bluuebunny/crossref_metadata_2025_split huggingface dataset:
Rural-urban disparities in breast cancer-related mortality in the United States (1999-2020).
Authors: Buzick Justin , Grewal Udhayvir Singh , Fleege Nicole Margo Grogan 
Published: October 2023

181 Background: Breast cancer is the most commonly diagnosed cancer and the second most common cause of cancer death among women in the United States (U.S.). While racial and ethnic disparities in outcomes are known, large population-based data on rural and urban disparities in breast cancer-related mortality are lacking. Methods: We retrieved de-identified data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) multiple causes of death database (years: 1999–2020) for females (aged 15 years and upwards) with “malignant neoplasm of breast” (ICD-10 C50) listed as “underlying cause of death”. We analyzed age-adjusted mortality rates (AAMRs) per 100,000 population and assessed temporal trends in the average percent change (APC) of AAMRs applying the simplest model with a maximum of 3 joinpoints (using Joinpoint regression program 4.9.1.0). We conducted nonparallel pairwise comparisons to assess differences in trends between large metropolitan, medium to small metropolitan and rural areas (per National Center for Health Statistics Urban-Rural Classification Scheme, 2016) using average annual percentage change difference (AAPCD). Results: A total of 909,467 breast-cancer related deaths were analyzed between 1999-2020. We noted a decline in breast cancer related AAMR overall and across large metropolitan, small to medium metropolitan and rural areas (table). However, the decline in AAMR was significantly higher among large metropolitan areas as compared to small to medium metropolitan (AAPCD -0.3371, 95% CI -0.61, -2.4187, p=0.02) and rural areas (AAPCD: -0.48, 95% CI -0.79, -3.12, p=0.002). No significant difference in AAMR trend in small to medium metropolitan and rural areas was noted (AAPCD -0.15, 95% CI -0.37, 0.08, p=0.19). Conclusions: We demonstrate disparities in decline in breast cancer related AAMR between urban and rural areas. A significantly higher decline in AAMR among large metropolitan areas compared to medium to small metropolitan and rural areas suggests discrepancy in access to cancer care among populations. Further work is needed to develop strategies aimed at ensuring equitable cancer care access for all patients with breast cancer regardless of their geographical location.[Table: see text]
Quality surgery for gastrointestinal cancers in the Deep South: Disparities in elements of the Enhanced Recovery Program.
Authors: Pisu Maria , Smith Burkely , Schoenberger Yu-Mei , Jones Bayley A , Wang Lingling , Ivankova Nataliya V. , Richman Joshua , Chu Daniel I 
Published: October 2023

183 Background: Disparities in surgical outcomes exist for Black gastrointestinal cancer patients and may be due to the lower likelihood of undergoing quality surgery that minimizes adverse surgical outcomes. The Enhanced Recovery Program (ERP) has shown to improve perioperative outcomes through standardization of care and to reduce disparities in surgical outcomes in certain settings. The extent to which ERP is applied across patient groups is currently unclear, especially for patients in high poverty states of the Deep South. Methods: The ASCENDS study conducted a survey of colorectal, pancreatic, and esophageal cancer patients (stage 1-3, diagnosed within 5 years, had surgery) in Alabama and Mississippi. Survivors were recruited through the Alabama Statewide Cancer Registry and select hospitals in these states. Survey questions asked about selected ERP components including: 1) education and counseling about surgery, i.e., i) surgeon/other health care provider in surgery clinic gave instructions about getting ready for surgery, ii) instructions were definitely easy to understand; 2) carbohydrate drink before surgery (e.g., Sprite); 3) pain medication; 4) anti-thrombotic and antibiotic prophylaxis; 5) bladder catheter (removed day after surgery); 6) early mobilization (walking) and nutrition on day of surgery, and mobilization the day after surgery. Fisher Exact or Chi Square tests were performed to examine significant differences across White (W) and Black, Indigenous, or persons of color (BIPOC) respondents. Results: Of 272 survey respondents (mean age 63.17±11.57, range 23-92), 71.3% were W, 28.3% BIPOC, 55.5% women, 76.8% had colorectal,16.2% pancreatic, and 7% esophageal cancer, 58.8% were from rural areas, 33.8% had low health literacy, 46.7% had private insurance, 32.3% Medicaid or Medicare/Medicaid, and 21.7% Medicare. See Table 1. Conclusions: Overall, there were no disparities in ERP components as recalled by survey respondents. Low uptake of some of the ERP components is worrisome, although data from medical records is needed to confirm findings. Improvements may be needed to improve surgery outcomes for alI GI cancer patients in the Deep South.[Table: see text]
Disparities in cancer incidence and mortality for individuals incarcerated in Massachusetts (MA) state prisons compared to the general population.
Authors: Manz Christopher , Tramontano Angela , Wright Alexi A. 
Published: October 2023

