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Background: Literature on colorectal cancer outcomes in individuals of Middle Eastern and North African (MENA) descent is limited. To address this gap, we estimated five-year colorectal cancer–specific survival by race and ethnicity, including MENA individuals, in a diverse, population-based sample in California. Methods: We identified adults (ages 18–79 years) diagnosed with a first or only colorectal cancer in 2004 to 2017 using the California Cancer Registry (CCR), including non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, Hispanic, and MENA individuals. For each racial/ethnic group, we calculated five-year colorectal cancer–specific survival and used Cox proportional hazards regression models to examine the association of race/ethnicity and survival, adjusting for clinical and socio demographic factors. Results: Of 110,192 persons diagnosed with colorectal cancer, five-year colorectal cancer–specific survival was lowest in Black (61.0%) and highest in MENA (73.2%) individuals. Asian (72.2%) individuals had higher survival than White (70.0%) and Hispanic (68.2%) individuals. In adjusted analysis, MENA [adjusted HR (aHR), 0.82; 95% confidence interval (CI), 0.76–0.89], Asian (aHR, 0.86; 95% CI, 0.83–0.90), and Hispanic (aHR, 0.94; 95% CI, 0.91–0.97) race/ethnicity were associated with higher, and Black (aHR, 1.13; 95% CI, 1.09–1.18) race/ethnicity was associated with lower survival compared with non-Hispanic White race/ethnicity. Conclusions: To our knowledge, this is the first study to report colorectal cancer survival in MENA individuals in the United States. We observed higher survival of MENA individuals compared with other racial/ethnic groups, adjusting for sociodemographic and clinical factors. Impact: Future studies are needed to identify factors contributing to cancer outcomes in this unique population.

BACKGROUND AND AIMS The use of forceps for removal of non-diminutive polyps is associated with incomplete resection compared to snare polypectomy. However, few studies have characterized the frequency of forceps polypectomy for non-diminutive polyps or identified strategies to improve this practice. To address this gap, we estimated prevalence and predictors of forceps polypectomy in clinical practice and examined the effectiveness of a multi-component intervention to reduce inappropriate forceps polypectomy. METHODS We retrospectively reviewed all colonoscopies with polypectomies performed at two U.S. health systems between 10/1/2017 and 9/30/2019. We used a mixed-effects logistic regression model to examine the effect of a multi-component intervention, including provider education and a financial incentive, to reduce inappropriate forceps polypectomy, defined as use of forceps polypectomy for polyps ≥5mm. RESULTS A total of 9968 colonoscopies with 25534 polypectomies were performed by 42 gastroenterologists during the study period. Overall, 8.5% (n=2176) of polyps were removed with inappropriate forceps polypectomy. Inappropriate forceps polypectomy significantly decreased after the intervention (OR 0.34, 95% CI 0.30-0.39), from 11.4% (n=1539) to 5.3% (n=637). Predictors of inappropriate forceps polypectomy included: inadequate bowel prep (OR 1.25, 95% CI 1.06 – 1.47), polyps in the right colon (vs. left: OR 1.29, 95% CI 1.09 – 1.51), and number of polyps removed (OR 0.96, 95% CI 0.94 – 0.97). Inappropriate forceps polypectomy also varied by gastroenterologist (median odds ratio 3.43). In a post-hoc analysis, the proportion of polyps >2mm removed with forceps decreased from 50.0% before the intervention to 43.0% after it (OR 0.62, 95% CI 0.58-0.68). CONCLUSIONS Inappropriate forceps polypectomy is common but modifiable. The proportion of non-diminutive polyps removed with forceps polypectomy should be considered as a quality measure.

Background: In May 2021, the U.S. Preventive Services Task Force began recommending initiating colorectal cancer screening at age 45 (vs. 50) years. Methods: We estimated prevalence of colorectal cancer screening (by colonoscopy, sigmoidoscopy, CT colonography, or stool-based tests) in adults ages 50 to 75 years using data from the National Health Interview Survey in 2000, 2003, 2005, 2008, 2010, 2013, 2015, and 2018. For each survey year, we estimated prevalence by age, race/ethnicity, educational attainment, family income, and health insurance. We also compared increases in prevalence of screening from 2000 to 2018 in 5-year age groups (50–54, 55–59, 60–64, 65–69, and 70–75 years). Results: Overall, prevalence of colorectal cancer screening increased from 36.7% in 2000 to 66.1% in 2018. Screening prevalence in 2018 was lowest for age 50 to 54 years (47.6%), Hispanics (56.5%), Asians (57.1%), and participants with less than a high school degree (53.6%), from low-income families (56.6%), or without insurance (39.7%). Increases in prevalence over time differed by five-year age group. For example, prevalence increased from 28.2% in 2000 to 47.6% in 2018 (+19.4%; 95% CI, 13.1–25.6) for age 50 to 54 years but from 46.4% to 78.0% (+31.6%; 95% CI, 25.4%–37.7%) for age 70 to 75 years. This pattern was consistent across race/ethnicity, educational attainment, family income, and health insurance. Conclusions: Prevalence of colorectal cancer screening remains low in adults ages 50 to 54 years. Impact: As new guidelines are implemented, care must be taken to ensure screening benefits are realized equally by all population groups, particularly newly eligible adults ages 45 to 49 years. See related commentary by Brawley, p. 1671

