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Cancer treatment often leads to work disruptions including loss of income, resulting in long-term financial instability for cancer survivors and their informal caregivers. In this sequential explanatory study, we conducted a cross-sectional survey of employment experiences among ethnically diverse, working-age individuals diagnosed with breast, colorectal, or prostate cancer. Following the survey, we conducted semi-structured interviews with cancer survivors and informal caregivers to explore changes in employment status and coping techniques to manage these changes. Among employed survivors (n = 333), cancer caused numerous work disruptions including issues with physical tasks (53.8%), mental tasks (46.5%) and productivity (76.0%) in the workplace. Prostate cancer survivors reported fewer work disruptions than female breast and male and female colorectal cancer survivors. Paid time off and flexible work schedules were work accommodations reported by 52.6% and 36.3% of survivors, respectively. In an adjusted regression analysis, household income was positively associated with having received a work accommodation. From the qualitative component of the study (survivors n = 17; caregivers n = 11), three key themes emerged: work disruptions, work accommodations, and coping mechanisms to address the disruptions. Survivors and caregivers shared concerns about lack of support at work and resources to navigate issues caused by changes in employment. This study characterized employment changes among a diverse group of cancer survivors. Work accommodations were identified as a specific unmet need, particularly among low-income cancer survivors. Addressing changes in employment among specific groups of cancer survivors and caregivers is critical to mitigate potential long-term consequences of cancer.

Objective Despite widespread cervical screening, an estimated 13,800 women will be diagnosed with cervical cancer in the United States in 2020. To inform improvements, the screening histories of women diagnosed with cervical cancer in New Mexico were assessed. Methods Data were collected on all cervical screening, diagnostic tests and treatment procedures for all women diagnosed with cervical cancer aged 25-64 yrs. in New Mexico from 2006 to 2016. Women were categorized by their screening attendance in the 5–40 months (screening interval) and 1–4 months (peri-diagnostic interval) prior to cancer diagnosis. Results Of the 504 women diagnosed between May 2009–December 2016, 64% were not screened or had only inadequate screening tests in the 5–40 months prior to diagnosis, and 90 of 182 screened women (49%) had only negative screens in this period. Only 32% (N = 162) of cervical cancers were screen-detected. Women with adenocarcinomas were more likely to have had a recent negative screen (41/57 = 722%) than women with squamous cancers (50/112 = 45%). Both older women (aged 45–64 years) and women with more advanced cancers were less likely to have been screened, and if screened, were more likely to have a false-negative outcome. Only 9% of cancers were diagnosed in women who did not attend biopsy or treatment after positive tests requiring clinical management. Screening currently prevents 35% of cancers, whereas full screening coverage could prevent 61% of cervical cancers. Conclusion Improved screening coverage has the largest potential for reducing cervical cancer incidence, though there is also a role for improved recall procedures and screening sensitivity., Highlights • 64% of women diagnosed with cervical cancer aged 25-64y had not been screened in the 3-years prior to diagnosis. • Screening currently prevents 35% of cancers; full screening coverage could prevent 61% of cancers. • One-third of cervical cancers were screen-detected (i.e. diagnosed within 4 months of a positive screen). • 72% of the adenocarcinomas had a negative screen in a 3-yr period prior to diagnosis. • 9% of cancers were associated with a failure to receive recommended diagnostic biopsy or treatment (failsafe failure).

Cervical cancer is widely preventable through screening, but little is known about the duration of protection offered by a negative screen in North America. A case–control study was conducted with records from population‐based registries in New Mexico. Cases were women diagnosed with cervical cancer in 2006–2016, obtained from the Tumor Registry. Five controls per case from the New Mexico HPV Pap Registry were matched to cases by sex, age and place of residence. Dates and results of all cervical screening and diagnostic tests since 2006 were identified from the pap registry. We estimated the odds ratio of nonlocalized (Stage II+) and localized (Stage I) cervical cancer associated with attending screening in the 3 years prior to case‐diagnosis compared to women not screened in 5 years. Of 876 cases, 527 were aged 25–64 years with ≥3 years of potential screening data. Only 38% of cases and 61% of controls attended screening in a 3‐year period. Women screened in the 3 years prior to diagnosis had 83% lower risk of nonlocalized cancer (odds ratio [OR] = 0.17, 95% CI: 0.12–0.24) and 48% lower odds of localized cancer (OR = 0.52, 95% CI: 0.38–0.72), compared to women not screened in the 5 years prior to diagnosis. Women remained at low risk of nonlocalized cancer for 3.5–5 years after a negative screen compared to women with no negative screens in the 5 years prior to diagnosis. Routine cervical screening is effective at preventing localized and nonlocalized cervical cancers; 3 yearly screening prevents 83% of nonlocalized cancers, with no additional benefit of more frequent screening. Increasing screening coverage remains essential to further reduce cervical cancer incidence., What's new? Screening is an effective means of preventing cervical cancer in women. However, while a negative screening result affords protection against cervical cancer, little is known about how long this protection lasts or when a woman should be screened again. Here, the authors estimate the impact of cervical screening at a state‐wide level, linking a U.S. population‐based screening registry with a SEER cancer registry. The results show that screening once every three years prevents 83 percent of stage 2+ cervical cancers, with no additional benefit from more frequent screening. The findings may help improve adherence to U.S. screening guidelines.

Background: Type II diabetes and certain diabetes treatments have been observed to impact breast cancer risk. However, their associations with different breast cancer molecular subtype defined by estrogen receptor (ER)/progesterone receptor (PR)/HER2 status are unclear. Methods: We conducted a retrospective multi-center population-based case–case study consisting of 4,557 breast cancer cases to evaluate the impact of type II diabetes and diabetes medications on the risk of different breast cancer molecular subtypes [ER+/HER2−, ER+/HER2+, triple negative (ER−/PR−/HER2−), and HER2 overexpressing (H2E, ER−/PR−/HER2+)]. Using ER+/HER2− cases as the reference group, we estimated ORs and corresponding 95% confidence intervals (CI) for each subtype using polytomous logistic regression. Results: Compared with those without a diabetes history, women with type II diabetes had a 38% (95% CI, 1.01–1.89) increased odds of triple-negative breast cancer (TNBC). Current and longer term recent metformin use (13–24 months of treatment within the 24-month period prior to breast cancer diagnosis) was associated with elevated odds of TNBC (OR = 1.54; 95% CI, 1.07–2.22 and OR = 1.80; 95% CI, 1.13–2.85, respectively). Conclusions: The odds of having a triple-negative rather than ER+/HER2− breast cancer is greater for women with type II diabetes, and particularly for those who were users of metformin. This finding is supported by some preclinical data suggesting that diabetes may be more strongly associated with risk of triple-negative disease. Impact: Our study provides novel evidence regarding potential differential effects of type II diabetes and metformin use on risk of different molecular subtypes of breast cancer.

PURPOSE: Improvements in colorectal cancer (CRC) prevention, early detection, and treatment have resulted in substantial gains in survival. However, the health-related quality of life (HRQoL) of CRC survivors often depends on access to supportive care, which differs by survivors’ socioeconomic characteristics. The purpose of this study was to investigate the relationship between socioeconomic characteristics and HRQoL in a diverse group of CRC survivors. METHODS: We conducted a population-based, cross-sectional study to examine the association between socioeconomic factors (household income, health literacy, and insurance status) and HRQoL domains of pain interference, fatigue, physical function, sleep disturbance, anxiety, and depression. PROMIS(®) Short Forms v.2.0 were used to assess domains of HRQoL. Linear regression modeling was used to estimate the coefficient representing the average HRQoL domain score and its 95% confidence interval (CI). RESULTS: Three-hundred-one CRC survivors participated in the survey. Low-income (≤$30,000) CRC survivors had, on average, a 4.70-point (95% CI 1.10-8.28) higher pain interference score, a 7.02-point (95% CI 3.27-10.77) higher fatigue score, a 5.13-point (95% CI −8.56 to −1.71) lower physical function score, and a 4.44-point (95% 1.40-7.49) higher depression score than CRC survivors with an income ≥$70,000. Survivors with Medicaid insurance reported significantly greater pain interference and worse physical function than privately-insured survivors. Survivors with low health literacy reported significantly greater pain interference compared to survivors with high health literacy. CONCLUSIONS: Substantial socioeconomic disparities in HRQoL were observed in this diverse population of CRC survivors. IMPLICATIONS FOR CANCER SURVIVORS: Designing supportive care interventions to improve HRQoL among low-income and Medicaid-insured CRC survivors is critical for eliminating disparities in CRC outcomes.

