit biases negatively influence decision making and communication in healthcare. The School of Medicine (SOM) at Wayne State University (WSU), based in the diverse yet segregated city of Detroit, Michigan, has faced the consequences of bias. Fortunately, within SOM/WSU, expertise on the problem of and solutions to implicit bias have flourished. We leveraged that expertise to design and implement a comprehensive and longitudinal implicit bias curriculum for SOM members and healthcare providers, including hematology/oncology faculty, providers, and trainees. We designed the curriculum to satisfy State of Michigan implicit bias training requirements for all healthcare providers. To date, we have implemented two modules. Prior to the second module, we received IRB-approval to recruit curriculum participants as study participants and tested effectiveness. Methods: The curriculum is comprised of 1½ hour modules offered every three months. Topics include how implicit bias influences clinical communication with a focus on the oncology care context, how structural racism influences health policy, among others. To evaluate, we utilize Kirkpatrick’s Four-Level Training Evaluation Model, to assess outcomes at 4 levels: 1. reaction, 2. learning, 3. behavior change and 4. long-term results. After obtaining passive consent from participants, we gathered effectiveness data at levels 1 and 2. Results: We implemented two modules (How Patient and Physician Race-Based Attitudes Influence Clinical Communication & Structural Racism 101: Basic Training for Doctors) in 2021 via Zoom. More than 160 people attended each module with many participants representing oncology-focused hospitals and academic departments. All participants received a certificate of participation as a part of the state requirements for implicit bias training, and CME credit. For Session 2 we asked participants to respond to a survey before (n = 106) and after (n = 35) the session assessing Levels 1 and 2. Participant evaluations (Level 1) were very positive, with many participants noting that they plan to put what they have learned into practice immediately. A common critique was the desire for more topics and more time to discuss. Findings show increased knowledge (Level 2) of structural racism (pre: 92% vs. post: 97%); spatial racism (pre: 87% vs. post: 91%); and how racism influences health policy (pre: 80% vs post: 86%). Conclusions: We successfully implemented a longitudinal implicit bias curriculum for SOM members and healthcare providers. Next steps include continuing to implement and assess the curriculum, and collecting data at Levels 3 and 4. This type of curriculum could be an important tool to decrease bias in cancer care and improve cancer care equity.