Background:Literature on colorectal cancer outcomes in individuals of Middle Eastern and North African (MENA) descent is limited. To address this gap, we estimated five-year colorectal cancer–specific survival by race and ethnicity, including MENA individuals, in a diverse, population-based sample in California.Methods:We identified adults (ages 18–79 years) diagnosed with a first or only colorectal cancer in 2004 to 2017 using the California Cancer Registry (CCR), including non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, Hispanic, and MENA individuals. For each racial/ethnic group, we calculated five-year colorectal cancer–specific survival and used Cox proportional hazards regression models to examine the association of race/ethnicity and survival, adjusting for clinical and socio demographic factors.Results:Of 110,192 persons diagnosed with colorectal cancer, five-year colorectal cancer–specific survival was lowest in Black (61.0%) and highest in MENA (73.2%) individuals. Asian (72.2%) individuals had higher survival than White (70.0%) and Hispanic (68.2%) individuals. In adjusted analysis, MENA [adjusted HR (aHR), 0.82; 95% confidence interval (CI), 0.76–0.89], Asian (aHR, 0.86; 95% CI, 0.83–0.90), and Hispanic (aHR, 0.94; 95% CI, 0.91–0.97) race/ethnicity were associated with higher, and Black (aHR, 1.13; 95% CI, 1.09–1.18) race/ethnicity was associated with lower survival compared with non-Hispanic White race/ethnicity.Conclusions:To our knowledge, this is the first study to report colorectal cancer survival in MENA individuals in the United States. We observed higher survival of MENA individuals compared with other racial/ethnic groups, adjusting for sociodemographic and clinical factors.Impact:Future studies are needed to identify factors contributing to cancer outcomes in this unique population.

Supplementary Table 1 provides treatment quality metrics for colon and rectal cancers using adherence to National Comprehensive Cancer Network guidelines.

PDF - 133KB, Covariance matrix for overdue subgroup (n=418).

PDF - 134KB, Covariance matrix for never screened subgroup (n=1,277).

Background: Few studies have examined the psychometric properties and invariance of scales measuring constructs relevant to colorectal cancer screening (CRCS). We sought to: (i) evaluate the factorial validity of four core constructs associated with CRCS (benefits, barriers, self-efficacy, and optimism); and (ii) examine measurement invariance by screening status (currently screened, overdue, never screened).Methods: We used baseline survey data from a longitudinal behavioral intervention trial to increase CRCS among U.S. veterans. Respondents were classified as currently screened (n = 3,498), overdue (n = 418), and never screened (n = 1,277). The measurement model was developed using a random half of the sample and then validated with the second half of the sample and the full baseline sample (n = 5,193). Single- and multi-group confirmatory factor analysis was used to examine measurement invariance by screening status.Results: The four-factor measurement model demonstrated good fit. Factor loadings, item intercepts, and residual item variance and covariance were invariant when comparing participants never screened and overdue for CRCS, indicating strict measurement invariance. All factor loadings were invariant among the currently screened and overdue groups. Only the benefits scale was invariant across current screeners and never screeners. Non-invariant items were primarily from the barriers scale.Conclusion: Our findings provide additional support for the construct validity of scales of CRCS benefits, barriers, self-efficacy, and optimism. A greater understanding of the differences between current and never screeners may improve measurement invariance.Impact: Measures of benefits, barriers, self-efficacy, and optimism may be used to specify intervention targets and effectively assess change pre- and post-intervention across screening groups. Cancer Epidemiol Biomarkers Prev; 22(12); 2295–302. ©2013 AACR.