INTRODUCTION: Oral contraceptive use is a well-established risk factor for breast cancer and is common among reproductive-aged women in the United States. Its relationship with less common, more aggressive, molecular subtypes is less clear. METHODS: A population-based case-case analysis was conducted comparing three less common molecular subtypes to luminal A breast cancer among 1701 premenopausal cases aged 21–49 diagnosed with a first primary invasive breast cancer between 2004 and 2015. Medical record reviews and structured interviewer administered questionnaires were used to collect data on oral contraceptive use. Multinomial logistic regression was used to estimate odds ratios (OR) and corresponding 95% confidence intervals (95% CI) for recency of oral contraceptive use for each subtype of breast cancer. RESULTS: Current use of oral contraceptives and use within five years before diagnosis was associated with lower odds of H2E tumors compared to luminal A tumors [odds ratio (OR)=0.5, 95% confidence interval (CI): 0.3, 0.9 and OR=0.5, 95% CI: 0.4, 0.8, respectively] with increasing duration associated with decreasing odds (p for trend

Background The Pooled Uranium Miners Analysis (PUMA) study draws together information from cohorts of uranium miners from Canada, the Czech Republic, France, Germany and the USA. Methods Vital status and cause of death were ascertained and compared with expectations based upon national mortality rates by computing standardized mortality ratios (SMRs) overall and by categories of time since first hire, calendar period of first employment and duration of employment as a miner. Results There were 51 787 deaths observed among 118 329 male miners [SMR = 1.05; 95% confidence interval (CI): 1.04, 1.06]. The SMR was elevated for all cancers (n = 16 633, SMR = 1.23; 95% CI: 1.21, 1.25), due primarily to excess mortality from cancers of the lung (n = 7756, SMR = 1.90; 95% CI: 1.86, 1.94), liver and gallbladder (n = 549, SMR = 1.15; 95% CI: 1.06, 1.25), larynx (n = 229, SMR = 1.10; 95% CI: 0.97, 1.26), stomach (n = 1058, SMR = 1.08; 95% CI: 1.02, 1.15) and pleura (n = 39, SMR = 1.06; 95% CI: 0.75, 1.44). Lung-cancer SMRs increased with duration of employment, decreased with calendar period and persisted with time since first hire. Among non-malignant causes, the SMR was elevated for external causes (n = 3362, SMR = 1.41; 95% CI: 1.36, 1.46) and respiratory diseases (n = 4508, SMR = 1.32; 95% CI: 1.28, 1.36), most notably silicosis (n = 814, SMR = 13.56; 95% CI: 12.64, 14.52), but not chronic obstructive pulmonary disease (n = 1729, SMR = 0.98; 95% CI: 0.93, 1.02). Conclusions Whereas there are important obstacles to the ability to detect adverse effects of occupational exposures via SMR analyses, PUMA provides evidence of excess mortality among uranium miners due to a range of categories of cause of death. The persistent elevation of SMRs with time since first hire as a uranium miner underscores the importance of long-term follow-up of these workers.

Background Older cancer survivors are at risk of the development or worsening of both age- and treatment-related morbidity. Sedentary behavior increases the risk of or exacerbates these chronic conditions. Light-intensity physical activity (LPA) is more common in older adults and is associated with better health and well-being. Thus, replacing sedentary time with LPA may provide a more successful strategy to reduce sedentary time and increase physical activity. Objective This study primarily aims to evaluate the feasibility, acceptability, and preliminary efficacy of a home-based mobile health (mHealth) intervention to interrupt and replace sedentary time with LPA (standing and stepping). The secondary objective of this study is to examine changes in objective measures of physical activity, physical performance, and self-reported quality of life. Methods Overall, 54 cancer survivors (aged 60-84 years) were randomized in a 1:1:1 allocation to the tech support intervention group, tech support plus health coaching intervention group, or waitlist control group. Intervention participants received a Jawbone UP2 activity monitor for use with their smartphone app for 13 weeks. Tech support and health coaching were provided via 5 telephone calls during the 13-week intervention. Sedentary behavior and physical activity were objectively measured using an activPAL monitor for 7 days before and after the intervention. Results Participants included survivors of breast cancer (21/54, 39%), prostate cancer (16/54, 30%), and a variety of other cancer types; a mean of 4.4 years (SD 1.6) had passed since their cancer diagnosis. Participants, on average, were 70 years old (SD 4.8), 55% (30/54) female, 24% (13/54) Hispanic, and 81% (44/54) overweight or obese. Malfunction of the Jawbone trackers occurred in one-third of the intervention group, resulting in enrollment stopping at 54 rather than the initial goal of 60 participants. Despite these technical issues, the retention in the intervention was high (47/54, 87%). Adherence was high for wearing the tracker (29/29, 100%) and checking the app daily (28/29, 96%) but low for specific aspects related to the sedentary features of the tracker and app (21%-25%). The acceptability of the intervention was moderately high (81%). There were no significant between-group differences in total sedentary time, number of breaks, or number of prolonged sedentary bouts. There were no significant between-group differences in physical activity. The only significant within-group change occurred within the health coaching group, which increased by 1675 daily steps (95% CI 444-2906; P=.009). This increase was caused by moderate-intensity stepping rather than light-intensity stepping (+15.2 minutes per day; 95% CI 4.1-26.2; P=.008). Conclusions A home-based mHealth program to disrupt and replace sedentary time with stepping was feasible among and acceptable to older cancer survivors. Future studies are needed to evaluate the optimal approach for replacing sedentary behavior with standing and/or physical activity in this population. Trial Registration ClinicalTrials.gov NCT03632694; https://clinicaltrials.gov/ct2/show/NCT03632694

Background Occupational exposures in mining and oil/gas extraction are known risk factors for thoracic malignancies (TMs). Given the relatively high proportion of these industries in New Mexico (NM), we conducted a feasibility study of adult lifetime occupational history among TM cases. We hypothesized a higher proportion of occupational TM in NM relative to the estimated national average of 10-14%. Methods We identified incident TM cases through the population-based New Mexico Tumor Registry (NMTR), from 2017- 2018. Cases completed a telephone interview. An adjudication panel reviewed case histories and classified cancers as probable, possible, or non-occupational related, taking into account the presence, duration, and latency of exposures. We characterized recruitment and describe job titles and exposures among those with occupational TMs. We also compared the distributions of industry between those with and without occupational TM. Results The NMTR identified 400 eligible TM cases, 290 of which were available to be recruited (n=285 lung/bronchial cancer; n=5 mesotheliomas). Of the latter, 60% refused and 18% were deceased, 9% had invalid addresses, 11% were unable to be reached by telephone, and 3% were too ill to participate. The 43 cases who completed an interview held 236 jobs. A total of 33% of cases were classified as probable occupational TM and 5% as possible occupational TM. Conclusions High rates of early mortality and refusals were significant barriers to study participation. Nonetheless, the proportion of probable occupational TMs greatly exceeded the estimated national average, highlighting the need for further study of occupational TM in the state.

Background Survivorship care plans (SCPs) summarize patients’ treatment and act as an education and communication tool between oncologists and primary care providers (PCPs). But creation and delivery of SCPs are challenging, labor intensive, and costly. The University of New Mexico Comprehensive Cancer Center (UNM CCC) treats a poor, rural, and minority patient population, and our purpose was to implement and evaluate a process to create and deliver SCPs to patients and PCPs. Methods Providers placed an electronic SCP order, basic information was imported, and staff compiled treatment details. Flagged SCPs were then ready for delivery, providers approved of and delivered the SCP at the next encounter, and the SCP was sent to the PCP. Results By April 2020, 283 SCPs were ordered, 241 (85.2%) were created by the designated staff, and 97 (34.2%) were given to patients after definitive therapy for breast cancer (59.1%), gynecological cancers (10.8%), prostate cancer (7.4%), colorectal cancer (5.1%), and lymphomas (4.8%). Of 97 SCPs eligible to be sent to PCPs, 75 (77.3%) were mailed or sent via EMR. Of the 41 (48.9%) SCPs sent via mail or fax, only 8 (8.3%) were received and 5 (5.2%) integrated. Conclusions This study shows that SCPs can be delivered to patients in a poor, rural, and minority patient population but that PCP receipt and integration of SCPs are poor. Future efforts need to ensure that an oncologist to PCP education and communication tool is able reach and be integrated by PCPs.