187 Background: More than 10 million people are incarcerated annually in the US. Incarcerated individuals are disproportionately affected by cancer disparities, yet receive healthcare while in prison which may offer opportunities for enhanced cancer screening and treatment. Little research has evaluated disparities in cancer incidence and survival among incarcerated patients. Methods: Name, birth date, and sex were obtained for individuals incarcerated in MA state prisons from 2010-2019 from the MA Department of Corrections and matched to MA state cancer registry data. Patients diagnosed with an incident cancer were classified as currently incarcerated (CI), formerly incarcerated (FI), or never incarcerated (NI) based upon incarceration status at diagnosis. We examined crude cancer incidence, standardized incidence ratios (SIR) and crude overall survival (OS) by incarceration status, and evaluated survival differences with Cox proportional hazards models adjusted for age, sex, race, ethnicity, diagnosis year and cancer type. Results: Of 416,267 cancers diagnosed in 2010-2019, 288 (0.1%) CI, 785 (0.2%) FI and 415,194 (99.7%) NI patients were diagnosed with cancer. Demographics differed by incarceration status (median age: 57 vs 54 vs 66 years for CI, FI and NI, respectively; males: 92.4% vs 71.6% vs 46.4%; and Whites: 69.8% vs 77.3% vs 89.4%; all P≤0.01). The most common cancers detected are in Table. Detection of screenable cancers were highest in CI and NI patients (51.4% and 51.0%) and lowest in FI patients (46.2%; p=0.03). However, of those diagnoses, 25.6% of CI and 22.6% of FI were diagnosed with Stage IV disease, compared with 16.4% of NI patients (p=<0.0001). Crude incidence per 100,000 patient years was 271.7 for CI, 267.9 for FI and 773.2 for NI patients. Compared to NI men, the SIR was 97.6 (95% CI 86.2-110.1) for CI men and 109.5 (95% CI 100.6-118.9) for FI men. Unadjusted 1-year all-cause OS was 68.1% for CI, 72.6% for FI and 76.5% for NI patients, while 5-year OS was 36.4% for CI, 53.2% for FI and 60.9% for NI patients (Table). In adjusted models, CI and FI patients had statistically worse OS, compared with NI (CI vs. NI: HR 2.17, 95% CI 1.84-2.56; FI vs. NI: HR 1.85, 95% CI 1.66-2.07). Conclusions: In MA, CI and NI patients are more likely than FI patients to have screenable cancers detected. However, CI and FI patients are more likely to be diagnosed with stage IV disease, and have worse all-cause OS, compared to NI patients. Research on cancer screening and treatment in prisons is needed to improve cancer outcomes for CI and FI patients.[Table: see text]
Prevalence of social risks among cancer patients in an integrated health system.
Authors: Ng Garett , Gill Simran , Glinsky Isabel , Frost Jennifer , Le Michele , Bocobo Omar 
Published: October 2023