Background We examined adverse birth outcomes among adolescent and young adult women diagnosed with cancer (AYA women, ages 15-39 years) during pregnancy. Methods We linked data from the Texas Cancer Registry, vital records, and Texas Birth Defects Registry to identify all singleton births to AYA women diagnosed during pregnancy from January 1999 to December 2016. We compared prevalence of adverse live birth outcomes between AYA women and women without cancer (matched 1:4 on age, race and ethnicity, and year). Among AYA women, we used log-binomial regression to identify factors associated with these outcomes. Statistical tests were 2-sided. Results AYA women had 1271 singleton live births and 20 stillbirths. AYA women (n = 1291) were 33.3% Hispanic and 9.8% non-Hispanic Black and most commonly had breast (22.5%), thyroid (19.8%), and gynecologic (13.3%) cancers. Among live births, AYA women had a higher prevalence of low birth weight offspring (30.1% vs 9.0%), very preterm (5.7% vs 1.2%), and preterm birth (25.1% vs 7.2%); cesarean delivery (44.3% vs 35.2%); and low Apgar score (2.7% vs 1.5%), compared with women without cancer (n = 5084) (all P Conclusions AYA women diagnosed during pregnancy have higher prevalence of adverse birth outcomes and face difficult decisions in balancing treatment risks and benefits.

Background Incidence rates of colorectal cancer (CRC) are increasing among adults born in and after the 1960s, implicating pregnancy-related exposures introduced at that time as risk factors. Dicyclomine, an antispasmodic used to treat irritable bowel syndrome, was initially included in Bendectin (comprising doxylamine, pyridoxine, and dicyclomine), an antiemetic prescribed during pregnancy in the 1960s. Methods We estimated the association between in utero exposure to Bendectin and risk of CRC in offspring of the Child Health and Development Studies, a multigenerational cohort that enrolled pregnant women in Oakland, CA, between 1959 and 1966 (n = 14 507 mothers and 18 751 liveborn offspring). We reviewed prescribed medications from mothers’ medical records to identify those who received Bendectin during pregnancy. Diagnoses of CRC in adult (aged ≥18 years) offspring were ascertained by linkage with the California Cancer Registry. Cox proportional hazards models were used to estimate adjusted hazard ratios, with follow-up accrued from birth through cancer diagnosis, death, or last contact. Results Approximately 5% of offspring (n = 1014) were exposed in utero to Bendectin. Risk of CRC was higher in offspring exposed in utero (adjusted hazard ratio = 3.38, 95% confidence interval [CI] = 1.69 to 6.77) compared with unexposed offspring. Incidence rates of CRC were 30.8 (95% CI = 15.9 to 53.7) and 10.1 (95% CI = 7.9 to 12.8) per 100 000 in offspring exposed to Bendectin and unexposed, respectively. Conclusions Higher risk of CRC in offspring exposed in utero may be driven by dicyclomine contained in the 3-part formulation of Bendectin used during the 1960s. Experimental studies are needed to clarify these findings and identify mechanisms of risk.

Background Screening with fecal immunochemical testing (FIT) reduces colorectal cancer mortality; however, screening remains low in underserved populations. Mailed outreach, including an invitation letter, FIT, and test instructions, is an evidence-based strategy to improve screening. Aims To examine screening completion and yield in a mailed outreach program in a safety-net healthcare system. Methods We identified and mailed outreach invitations to patients due for screening in a large safety-net system between September 1, 2018, and August 31, 2019. We examined: (1) screening completion, the proportion of patients completing FIT or screening colonoscopy within 6 months of the mailed invitation; and (2) timely diagnostic colonoscopy, the proportion of patients completing colonoscopy within 6 months of positive FIT. Results We mailed 14,879 invitations to 13,190 patients. Nearly half (n = 6098, 46.2%) of patients completed screening: 4,896 (80.3%) completed FIT through mailed outreach; 1,114 (18.3%) FIT through usual care; and 88 (1.4%) screening colonoscopy through usual care. Of patients with a positive FIT (n = 289), 50.5% completed diagnostic colonoscopy within 6 months, 10.7% within 6–12 months, and 4.8% after 12 months. A total of 8 cancers and 83 advanced adenomas were detected in the 191 patients completing diagnostic colonoscopy. Conclusion After implementing and scaling up mailed outreach in a safety-net system, about half of patients completed screening, and the majority did so through mailed outreach. However, many patients failed to complete diagnostic colonoscopy after positive FIT. Results highlight the importance of adapting mailed outreach programs to local contexts and constraints of healthcare systems, in order to support efforts to improve CRC screening in underserved populations.