PURPOSE: Financial hardship is increasingly understood as a negative consequence of cancer and its treatment. As patients with cancer face financial challenges, they may be forced to make a trade-off between food and medical care. We characterized food insecurity and its relationship to treatment adherence in a population-based sample of cancer survivors. METHODS: Individuals 21 to 64 years old, diagnosed between 2008 and 2016 with stage I-III breast, colorectal, or prostate cancer were identified from the New Mexico Tumor Registry and invited to complete a survey, recalling their financial experience in the year before and the year after cancer diagnosis. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95%CIs. RESULTS: Among 394 cancer survivors, 229 (58%) were food secure in both the year before and the year after cancer diagnosis (persistently food secure), 38 (10%) were food secure in the year before and food insecure in the year after diagnosis (newly food insecure), and 101 (26%) were food insecure at both times (persistently food insecure). Newly food-insecure (OR, 2.82; 95% CI, 1.02 to 7.79) and persistently food-insecure (OR, 3.04; 95% CI,1.36 to 6.77) cancer survivors were considerably more likely to forgo, delay, or make changes to prescription medication than persistently food-secure survivors. In addition, compared with persistently food-secure cancer survivors, newly food-insecure (OR, 9.23; 95% CI, 2.90 to 29.3), and persistently food-insecure (OR, 9.93; 95% CI, 3.53 to 27.9) cancer survivors were substantially more likely to forgo, delay, or make changes to treatment other than prescription medication. CONCLUSION: New and persistent food insecurity are negatively associated with treatment adherence. Efforts to screen for and address food insecurity among individuals undergoing cancer treatment should be investigated as a strategy to reduce socioeconomic disparities in cancer outcomes.

ObjectivesEpidemiological studies of underground miners have provided clear evidence that inhalation of radon decay products causes lung cancer. Moreover, these studies have served as a quantitative basis for estimation of radon-associated excess lung cancer risk. However, questions remain regarding the effects of exposure to the low levels of radon decay products typically encountered in contemporary occupational and environmental settings on the risk of lung cancer and other diseases, and on the modifiers of these associations. These issues are of central importance for estimation of risks associated with residential and occupational radon exposures.MethodsThe Pooled Uranium Miner Analysis (PUMA) assembles information on cohorts of uranium miners in North America and Europe. Data available include individual annual estimates of exposure to radon decay products, demographic and employment history information on each worker and information on vital status, date of death and cause of death. Some, but not all, cohorts also have individual information on cigarette smoking, external gamma radiation exposure and non-radiological occupational exposures.ResultsThe PUMA study represents the largest study of uranium miners conducted to date, encompassing 124 507 miners, 4.51 million person-years at risk and 54 462 deaths, including 7825 deaths due to lung cancer. Planned research topics include analyses of associations between radon exposure and mortality due to lung cancer, cancers other than lung, non-malignant disease, modifiers of these associations and characterisation of overall relative mortality excesses and lifetime risks.ConclusionPUMA provides opportunities to evaluate new research questions and to conduct analyses to assess potential health risks associated with uranium mining that have greater statistical power than can be achieved with any single cohort.

Background: Cancer survivors increasingly report financial hardship as a consequence of the high cost of cancer care, yet the financial experience of rural cancer survivors remains largely unstudied. The purpose of this study was to investigate potential rural disparities in the likelihood of financial hardship and nonadherence to surveillance colonoscopy. Methods: Individuals diagnosed with localized or regional colorectal cancer between 2004 and 2012 were ascertained by the population-based New Mexico Tumor Registry. Participants completed a mailed questionnaire or telephone survey about their colorectal cancer survivorship experience, including treatment-related financial hardship and receipt of surveillance colonoscopy. Multivariable logistic regression was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Results: Compared with urban colorectal cancer survivors (n = 168), rural colorectal cancer survivors (n = 109) were slightly older; more likely to be married (65% vs. 59%) and have an annual income Conclusions: Substantial rural disparities in the likelihood of financial hardship and nonadherence to surveillance colonoscopy exist. Impact: Treatment-related financial hardship among rural colorectal cancer survivors may negatively affect adherence to guideline-recommended follow-up care. Cancer Epidemiol Biomarkers Prev; 27(11); 1275–82. ©2018 AACR.

Background Although national guidelines for cancer genetic risk assessment (CGRA) for hereditary breast and ovarian cancer (HBOC) have been available for over two decades, less than half of high-risk women have accessed these services, especially underserved minority and rural populations. Identification of high-risk individuals is crucial for cancer survivors and their families to benefit from biomedical advances in cancer prevention, early detection, and treatment. Methods This paper describes community-engaged formative research and the protocol of the ongoing randomized 3-arm controlled Genetic Risk Assessment for Cancer Education and Empowerment (GRACE) trial. Ethnically and geographically diverse breast and ovarian cancer survivors at increased risk for hereditary cancer predisposition who have not had a CGRA are recruited through the three statewide cancer registries. The specific aims are to: 1) compare the effectiveness of a targeted intervention (TP) vs. a tailored counseling and navigation(TCN) intervention vs. usual care (UC) on CGRA utilization at 6 months post-diagnosis (primary outcome); compare the effectiveness of the interventions on genetic counseling uptake at 12 months after removal of cost barriers (secondary outcome); 2) examine potential underlying theoretical mediating and moderating mechanisms; and 3) conduct a cost evaluation to guide dissemination strategies. Discussion The ongoing GRACE trial addresses an important translational gap by developing and implementing evidence-based strategies to promote guideline-based care and reduce disparities in CGRA utilization among ethnically and geographically diverse women. If effective, these interventions have the potential to reach a large number of high-risk families and reduce disparities through broad dissemination. Trial registration number: NCT03326713 ; clinicaltrials.gov .

Background: For individuals with hepatocellular carcinoma (HCC), type of insurance may be an important prognostic factor because of its impact on access to care. This study investigates the relationship between insurance type at diagnosis and stage-specific survival. Methods: This retrospective cohort analysis used data from 18 Surveillance, Epidemiology, and End Results Program cancer registries. Individuals ages 20 to 64 years, diagnosed with primary HCC between 2010 and 2015, with either private, Medicaid, or no insurance were eligible for cohort inclusion. Adjusted Cox proportional-hazards regression models were used to generate HRs and 95% confidence intervals (CI) for associations between insurance type at diagnosis and overall survival. All models were stratified by stage at diagnosis. Results: This analysis included 14,655 cases. Compared with privately insured individuals with the same stage of disease, those with Medicaid had a 43% (HR = 1.43; 95% CI, 1.13–1.32), 22% (HR = 1.22; 95% CI, 1.13–1.32), and 7% higher risk of death for localized, regional, and distant stage, respectively. Uninsured individuals had an 88% (HR = 1.88; 95% CI, 1.65–2.14), 59% (HR = 1.59; 95% CI, 1.41–1.80), and 35% (HR = 1.35; 95% CI, 1.18–1.55) higher risk of death for localized, regional, and distant stage, respectively, compared with privately insured individuals. Conclusions: Disparities in survival exist by the type of insurance that individuals with HCC have at the time of diagnosis. Impact: These findings support the need for additional research on access to and quality of cancer care for Medicaid and uninsured patients.

Epidemiological evidence is limited on how alcohol consumption and smoking are associated with risk of different subtypes of breast cancer, such as triple-negative (TN) and human epidermal growth factor receptor 2-overexpressing (H2E) breast cancers, which may have different etiologies from more common luminal (estrogen receptor [ER+]) breast cancers. In this population-based case-case study, we evaluated the association between alcohol, smoking, and risk of H2E and TN breast cancer, compared with ER+ breast cancers, among women aged 20-69 years. Using polytomous regression, associations between alcohol consumption, smoking, and breast cancer risk were evaluated in 909 ER+, 1,290 TN, and 489 H2E breast cancer patients, with ER+ breast cancer patients as the reference group. Current alcohol consumption at diagnosis was associated with a lower risk of H2E breast cancer (odds ratio = 0.74, 95% confidence interval: 0.58-0.92) relative to ER+ cancers. No difference in association was observed by menopausal status. No association between alcohol consumption and TN breast cancer relative to ER+ breast cancer was observed. Women who smoked did not have an altered risk of TN or H2E breast cancer, relative to ER+ cancer. Our results suggest that alcohol is associated with lower risk of H2E breast cancer relative to ER+ breast cancer. This study adds to the body of epidemiologic evidence that breast cancer etiology differs by breast cancer subtype.