195 Background: Social risks can lead to adverse cancer outcomes, including poor quality of life and increased mortality. These risks also contribute to health disparities and inequities, deepening needs for social care and support of cancer patients. Kaiser Permanente (KP) evaluated its social determinants of health (SDOH) questionnaires to assess the prevalence of social risks among cancer patients and members to design solutions that would address their social support needs. Methods: KP uses standard and non-standard SDOH questionnaires across markets to screen pediatric and adult members for social risk factors such as financial strain, housing instability, and social isolation. Screening is built into KP’s electronic health record (EHR), where the survey is administered by clinical staff, call center agents, or patients when logged into KP.org. SDOH screening data was collected between January 2021 to September 2022 for this analysis. Electronic Medical Record (EHR) and claims data were used to identify KP members with care associated with a cancer diagnosis between September 2017 to September 2022. Benign neoplasm and basal/squamous cell diagnoses were excluded. Results: There were 608K patients identified with visits associated with a cancer diagnosis in the 5-year period. Of these 608K cancer patients, 18% (n=109,773) were screened for social risk using standard and non-standard SDOH surveys. For comparable results across KP markets, standard questionnaires yielded 39% (n=7,507) presenting at least one positive social risk factor out of 19,274 cancer patients screened. Financial strain and social isolation were the most prevalent factors. Members across all major health plan products screened positive for at least one risk. When stratified by product, 65% (n=825) of Medicaid members screened were the highest observed group with at least 1 social risk, and commercial members screened were the second highest (40%, n=2,700). Cancer patients’ positive social risks were consistent with the overall screened population at 38% (n=102,392). Conclusions: KP cancer members yielded a similar measure of social risks as the general screened population, and the prevalence of these risks across major health plan products signals a call to action. The top social needs surfaced from this analysis informed how KP can support members by designing solutions that will provide access and referrals to appropriate resources. Deploying standardized social needs screenings and integrating them with clinical workflows are critical success factors. KP is building screening tools in multiple languages and will offer additional screening modalities to broaden equitable access. Though wide evidence demonstrates social factors have a major impact on health and well-being, more research is required to understand their effects on disparities, other dimensions of inequity, and health outcomes among cancer patients and members.
Using standard-of-care screening to identify inequities in cancer-related financial hardship.
Authors: Williams Courtney , Liang Margaret Irene , Rocque Gabrielle Betty , Gidwani Risha , Caston Nicole E. , Pisu Maria 
Published: October 2023

196 Background: Financial hardship is known as an “adverse event” for individuals with cancer. This study used data collected as part of routine care to understand the magnitude of and potential inequities in cancer-related financial hardship for patients with cancer receiving care in the Deep South. Methods: Universal financial hardship screening was piloted among oncology patients initiating treatment at University of Alabama at Birmingham from October 2020-May 2023. Financial hardship screening questions were added to a standard-of-care treatment planning survey administered by lay navigators. Questions included measures of (1) financial distress (Comprehensive Score for financial Toxicity [COST], scored 0-44; scores <26 indicate financial distress), and (2) financial difficulties affording one or more of 10 items. Proportions of screens completed and variations in financial hardship were calculated overall and by patient race and rurality. Results: Patients who completed treatment planning surveys (N=2,741) were an average 62 years old (SD 13), 18% Black, Indigenous, or persons of color (BIPOC), and 16% rural dwelling. Financial hardship screening was completed by the majority (90%) of patients with treatment planning surveys. Patients with a breast (23%), gynecologic (16%), or gastrointestinal (14%) cancer most commonly completed screening. Completion was similar by race and rurality. Screening identified 34% of patients were experiencing financial distress (mean COST 28, SD 11). However, 49% of BIPOC patients screened positive for financial distress compared to 30% of White patients. The most commonly reported financial difficulties were insurance or medical bills (reported by 32% of patients), upfront medical payments (29%), and medications (22%). Large differences in reported financial difficulties were seen comparing patients who were BIPOC and White (Table). Rural- and non-rural-dwelling patients reported similar proportions of financial difficulties. Conclusions: Most patients completed lay navigator-led financial hardship screening, which identified racial inequities in financial hardship even before treatment initiation. Efforts to collect patient economic data should support the design, implementation, and evaluation of patient-centered interventions to improve equity and reduce adverse cancer-related economic outcomes.[Table: see text]
Establishing an evidence-based cultural competency program with advanced practice providers in a community oncology setting.
Authors: Marti-Smith Marissa , Mikan Sabrina Q. , Broussard Stephanie Broadnax , Cone Kelly 
Published: October 2023