PURPOSE: To evaluate liver cancer incidence rates and risk factor correlations in non-Hispanic AI/AN populations for the years 1999–2009. METHODS: We linked data from 51 central cancer registries with the Indian Health Service patient registration databases to improve identification of the AI/AN population. Analyses were restricted to non-Hispanic persons living in Contract Health Service Delivery Area counties. We compared age-adjusted liver cancer incidence rates (per 100,000) for AI/AN to white populations using rate ratios. Annual percent changes (APCs) and trends were estimated using joinpoint regression analyses. We evaluated correlations between regional liver cancer incidence rates and risk factors using Pearson correlation coefficients. RESULTS: AI/AN persons had higher liver cancer incidence rates than whites overall (11.5 versus 4.8, RR = 2.4, 95% CI 2.3– 2.6). Rate ratios ranged from 1.6 (Southwest) to 3.4 (Northern Plains and Alaska). We observed an increasing trend among AI/AN persons (APC 1999–2009 = 5%). Rates of distant disease were higher in the AI/AN versus white population for all regions except Alaska. Alcohol use (r = 0.84) and obesity (r = 0.79) were correlated with liver cancer incidence by region. CONCLUSIONS: Findings highlight disparities in liver cancer incidence between AI/AN and white populations and emphasize opportunities to decrease liver cancer risk factor prevalence.

BACKGROUND Recent cancer survival trends among American Indian and Alaska Native (AN) people are not well understood; survival has not been reported among AN people since 2001. METHODS This study examined cause-specific survival among AN cancer patients for lung, colorectal, female breast, prostate, and kidney cancers. It evaluated whether survival differed between cancers diagnosed in 1992-2002 (the earlier period) and cancers diagnosed in 2003-2013 (the later period) and by the age at diagnosis (

BACKGROUND: Overall, cervical cancer survival in the United States has been reported to be among the highest in the world, despite slight decreases over the last decade. Objective of the current study was to describe cervical cancer survival trends among US women and examine differences by race and stage. METHODS: This study used data from the CONCORD-2 study to compare survival among women (aged 15-99 years) diagnosed in 37 states covering 80% of the US population. Survival was adjusted for background mortality (net survival) with state- and race-specific life tables and was age-standardized with the International Cancer Survival Standard weights. Five-year survival was compared by race (all races, blacks, and whites). Two time periods, 2001-2003 and 2004-2009, were considered because of changes in how the staging variable was collected. RESULTS: From 2001 to 2009, 90,620 women were diagnosed with invasive cervical cancer. The proportion of cancers diagnosed at a regional or distant stage increased over time in most states. Overall, the 5-year survival was 63.5% in 2001-2003 and 62.8% in 2004-2009. The survival was lower for black women versus white women in both calendar periods and in most states; black women had a higher proportion of distant-stage cancers. CONCLUSIONS: The stability of the overall survival over time and the persistent differences in survival between white and black women in all US states suggest that there is a need for targeted interventions and improved access to screening, timely treatment, and follow-up care, especially among black women. Cancer 2017;123:5119-37. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

While the estrogen receptor (ER) is the single most widely used biomarker to evaluate breast cancer outcomes, aspects of ER marker biology remain poorly understood. We sought to determine whether quantitative measures of ER, such as protein expression and intensity, were associated with survival, or with survival disparities experienced by Hispanic women. A case-cohort study included a 15% random sample of invasive breast cancer cases diagnosed from 1997 to 2009 in six New Mexico counties and all deaths due to breast cancer-related causes. Pathology reports and tissue microarrays served as sources of ER information. Analyses were restricted to women with ≥1% ER immunohistochemical staining. Hazard ratios (HR) and 95% confidence intervals (CI) for breast cancer death were estimated using Cox proportional hazards models. Included women represented 4336 ER+ breast cancer cases and 448 deaths. Median follow-up was 93 months. ER percent expression was not associated with breast cancer survival after adjustment for standard prognostic factors (p trend = 0.76). ER intensity remained a strong and independent risk factor for breast cancer survival in multivariate analyses: Women whose tumors expressed ER at intensity = 2 (HR 0.6; 95% CI 0.4–1.0) or 3 (HR 0.5; 95% CI 0.2–0.9) had a reduced risk of breast cancer mortality, compared to ER intensity = 1 (p trend = 0.02). Neither ER protein expression nor intensity influenced Hispanic survival disparities. Estrogen receptor percent positive staining is not independently related to breast cancer survival after adjustment for other survival-related factors. ER intensity, in contrast, demonstrates promise for prognostic utility.

Introduction: In New Mexico, Hispanic women have a 1.7-fold increased risk of breast cancer-specific death compared to non-Hispanic white women. In previous studies, race/ethnic minority women have had larger survival disparities in estrogen receptor positive (ER+) than ER- disease, suggesting some aspect of ER may mediate survival outcomes. We thus conducted an extensive assessment of ER quantitative measures. Objective: To determine whether ER percent positive and intensity differs by ethnicity, and to evaluate whether that potential difference might account for a proportion of survival disparities. Methods: We conducted a population-based case-cohort study of first invasive breast cancer diagnosed in white females from 1997-2009 in six NM counties, identified through Surveillance Epidemiology End Results (SEER). We selected 15% of breast cancer cases and all breast cancer deaths through 2012. After IRB approval, pathology reports and tissue microarrays served as sources of ER, PR, and Her2 information. Tumors were classified according to modified intrinsic subtypes based on immunohistochemistry. Data were analyzed using Cox proportional hazards models adapted for case-cohort with weighted estimates (cohort weighted by 6.67x), and estimated hazard ratios (HR) and 95% confidence intervals (CI) using the robust variance and alpha=.05. The proportional hazards assumption was verified by Schoenfeld residuals. All analyses were adjusted for age. Interaction was assessed by inclusion of main effects and a product term (subtype* exposure). Results: ER and intrinsic subtype information was available for 76% of the cohort (867/1143) and 70% of breast cancer deaths (689/991). Median follow up was 7.8 years. In analyses stratified by intrinsic subtype, Hispanic women experienced elevated mortality relative to non-Hispanic whites for luminal A (HR 1.9;95% CI 1.4-2.6), Luminal B (HR 2.9;95% CI 1.5-5.7), and TN tumors (HR 1.9;95% CI 1.0-3.6) but not Her2+ER- disease (HR 1.1;95% 0.3-3.4). Overall ER Quantitative measures: Among ER+ women, breast cancer mortality decreased with increasing ER+ staining, measured by percent (p-trend=.004) or quartile (p-trend=.002). After adjustment for ER percent(ER%+), women with increased ER intensity (score>2) had reduced mortality, relative to score=1 (HR 0.6;95% CI 0.4-.1.0). Results did not differ by Luminal A or B subtype (p interaction> .05). Ethnicity-specific ER quantitative measures: ER%+ distribution did not differ by Hispanic ethnicity. However, among Hispanic women, interaction terms for ER%+ (p=.04) or quartile (p=.08) by subtype in relation to breast cancer survival suggest that Hispanic women with increasing ER staining have a reduced risk of mortality in Luminal A but not Luminal B tumors. Such differences were not evident among non-Hispanic white women. In multivariate models, inclusion of ER%+ and staining intensity did not alter Hispanic survival disparity overall, but mediated 8.6% in Luminal B. Conclusion: After inclusion of ER%+, ER staining intensity is an independent risk factor for breast cancer survival. Differences in ER quantitative measures appear to account for only a small proportion of survival disparities. Survival gaps in ER+ breast cancer may be attributable to host or other tumor factors.Introduction: In New Mexico, Hispanic women have a 1.7-fold increased risk of breast cancer-specific death compared to non-Hispanic white women. In previous studies, race/ethnic minority women have had larger survival disparities in estrogen receptor positive (ER+) than ER- disease, suggesting some aspect of ER may mediate survival outcomes. We thus conducted an extensive assessment of ER quantitative measures. Objective: To determine whether ER percent positive and intensity differs by ethnicity, and to evaluate whether that potential difference might account for a proportion of survival disparities. Methods: We conducted a population-based case-cohort study of first invasive breast cancer diagnosed in white females from 1997-2009 in six NM counties, identified through Surveillance Epidemiology End Results (SEER). We selected 15% of breast cancer cases and all breast cancer deaths through 2012. After IRB approval, pathology reports and tissue microarrays served as sources of ER, PR, and Her2 information. Tumors were classified according to modified intrinsic subtypes based on immunohistochemistry. Data were analyzed using Cox proportional hazards models adapted for case-cohort with weighted estimates (cohort weighted by 6.67x), and estimated hazard ratios (HR) and 95% confidence intervals (CI) using the robust variance and alpha=.05. The proportional hazards assumption was verified by Schoenfeld residuals. All analyses were adjusted for age. Interaction was assessed by inclusion of main effects and a product term (subtype* exposure). Results: ER and intrinsic subtype information was available for 76% of the cohort (867/1143) and 70% of breast cancer deaths (689/991). Median follow up was 7.8 years. In analyses stratified by intrinsic subtype, Hispanic women experienced elevated mortality relative to non-Hispanic whites for luminal A (HR 1.9;95% CI 1.4-2.6), Luminal B (HR 2.9;95% CI 1.5-5.7), and TN tumors (HR 1.9;95% CI 1.0-3.6) but not Her2+ER- disease (HR 1.1;95% 0.3-3.4). Overall ER Quantitative measures: Among ER+ women, breast cancer mortality decreased with increasing ER+ staining, measured by percent (p-trend=.004) or quartile (p-trend=.002). After adjustment for ER percent(ER%+), women with increased ER intensity (score>2) had reduced mortality, relative to score=1 (HR 0.6;95% CI 0.4-.1.0). Results did not differ by Luminal A or B subtype (p interaction> .05). Ethnicity-specific ER quantitative measures: ER%+ distribution did not differ by Hispanic ethnicity. However, among Hispanic women, interaction terms for ER%+ (p=.04) or quartile (p=.08) by subtype in relation to breast cancer survival suggest that Hispanic women with increasing ER staining have a reduced risk of mortality in Luminal A but not Luminal B tumors. Such differences were not evident among non-Hispanic white women. In multivariate models, inclusion of ER%+ and staining intensity did not alter Hispanic survival disparity overall, but mediated 8.6% in Luminal B. Conclusion: After inclusion of ER%+, ER staining intensity is an independent risk factor for breast cancer survival. Differences in ER quantitative measures appear to account for only a small proportion of survival disparities. Survival gaps in ER+ breast cancer may be attributable to host or other tumor factors. Citation Format: Hill D, Royce M, Lomo L, Barry M, Kang H, Wiggins C, Prossnitz E. Estrogen receptor quantitative measures and differences in breast cancer survival [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-10-08.

Background: Multiple Myeloma is a plasma cell neoplasm which is characterized by an increase in monoclonal proteins or light chains and end-organ damage. Multiple Myeloma accounts for 1.8% of all new cancer cases in the United States, with an estimated 32,110 new cases annually. In population-based studies, African Americans have a higher incidence of Myeloma and inferior outcomes when compared to Caucasians. Disparities in the incidence of Myeloma for other races in the United States also exist but are not well studied.(1). Analyses of Surveillance, Epidemiology, and End Results program (SEER) data showed that Hispanics had poor or delayed access to novel agents and transplant, and poor overall survival.(2). Data for Native Americans was not reported due to small or insignificant numbers. New Mexico is a majority minority state, with approximately 1 million Hispanics residing in the state, constituting 49.1% of the total population and the largest statewide percentage of Hispanic residents nationally. (3) New Mexico also has a sizable population of 219,237 Native Americans, who make-up nearly 10.5% of the state's entire population. (3) Hence, the significant minority population in New Mexico allows the comparison of incidence between racial and ethnic subgroups as well as disease specific survival of Myeloma in New Mexico residents using the New Mexico Tumor Registry. Methods: We utilized data from the New Mexico Tumor Registry to study patients with a documented diagnosis of Myeloma. Descriptive statistics including the incidence rates of myeloma and Kaplan-Meier product-limit methods to assess cause-specific survival for incident myeloma cases diagnosed among New Mexico residents during the time period 2008-2017. Other variables including transplantation rates were also studied but are not reported in this abstract. Results: Men had higher incidence of Myeloma compared to females (p Conclusion: Racial-ethnic differences in incidence and disease specific survival of Multiple Myeloma were evident but were not statistically significant in New Mexico, except incidence of Multiple Myeloma among Hispanic females compared to Non-Hispanic white females. Further study of disease-related factors (high risk disease, mutational profiles, stage at diagnosis) and patient-related factors (access to standard treatments, transplantation or clinical trials) may be needed to understand these differences and better care for the patients. Disclosures Andritsos: Innate Pharma: Consultancy, Honoraria.

Background: Cancer incidence rates for American Indian and Alaska Native (AI/AN) populations vary by geographic region in the United States. The purpose of this study is to examine cancer incidence rates and trends in the AI/AN population compared with the non-Hispanic white population in the United States for the years 2010 to 2015. Methods: Cases diagnosed during 2010 to 2015 were identified from population-based cancer registries and linked with the Indian Health Service (IHS) patient registration databases to describe cancer incidence rates in non-Hispanic AI/AN persons compared with non-Hispanic whites (whites) living in IHS purchased/referred care delivery area counties. Age-adjusted rates were calculated for the 15 most common cancer sites, expressed per 100,000 per year. Incidence rates are presented overall as well as by region. Trends were estimated using joinpoint regression analyses. Results: Lung and colorectal cancer incidence rates were nearly 20% to 2.5 times higher in AI/AN males and nearly 20% to nearly 3 times higher in AI/AN females compared with whites in the Northern Plains, Southern Plains, Pacific Coast, and Alaska. Cancers of the liver, kidney, and stomach were significantly higher in the AI/AN compared with the white population in all regions. We observed more significant decreases in cancer incidence rates in the white population compared with the AI/AN population. Conclusions: Findings demonstrate the importance of examining cancer disparities between AI/AN and white populations. Disparities have widened for lung, female breast, and liver cancers. Impact: These findings highlight opportunities for targeted public health interventions to reduce AI/AN cancer incidence.

PURPOSE: Lifestyle factors may have a synergistic effect on health. We evaluated the correlates of poor adherence to a healthy lifestyle among a diverse sample of colorectal cancer (CRC) survivors to inform future lifestyle promotion programs. METHODS: Lifestyle questions from a cross-sectional survey were completed by 283 CRC survivors (41% Hispanic, 40% rural; 33% low income). Adherence to recommendations (yes/no) for physical activity, fruit and vegetable servings/day, avoiding tobacco, and healthy weight were summed to create an overall lifestyle quality score. Polytomous logistic regression was used to evaluate correlates of good (reference group), moderate and poor overall lifestyle quality. Potential correlates included sociodemographic characteristics, cancer-related factors, and indicators of health and well-being. RESULTS: CRC survivors with poor adherence were 2- to 3.4-fold significantly more likely to report multiple comorbidities, poor physical functioning, fatigue, anxiety/depressive symptoms, and poor social participation. In multivariable analyses, poor physical functioning was the only significant correlate of poor adherence to lifestyle recommendations, compared to good adherence (OR [95% CI] =3.4 [1.8–6.4]). The majority of survivors, 71% and 78%, indicated interest in receiving information on exercise and eating a healthy diet, respectively. CONCLUSION: Future lifestyle promotion programs for CRC survivors should carefully consider indicators of physical and psychosocial health and well-being, especially poor physical functioning, in the design, recruitment, and implementation of these health programs.

Obesity exerts adverse effects on breast cancer survival, but the means have not been fully elucidated. We evaluated obesity as a contributor to breast cancer survival according to tumor molecular subtypes in a population-based case–cohort study using data from the Surveillance Epidemiology and End Results (SEER) program. We determined whether obese women were more likely to be diagnosed with poor prognosis tumor characteristics and quantified the contribution of obesity to survival. Hazard ratios (HRs) and 95% confidence intervals (CI) were calculated via Cox multivariate models. The effect of obesity on survival was evaluated among 859 incident breast cancers (subcohort; 15% random sample; median survival 7.8 years) and 697 deaths from breast cancer (cases; 100% sample). Obese women had a 1.7- and 1.8-fold increased risk of stage III/IV disease and grade 3/4 tumors, respectively. Obese women with Luminal A- and Luminal B-like breast cancer were 1.8 (95% CI 1.3–2.5) and 2.2 (95% CI 0.9–5.0) times more likely to die from their cancer compared to normal weight women. In mediation analyses, the proportion of excess mortality attributable to tumor characteristics was 36.1% overall and 41% and 38% for Luminal A- and Luminal B-like disease, respectively. Obesity was not associated with breast cancer-specific mortality among women who had Her2-overexpressing or triple-negative tumors. Obesity may influence hormone-positive breast cancer-specific mortality in part through fostering poor prognosis tumors. When tumor biology is considered as part of the causal pathway, the public health impact of obesity on breast cancer survival may be greater than previously estimated.