199 Background: The United States continues to grow in both population and diversity. The trigger for this project was the dramatic increase in patient diversity in Texas and the lack of adequate cultural competency training for providers at a Texas Oncology clinic network. Clinicians must increase their self-awareness and knowledge to provide culturally competent care. The literature review found multiple educational modalities, across many health care disciplines, used by researchers to improve the cultural competency of health care providers. Methods: This project sought to improve satisfaction and adherence of patients over the age of 25 diagnosed with cancer by increasing provider cultural sensitivity and self-awareness of bias within 1 month of cultural competency training. The project sample was 14 advanced practice providers, 10 APRNs and 4 PAs. The educational plan for this project included an evidence-based course and a follow-up focus group to reinforce learning. Quantitative data were analyzed using the Cultural Competence Assessment tool to compare participants’ anonymous pre- and posteducation with the Wilcoxon signed-rank test. Qualitative data was obtained during focus groups. Results: The quantitative data indicated that cultural awareness and sensitivity increased following training, with median scores increasing from 6.09 to 6.55, p = 0.03. However, the data do not suggest that cultural competence and behavior changed after training, as median scores went from 3.96 to 4.23 after training, p = 0.06. Overall, the focus group participants agreed about improving self-awareness, identifying biases, improving patient experience by asking more open-ended questions, and being vulnerable. Conclusions: Despite the small sample size, the quantitative and qualitative data suggest that cultural awareness and sensitivity improved following the EBP course and focus group meetings. Cultural competency and behavior did not change according to the data. However, the project implications include improvement in provider knowledge and increased self-awareness, which promote individualized, culturally sensitive care.
Pembrolizumab vs chemotherapy in the first-line setting of PD-L1≥50% metastatic non-small cell lung cancer: A real-world cost-effectiveness analysis.
Authors: Lu Brandon , Parmar Ambika , Luo Jin , Chan Kelvin K. 
Published: October 2023

21 Background: Despite the voiced concerns around the initial economic decision models for first-line pembrolizumab in PD-L1≥50% metastatic non-small cell lung cancer (mNSCLC), there has been a paucity of evidence on the anticipated cost-effectiveness of pembrolizumab in the real world. To resolve the uncertainties associated with the initial assessment, we evaluated the real-world cost-effectiveness of first line pembrolizumab versus platinum-based chemotherapy for mNSCLC patients with PD-L1≥50%. Methods: We retrospectively identified a population-based cohort of mNSCLC patients who received first-line pembrolizumab or platinum-based chemotherapy between April 1, 2013, and March 31, 2021, in Ontario, Canada. Employing a public payer’s perspective, all costs (in Canadian dollars) and effects were estimated over a 4-year horizon, adjusted for censoring and discounted at 1.5% yearly. The primary outcomes were incremental cost-effectiveness ratios (ICERs) for life-years gained (LYG) and quality-adjusted life year (QALY). To examine the sensitivity of the ICER to drug acquisition costs and discounting, we conducted a price reduction analysis and a scenario analysis of different discount rates. Results: Propensity-score matching resulted in a total of 1,142 pairs of matched mNSCLC patients. Pembrolizumab extended survival with an incremental effect of 0.37 LYG and 0.35 QALY, but at an incremental cost of $56,681; the resulting ICERs were $154,941/LYG and $163,039/QALY. Though the ICERs were not sensitive to discounting rate, 31% and 55% reductions to the price of pembrolizumab brought the ICER below $100,000/QALY and $50,000/QALY, respectively. Conclusions: In the real world, first-line pembrolizumab is not considered to be cost-effective for mNSCLC patients with PD-L1≥50%. Improvements in cost-effectiveness, however, may be achievable through price renegotiations for pembrolizumab.
Potential out-of-pocket savings from hematology/oncology drugs for commercially insured patients via Mark Cuban Cost Plus Drug Company.
Authors: Xiang Jenny Jing , Lei Xiudong , Li Meng , Giordano Sharon H. , Shih Ya-Chen Tina , Lin John Kent 
Published: October 2023