Background: Reproductive factors are among the most well-established risk factors for breast cancer. However, their associations with different breast cancer subtypes defined by joint estrogen receptor (ER)/progesterone receptor (PR)/HER2 status remain unclear. Methods: We assessed relationships between reproductive factors and risks of luminal A (ER+/HER2−), luminal B (ER+/HER2+), triple-negative (TN; ER−/PR−/HER2−), and HER2-overexpressing (H2E; ER−/HER2+) breast cancers in a population-based case–case study consisting of 2,710 women ages 20–69 years diagnosed between 2004 and 2012. ORs and 95% confidence intervals (CI) were estimated with luminal A cases serving as the reference group using polytomous logistic regression. Results: Earlier age at first full-term pregnancy and age at menopause were positively associated with odds of TN breast cancer (Ptrend: 0.003 and 0.024, respectively). Parity was associated with a 43% (95% CI, 1.08–1.89) elevated odds of H2E breast cancer, and women who had ≥3 full-term pregnancies had a 63% (95% CI, 1.16–2.29, Ptrend = 0.013) increased odds of this subtype compared with nulliparous women. Breast feeding for ≥36 months was associated with a 49% (OR 0.51; 95% CI, 0.27–0.99) lower odds of TN breast cancer. Conclusion: Our results suggest that reproductive factors contribute differently to risks of the major molecular subtypes of breast cancer. Impact: African American and Hispanic women have higher incidence rates of the more aggressive TN and H2E breast cancers and their younger average age at first pregnancy, higher parity, and less frequent breast feeding could in part contribute to this disparity. Cancer Epidemiol Biomarkers Prev; 25(9); 1297–304. ©2016 AACR.

Triple negative (TN, tumors that do not express estrogen receptor (ER), progesterone receptor (PR), or human epidermal growth factor receptor 2 (HER2)) and HER2-overexpressing (H2E, ER-/HER2+) tumors are two particularly aggressive subtypes of breast cancer. There is a lack of knowledge regarding the etiologies of these cancers and in particular how anthropometric factors are related to risk. We conducted a population-based case-case study consisting of 2659 women aged 20-69 years diagnosed with invasive breast cancer from 2004 to 2012. Four case groups defined based on joint ER/PR/HER2 status were included: TN, H2E, luminal A (ER+/HER2-), and luminal B (ER+/HER2+). Polytomous logistic regression was used to estimate odds ratios (ORs) and associated 95 % confidence intervals (CIs) where luminal A patients served as the reference group. Obese premenopausal women [body mass index (BMI) ≥30 kg/m(2)] had an 82 % (95 % CI 1.32-2.51) increased risk of TN breast cancer compared to women whose BMI25 kg/m(2), and those in the highest weight quartile (quartiles were categorized based on the distribution among luminal A patients) had a 79 % (95 % CI 1.23-2.64) increased risk of TN disease compared to those in the lowest quartile. Among postmenopausal women obesity was associated with reduced risks of both TN (OR = 0.74, 95 % CI 0.54-1.00) and H2E (OR = 0.47, 95 % CI 0.32-0.69) cancers. Our results suggest obesity has divergent impacts on risk of aggressive subtypes of breast cancer in premenopausal versus postmenopausal women, which may contribute to the higher incidence rates of TN cancers observed among younger African American and Hispanic women.

Background: The advent of PSA testing in the late 1980s substantially increased prostate cancer incidence rates. Concerns about overscreening and overdiagnosis subsequently led professional guidelines (circa 2000 and later) to recommend against routine PSA testing. We evaluated trends in prostate cancer incidence, including late-stage diagnoses, from 1995 through 2012. Methods: We used joinpoint regression analyses to evaluate all-, localized/regional-, and distant-stage prostate cancer incidence trends based on Surveillance, Epidemiology, and End Results (SEER) data. We stratified analyses by age (50–69, 70+). We reported incidence trends as annual percent change (APC). Results: Overall age-adjusted incidence rates for localized/regional stage prostate cancer have been declining since 2001, sharply from 2010 to 2012 [APC, −13.1; 95% confidence intervals (CI), −23.5 to −1.3]. Distant-stage incidence rates have declined since 1995, with greater declines from 1995 to 1997 (APC, −8.4; 95% CI, −2.3 to −14.1) than from 2003 to 2012 (APC, −1.0; 95% CI, −1.7 to −0.4). Distant-stage incidence rates declined for men ages 70+ from 1995 to 2012, but increased in men ages 50 to 69 years from 2004 to 2012 (APC, 1.7; 95% CI, 0.2 to 3.2). Conclusions: Guidelines discouraging routine prostate cancer screening were temporally associated with declining localized/regional prostate cancer incidence rates; however, incidence rates of distant-stage disease are now increasing in younger men. Impact: This trend may adversely affect prostate cancer mortality rates. Cancer Epidemiol Biomarkers Prev; 25(2); 259–63. ©2015 AACR.

Background: Financial well-being (FWB) is defined by an individual’s ability to fully meet current and ongoing financial obligations, secure their financial future, and make choices that allow them to enjoy life. High out-of-pocket costs, and lost income following a cancer diagnosis and treatment, are associated with negative financial outcomes for many cancer patients and their families. Unsurprisingly, those who start off with the fewest resources are particularly vulnerable to the financial shock of cancer. What is not known, however, is how FWB changes over time for socioeconomically vulnerable individuals or how changes in FWB following a cancer diagnosis are related to clinical outcomes. Methods: We conducted a cross-sectional survey of stage I-III breast, colorectal, and prostate cancer survivors, age 21-64 years, diagnosed between 2008 and 2016, and identified from the population-based New Mexico Tumor Registry. Participants were asked to recall their financial situation at three time points: 1) in the year prior to cancer diagnosis, 2) in the year post-diagnosis, and 3) at the time of the survey. FWB was ascertained at all three of these time points using the validated Consumer Financial Protection Bureau Financial Well Being Scale (0-100; US Population Average=54) and mental and physical QoL were determined using PROMIS measures. Propensity score weighted multivariable linear regression was used to identify factors associated with changes in FWB over time and to estimate relationships between changes in FWB and mental and physical QoL. Results: A total of 394 cancer survivors completed the survey (response rate 33%; mean age 51y, mean time since diagnosis 6y, 42% Hispanic, 52% ≤ high school degree, 22% Medicaid-insured, 31% income Citation Format: Jean A. McDougall, Jessica Anderson, Shoshana Adler Jaffe, Charles L. Wiggins, Angela L. Meisner, Dolores D. Guest, Andrew L. Sussman, V. Shane Pankratz. Financial well-being and quality of life following a cancer diagnosis: A focus on socioeconomic disparities [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A120.

Background: Cancer and its treatment interfere with employment, often leading to prolonged leave, changes in hours, and reduced productivity. Socioeconomic disparities in employment outcomes have been documented previously, but the relationship between employment outcomes following a cancer diagnosis and long-term financial well-being (FWB) is poorly understood. The objectives of this analysis were to identify patient sociodemographic characteristics associated with negative changes in employment and productivity and to explore the relationship between these changes and FWB. Methods: In this cross-sectional study, working-age individuals diagnosed with stage I-III breast, colorectal, or prostate cancer were sampled from the New Mexico Tumor Registry. Participants completed a survey about their economic experience at three different time points (the year prior to cancer diagnosis, the year after diagnosis, and at the time of the survey). Changes in self-reported employment status and productivity were ascertained using validated questions from the Medical Expenditure Panel Survey Experiences with Cancer Supplement. FWB was characterized using the Financial Well-Being Scale (0-100) from the Consumer Financial Protection Bureau. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association between sociodemographic characteristics and employment changes or productivity. Multivariable linear regression with propensity score weighting was used to model the relationship between changes in employment, changes in productivity, and FWB. Results: A total of 292 employed cancer survivors completed the survey (median age 51, female 68%, Hispanic 37%, rural 33%). Survivors who reported a change in employment (n=236, 80%), were more likely to be Hispanic v. non-Hispanic white (OR 2.01, 95% CI 1.02, 3.96) or unmarried females v. married males (OR 3.80, 95% CI 1.40,10.3). In addition, survivors reporting a change in employment had, on average, a 7-point lower FWB score (estimate=-6.93, 95% CI -11.0,-2.78) after adjusting for age, comorbidities, marital status, and income. A reduction in productivity at work (n=223, 77%) was more common among unmarried females (OR 4.90, 95% CI 1.86, 13.0) and married females (OR 2.18, 95% CI 1.09, 4.35) compared to married males. In addition, survivors reporting a change in productivity had, on average, a 5-point lower current FWB score (estimate=-5.10, 95% CI -9.33,-0.88) than individuals who did not experience a change in productivity, adjusted for age, comorbidities, marital status and insurance. Disparities in the likelihood of changes in employment or productivity were not observed between rural and urban cancer survivors. Conclusion: Hispanic and female cancer survivors may be particularly vulnerable to negative employment outcomes following a cancer diagnosis. These disparities are important because changes in employment and productivity appear to have detrimental, long-term effects on FWB. Citation Format: Shoshana Adler Jaffe, Jessica Anderson, Yvonne Dailey, Dolores Guest, Andrew Sussman, Angela Meisner, Charles Wiggins, Jean McDougall. Changes in employment status and productivity after a cancer diagnosis as markers of long-term financial well-being [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A114.

e24181 Background: The number of cancer survivors is rapidly climbing due to increased screening and improved treatment. Survivorship Care Plans (SCPS) summarize the patients’ treatment and is a communication tool between oncologists and primary care physicians (PCP)s. Creation and delivery of the SCPs has been labor intensive and costly for many healthcare systems and a previous paper based system at our institution was ineffective. The University of New Mexico Comprehensive Cancer Center (UNMCCC) treats a unique population of lower socioeconomic status (SES) (poverty rate 19.7%), rural (22.6%) and minority (Native Americans and Hispanics constitute 10.4% and 48% of the population respectively) patients in a large rural state. Methods: Beginning March 2019, UNMCCC initiated a process for creation and delivery of SCPs through the Electronic Medical Record (EMR). EMRs are not designed to delivery SCPs to patients and PCPs, so EMR functions were creatively repurposed. Upon identification of eligible patients, providers would place an electronic SCP order through the EMR. Designated staff then partially completes the SCPs based on medical record review while the EMR imports demographics, PCP, cancer and stage. Then the EMR flags SCPs ready for delivery and the provider edits, approves and prints the SCP for the patient at the next encounter. Once printed, the EMR alerts medical records to send the SCP to the PCP via mail or EMR routing. Results: 282 SCPs were ordered, 222 (78.7%) were created and 86 (38.7%) given to patients after definitive therapy of Breast (77.9%), Colorectal (7.0%), Gynecological (9.3%) and Prostate Cancer (5.8%). Of 72 SCPs eligible to be sent to PCPs, 48 (66.7%) were successfully mailed or sent via EMR, 13 (18.1%) had PCP discrepancies, 6 (8.3%) had no PCP and 5 (6.9%) had PCPs in systems which do not accept unsolicited records. Conclusions: The UNMCCC cares for low SES, rural and minority patients and was able to create and deliver SCPs to a significant number of patients and PCPs. Future process steps will involve creating tailored SCPs for other diagnoses, resolving PCP discrepancy issues and creating an EMR alert for PCPs when they receive an SCP. Additionally, assessment of both patient and PCP perceptions is ongoing.

PURPOSE: The role of appropriate therapy in breast cancer survival and survival disparities by race/ethnicity have not been fully elucidated. We investigated whether guideline-inconsistent therapy contributed to survival differences overall and among Hispanics relative to non-Hispanic white (NHW) women in a case-cohort study. METHODS: This study included a 15% random sample of female invasive breast cancer patients diagnosed from 1997–2009 in 6 New Mexico counties and all deaths due to breast cancer-related causes. Information was obtained from comprehensive medical chart reviews. National Comprehensive Cancer Network (NCCN(®)) guideline-consistent treatment was assessed among white women aged < 70 who were free of contraindications for recommended therapy, had stage I–III tumors, and had survived at least 12 months. Hazard ratios (HRs) and 95% confidence intervals (CIs) for breast cancer death were estimated using Cox proportional hazards models. RESULTS: The median survival was 101 months. The included women represented 4635 patients and 449 breast cancer deaths. Women who met specific NCCN treatment criteria but did not receive radiotherapy (HR 2.3; 95% CI 1.2–4.4) or endocrine therapy (HR 2.0; 95% CI 1.0–4.0) had an increased risk of breast cancer death relative to those who did receive these therapies. Guideline-consistent therapy receipt did not differ between Hispanic and NHW women for chemotherapy (84.2% vs. 81.3%, respectively), radiotherapy (89.2% vs. 91.1%, respectively) or endocrine therapy (89.2% vs. 85.8%, respectively), and it did not influence Hispanic survival disparities. CONCLUSIONS: Guideline-concordant receipt of radiotherapy and endocrine therapy contributed to survival as strongly as other established prognostic indicators. Hispanic survival disparities in this population do not appear to be attributable to treatment differences.

Objective Relatives of colorectal cancer (CRC) patients are at increased risk for the disease, yet screening rates still remain low. Guided by the Extended Parallel Process Model, we examined the impact of a personalized, remote risk communication intervention on behavioral intention and colonoscopy uptake in relatives of CRC patients, assessing the original additive model and an alternative model in which each theoretical construct contributes uniquely. Methods We collected intention-to-screen and medical record-verified colonoscopy information on 218 individuals who received the personalized intervention. Results Structural equation modeling showed poor main model fit (root mean square error of approximation (RMSEA) = 0.109; standardized root mean residual (SRMR) = 0.134; comparative fit index (CFI) = 0.797; Akaike information criterion (AIC) = 11,601; Bayesian information criterion (BIC) = 11,884). However, the alternative model (RMSEA = 0.070; SRMR = 0.105; CFI = 0.918; AIC = 11,186; BIC = 11,498) showed good fit. Cancer susceptibility (B = 0.319, p

Background and Aims: Hepatocellular carcinoma (HCC) incidence is expected to rise dramatically over the next decades because of increasing hepatitis C infections and obesity-related comorbidities. However, little information exists regarding the treatment of patients with HCC in the community setting. The purpose of this article was to characterize patterns of diagnosis, treatment, and survival for HCC in the community. Methods: We identified 946 HCC patients in the 2007 National Cancer Institute's Patterns of Care study. Chi-square analyses and multivariable regression were used to examine patient and provider factors associated with treatment and survival by stage at diagnosis. Results: Our primary findings indicate that liver transplants, embolization, or radiofrequency ablation for Barcelona Clinic Liver Cancer stage A patients were performed significantly less often for non-Hispanic blacks, Hispanics, patients in the highest income quartile, and patients with Medicaid. Patients with stage D disease were less likely to receive cancer therapy if they had Medicaid insurance compared to private insurance (pConclusions: This is the first population-based study to evaluate therapy provided for HCC in the community. Current therapy depended on patients' HCC stage at diagnosis and other clinical and demographic factors. Overall, our study identifies those least likely to receive specific therapies in a variety of health care settings and can inform strategies for promoting appropriate therapy now and as new agents are developed.

Introduction: American Society of Clinical Oncology (ASCO) guidelines recommend that all patients with metastatic colorectal cancer (mCRC) receive KRAS testing to guide anti-EGFR monoclonal antibody treatment. The aim of this study was to assess for disparities in KRAS testing and mutational status. Methods: The New Mexico Tumor Registry (NMTR), a population-based cancer registry participating in the National Cancer Institute’s Surveillance, Epidemiology and End Results program, was queried to identify all incident cases of CRC diagnosed among New Mexico residents from 2010 to 2013. Results: Six hundred thirty-seven patients were diagnosed with mCRC from 2010–2013. As expected, KRAS testing in Stage 4 patients presented the highest frequency (38.4%), though testing in stage 3 (8.5%), stage 2 (3.4%) and stage 1 (1.2%) was also observed. In those with metastatic disease, younger patients (≤ 64 years) were more likely to have had testing than patients 65 years and older (p < 0.0001). Patients residing in urban areas received KRAS testing more often than patients living in rural areas (p = 0.019). No significant racial/ethnic disparities were observed (p = 0.66). No significant differences were seen by year of testing. Conclusion: Age and geographic disparities exist in the rates of KRAS testing, while sex, race/ethnicity and the year tested were not significantly associated with testing. Further study is required to assess the reasons for these disparities and continued suboptimal adherence to current ASCO KRAS testing guidelines.

This study analyzed the survival of patients with multiple myeloma. Surveillance, Epidemiology, and End Results (SEER) and Centers for Disease Control and Prevention (CDC) databases were queried to calculate myeloma cause-specific survival curves by the Kaplan and Meier product-limit method. The Cox proportional hazards model was used to assess univariate and multivariate predictors of myeloma cause-specific survival. The outcome of interest was death due to myeloma. Results from a Cox proportional hazards model restricted to age and time period at diagnosis demonstrated that the magnitude of improvement in survival by time period varied by age at diagnosis. Among patients under 60 years at diagnosis, hazard ratios for myeloma cause-specific death decreased by more 50% from the first interval of observation to the last. Hazard ratios decreased during the study period by 39% among patients 60-69 years of age and by 27% among patients who were 70 years of age and older. Survival is improving in patients with myeloma of all ages.