22 Background: Prescription drug out-of-pocket (OOP) costs remain a major source of financial toxicity in hematology/oncology (heme/onc). Mark Cuban Cost Plus Drug Company (MCCPDC) sells generic drugs directly to patients, bypassing insurance. The purchase cost is equal to drug cost (manufacturing cost, 15% markup, $3 pharmacy fee) and $5 shipping fee. Research shows MCCPDC provides potential savings for Medicare beneficiaries, but its benefit for the commercially insured remains unknown. We assess OOP savings if the eight MCCPDC drugs with heme/onc indications were purchased directly from MCCPDC instead of commercial insurance. Methods: MCCPDC purchase costs were matched with equivalent drugs claims in IBM Marketscan (2021) based on name, strength, formulation, and amount dispensed, using claims with the most frequent days’ supply. Potential OOP savings were calculated by subtracting insurance claim OOP costs (copay + coinsurance + deductible) from MCCPDC purchase cost. Outcomes included % claims with cost savings and amount saved. Savings were calculated for brand-name drugs for which a MCCPDC generic may often be appropriately substituted. Results: Of 145,403 claims, 6.8-24.5% of generic antineoplastics approved post-1990 in MCCPDC and 26% of deferasirox claims would have OOP savings if purchased through MCCPDC, with median savings $63-$561 (Table). 14.8% of brand-name 2nd generation antiandrogen claims would save switching to abiraterone, with median (IQR) saving of $1045 (345, 2010). 43.2% of brand-name 1st/2nd generation BCR/ABL tyrosine kinase inhibitors (TKI) claims would save switching to imatinib, with median (IQR) saving of $116 (31, 1286). The share of newer generic antineoplastic claims with savings varied by insurance: high deductible health plan (HDHP) (28.1%), health maintenance organization (HMO) (23.5%), and preferred provider organization (PPO) (13.2%) (p<0.001). Conclusions: Some patients can save hundreds or thousands of dollars per fill by purchasing heme/onc drugs through MCCPDC instead of commercial insurance, with greater savings for HDHP/HMO and from brand-name antineoplastics to appropriately substitutable generics. MCCPDC is a new avenue to decrease financial toxicity. [Table: see text]
Self and proxy symptom reporting in patient-caregiver dyads coping with a primary brain tumor: The role of psychosocial function in rating agreement.
Authors: Whisenant Meagan , Snyder Stella , Weathers Shiao-Pei S. , Bruera Eduardo , Milbury Kathrin 
Published: October 2023

223 Background: Patients with glioma experience high levels of symptom burden with often sudden performance declines. As such, family caregivers tend to report on the patient’s symptoms; yet previous research examining the validity of proxy symptom reporting points to inconsistent findings. While prior studies focused on identifying patient clinical variables that may be related to agreement, caregiver characteristics may also be important for accurately perceiving patient symptoms. We examined the associations between symptom agreement and patient and caregiver perceived illness communication, depressive symptoms, and QOL. Methods: As part of a behavioral intervention trial, baseline assessments were collected prior to randomization in 67 dyads. We report on patient symptom burden (MDASI-BT) and patient and caregiver depressive symptoms (CES-D), illness communication (CICS), and QOL (SF-36). Paired t-tests, difference scores and inter-correlations coefficients (ICCs) were used to test for agreement, accuracy and congruence in proxy symptom scores, respectively. Bivariate correlations were calculated to examine the association between psychosocial function variables and symptom agreement. Dyadic level associations between symptom agreement and QOL were examined using multi-level modeling. Results: Thirty-nine percent of patients (63% male; 93% non-Hispanic White; mean age=47 years; 84% Grade III-IV) and 49% of caregivers (79% female; 90% non-Hispanic White; mean age=51 years) endorsed clinical levels of depression. Clinically significant disagreement was found for all means scores of the MDASI-BT subscales except for GI symptoms and general symptoms. 22% of caregivers overestimated and 13% underestimated overall symptom severity and 32% overestimated and 21% underestimated symptom interference. ICCs of patient and caregiver proxy ratings were significant (except cognitive and GI subscales) ranging from small to moderate coefficients (.09 - .50). Patient illness communication was associated with agreement in overall symptom severity (r=-.27, p=.03) and affective symptom subscale (r=-.34, p<.01). Caregiver illness communication (r=-.33, p<.01) and depressive symptoms (r=.46, p<.0001) were associated with symptom interference agreement. Caregiver overestimation of patient symptom severity was significantly associated with poor caregiver physical QOL, while underestimation was significantly associated with poor patient physical and mental QOL and poor caregiver mental QOL. Conclusions: The psychosocial context of the family plays an important role in the accuracy of proxy symptom reporting. Moreover, inaccurately understanding patients' experience is related to poor QOL for both patients and caregivers, which points to important targets for symptom management interventions that involve family caregivers.