69 Background: The Institute of Medicine endorses delivery of survivorship care plans (SCPs) to the growing number of cancer survivors in order to improve the coordination of care between oncologists and primary care providers (PCPs). In response, the Commission on Cancer (COC) has increased the SCP delivery requirement to >50% of eligible patients, a goal that is difficult to meet given limited resources. Here we outline the initiatives taken to achieve this goal at the University of New Mexico Comprehensive Cancer Center (UNMCCC). Methods: Prior to 2017, SCPs were not routinely delivered. Beginning 2017, providers were tasked to complete and deliver printed SCPs , resulting in a 17% rate of SCP completion. However, there was general lack of provider support and enthusiasm as the process was time consuming with no method for identifying eligible patients and tracking SCP delivery. In 2018, designated staff was assigned to partially complete the SCPs to assist providers, resulting in an increase in SCP delivery rate to 41%. However, the same barriers existed. SCP softwares, although available, were expensive. A cost effective process therefore was needed. A committee was then formed to create a system-wide process utilizing the existing electronic health record (EHR) MOSAIQ. ASCO based SCPs were created. Once providers identify eligible patients, an SCP electronic order was initiated. Designated staff then partially completes the SCPs based on review of medical records. The EHR extracts data items including demographics, PCP information, cancer type and stage. The EHR is programmed to flag SCPs ready for delivery which the provider then edits and approves. This system tracks multiple time points including referral, completion and delivery of SCPs. This new process was implemented in April 2019. Quarterly reviews are set to assess metrics. Results: Utilizing existing EHR (MOSAIQ), a new SCP delivery process was created that allows tracking of assembly, completion and timing of delivery. Conclusions: To overcome existing barriers to SCP completion and delivery, a new cost effective process was created utilizing existing staff and EHR resources. Institutional support is key to the success of this initiative.

Exposure variables in occupational and environmental epidemiology are usually measured with error. This error tends to flatten the estimated exposure-response relationship. Here, we extended the ri...

The 21-gene Recurrence Score assay is validated to predict recurrence risk and chemotherapy benefit in hormone-receptor-positive (HR+) invasive breast cancer. To determine prospective breast-cancer-specific mortality (BCSM) outcomes by baseline Recurrence Score results and clinical covariates, the National Cancer Institute collaborated with Genomic Health and 14 population-based registries in the the Surveillance, Epidemiology, and End Results (SEER) Program to electronically supplement cancer surveillance data with Recurrence Score results. The prespecified primary analysis cohort was 40–84 years of age, and had node-negative, HR+, HER2-negative, nonmetastatic disease diagnosed between January 2004 and December 2011 in the entire SEER population, and Recurrence Score results (N=38,568). Unadjusted 5-year BCSM were 0.4% (n=21,023; 95% confidence interval (CI), 0.3–0.6%), 1.4% (n=14,494; 95% CI, 1.1–1.7%), and 4.4% (n=3,051; 95% CI, 3.4–5.6%) for Recurrence Score

The University of New Mexico School of Medicine (UNMSOM) sought to train medical students in public health concepts, knowledge, and skills as a means of improving the health of communities statewide. Faculty members from every UNMSOM department collaborated to create and integrate a public health focus into all years of the medical school curriculum. They identified key competencies and developed new courses that would synchronize students' learning public health subjects with the mainstream medical school content. New courses include: Health Equity: Principles of Public Health; Epidemiology and Biostatistics; Evidence-Based Practice; Community-Based Service Learning; and Ethics in Public Health. Students experiencing the new courses, first in pilot and then final forms, gave high quantitative ratings to all courses. Some students' qualitative comments suggest that the Public Health Certificate has had a profound transformative effect. Instituting the integrated Public Health Certificate at UNMSOM places it among the first medical schools to require all its medical students to complete medical school with public health training. The new UNMSOM Public Health Certificate courses reunite medicine and public health in a unified curriculum.

SEER (Surveillance, Epidemiology and End Results) is the leading source of population level data on prostate cancer, including the positive surgical margin incidence at radical prostatectomy. Recently studies showed wide ranges in positive surgical margin rates among individual registries, which we hypothesized was the result of coding inaccuracies. Thus, we systematically audited SEER prostate cancer data.The New Mexico Tumor Registry, a SEER core registry, was queried for incident prostate cancer cases in 2007 that met certain criteria, including 1) adenocarcinoma histology, 2) malignant behavior and 3) radical prostatectomy as the first course of therapy. Pathological stage codes were audited by examining original radical prostatectomy pathology reports in accordance with SEER coding guidelines. The incidence and sites of positive surgical margins were critically analyzed.Of the 305 cases that met all study inclusion criteria with complete source documents available 92 (30%) were coded incorrectly. The most common error was failure to properly account for surgical margin status (46 of 92 cases or 50%). The incidence of positive surgical margins in organ confined disease cases was 13% by SEER coding rules but 28% by a more clinical definition of positive surgical margins (p0.001). In organ confined cases positive surgical margins occurred principally at the apex but in nonorgan confined cases most were multifocal.In this SEER registry 30% of radical prostatectomy cases in 2007 were coded inaccurately. SEER coding guidelines result in underestimating the positive surgical margin incidence. Clinicians and investigators should recognize the limitations of tumor registry data on positive surgical margins.

Introduction: Cancer survivors increasingly report financial hardship as a consequence of the high cost of cancer care, yet the financial experience of traditionally underserved patients, including racial/ethnic minorities, non-English speakers, and rural residents, remains largely unstudied. The purpose of this study was to investigate potential disparities in the likelihood of financial hardship and nonadherence to surveillance colonoscopy. Methods: In this cross-sectional study, individuals diagnosed with localized or regional colorectal cancer between 2004-2012 were ascertained by the population-based New Mexico Tumor Registry. Participants completed a mailed questionnaire or telephone survey about their cancer survivorship experience, including treatment-related financial hardship and receipt of surveillance colonoscopy. Participants were considered to have experienced treatment-related financial hardship if they reported any debt accumulation, bankruptcy filing, other financial sacrifices, or inability to pay medical bills as a consequence of their illness, its treatment, or its lasting effects. Multivariable logistic regression was used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI). Results: In this sample of 277 colorectal cancer survivors, 44% of participants reported financial hardship. Individuals with low health literacy (OR 5.41, 95% CI 1.45-20.1), Spanish-speaking Hispanics (OR 3.09, 95% CI 1.39-6.87), divorced, separated or single survivors (OR 1.94, 95% CI 1.94, 95% CI 1.06-3.54), and rural residents (OR 1.86, 95% CI 1.06-3.28) were more likely to report financial hardship. Nonadherence to surveillance colonoscopy guidelines was two times as likely among participants reporting financial hardship (OR 2.17 95% CI 1.01-4.67) and among rural residents (OR 2.28, 95% CI 1.07-4.48) than those reporting no financial hardship and urban residents, respectively. Conclusions: Substantial disparities in the likelihood of financial hardship and nonadherence to surveillance colonoscopy exist. Identifying patients at risk of financial hardship and developing interventions to reduce the financial burden of cancer may improve adherence to surveillance recommendations. Citation Format: Jean A. McDougall, Matthew P. Banegas, Charles Wiggins, Ashwani Rajput, Vi K. Chiu, Kristina G. Flores, Anita Y. Kinney. Disparities in treatment-related financial hardship and adherence to surveillance colonoscopy guidelines in ethnically, linguistically, and geographically diverse colorectal cancer survivors [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C52.

In the original version of the published article, line three of the third paragraph of the methods stated “Excluding patients with micrometastatic disease, the 5-year BCSM for patients with Recurrence Score results n = 2,617) was 1.3% (95% CI, 0.6–2.9%).” To improve clarity this statement has been replaced with “Excluding patients with micrometastatic disease, there were 2,617 patients with 1–3 positive nodes. Of these, 1,487 also had Recurrence Score results

Background: Advanced renal cell carcinoma (RCC) results in over 14,000 deaths each year in the United States alone. The therapeutic landscape for advanced RCC changed dramatically with the approval of tyrosine kinase inhibitors (TKI) between 2006 and 2012. A large-scale analysis of survival trends has not been performed in the TKI era to determine their impact on outcomes for advanced RCC patients. Methods: The Surveillance, Epidemiology and End-Results (SEER) database was queried for adult patients with advanced RCC diagnosed between 2000 and 2013. Patients were divided into two cohorts based on the year of diagnosis—pre-TKI cohort [2000–2006] and TKI cohort [2007–2013]. Kaplan-Meier survival and multivariate Cox proportional hazards analyses were performed. Results: A total of 14,976 patients were included in our study. Median age at diagnosis was 64 years (range, 18–89 years). Median (cancer-specific) overall survival was 10.0 months in the TKI cohort compared with 8.0 months in the pre-TKI cohort, corresponding to a 13% improvement in survival in the TKI area [hazard ratio (HR) for death 0.87; 95% confidence interval (CI), 0.84–0.91, P