We examined the association between polypharmacy-an established risk factor for nonadherence in the elderly-and medication fill nonadherence in a large national sample of adolescent and young adult cancer survivors (AYAs) in the USA.We pooled data (2008-2017) from the Medical Expenditure Panel Survey. We defined polypharmacy as ≥ 3 unique medications prescribed, based on self-report and pharmacy data, and medication fill nonadherence as self-reported delay or inability to obtain a necessary medication. We estimated prevalence of medication fill nonadherence among AYAs (age 18-39 years with a cancer history). We used logistic regression to estimate the association between (1) polypharmacy and medication fill nonadherence in AYAs, and (2) total number of medications prescribed and medication fill nonadherence, controlling for sex, number of chronic conditions, disability, and survey year.AYAs (n = 598) were predominantly female (76.2%), age 30-39 years (64.9%), and non-Hispanic White (72.1%). Nearly half were poor (19.0%) or near-poor/low income (21.6%). One in ten AYAs reported medication fill nonadherence (9.75%). Of these, more than 70% cited cost-related barriers as the reason. AYAs with polypharmacy had 2.49 times higher odds of medication fill nonadherence (95%CI 1.11-5.59), compared to those without polypharmacy. Odds of medication fill nonadherence increased by 16% with each additional medication prescribed (AOR 1.16, 95% CI 1.07-1.25).Polypharmacy may be an important risk factor for medication fill nonadherence in AYAs in the USA.Improving AYAs' medication adherence requires eliminating cost-related barriers, particularly for those with polypharmacy.

ObjectiveTo estimate the prevalence of polypharmacy, identify risk factors and examine related adverse outcomes in the US children with asthma.Design, setting and participantsThis population-based, cross-sectional study included 1776 children with asthma from the 2011–2020 National Health and Nutrition Examination Surveys.ExposuresPolypharmacy is defined as taking ≥2 medications concurrently for ≥1 day over the past 30 days.Main outcomes and measures(1) Weighted prevalence estimates of polypharmacy in children with asthma; (2) asthma attacks and emergency department (ED) visits.ResultsThe estimated prevalence of polypharmacy in the US children with asthma was 33.49% (95% CI 31.81% to 35.17%). 15.53% (95% CI 14.31% to 16.75%), 12.63% (95% CI 11.37% to 13.88%) and 5.33% (95% CI) of participants were taking 2, 3–4, and 5 prescription medications, respectively. In addition to asthma medications, the most common sources of polypharmacy included antihistamines (20.17%, 95% CI 16.07% to 24.28%), glucocorticoids (16.67%, 95% 12.57% to 20.78%), and anti-infectives (14.28%, 95% CI 10.29 to 18.28). Risk factors for the increased number of medications included age 5–11 years old (vs 1–4 years: adjusted incidence rate ratio (aIRR) 1.38, 95% CI 1.10 to 1.72), fair-to-poor health (vs excellent or very good: aIRR 1.42, 95% CI 1.05 to 1.92), or ≥6 healthcare utilisation encounters over the last year (vs 0–5 encounters: aIRR 1.45, 95% CI 1.26 to 1.66). Polypharmacy increased the odds of an asthma attack (adjusted OR (aOR) 2.80, 95% CI 1.99 to 3.93) and ED visit (aOR 2.41, 95%1.59–3.63) after adjusting for demographics, insurance and health status.ConclusionsEvery one in three US children with asthma experienced polypharmacy. Although it may reflect the treatment guidelines that various asthma medications are needed for maintenance therapy, our results suggested that polypharmacy increased the odds of asthma attacks or ED visits. This may be due to the concurrent use with other non-asthma medications indicating that there is an opportunity to improve medication management in children with asthma.

This cohort study examines the associations of multiple social risk factors with mortality risk among patients newly diagnosed with cancer in the US.

Background As use of oral cancer therapies increases, patient adherence has become critical when evaluating the effectiveness of therapy. In a phase III trial for renal cell carcinoma, we: (a) characterized adherence to sorafenib, sunitinib, and/or placebo and (b) identified factors associated with non‐adherence. Methods ECOG‐ACRIN E2805 was a double‐blind, placebo‐controlled, randomized trial comparing adjuvant sorafenib or sunitinib in patients with resected primary renal cell carcinoma at high risk for recurrence. We used patient‐completed pill diaries to measure adherence as the number of pills taken divided by the number of pills prescribed. Log‐binomial regression was used to identify correlates of non‐adherence (, In a randomized clinical trial for renal cell carcinoma, adherence to oral therapy was lower (85%) than adherence to placebo (95%). Adherence was also worse among racial/ethnic minorities, patients experiencing certain toxicities, and high volume enrolling sites, highlighting several challenges to address in clinical practice as oral therapies become increasingly common.

Patients with previous cancer are often excluded from clinical trials despite limited evidence about their prognosis. We examined the effect of previous cancer on overall and colorectal cancer (CRC)‐specific survival of patients newly diagnosed with CRC. This population‐based cohort study from the U.S.A. included patients aged ≥66 years and diagnosed with CRC between 2005 and 2015 in linked Surveillance, Epidemiology, and End Results‐Medicare data. We estimated the stage‐specific effects of a previous cancer on overall survival using Cox regression and on CRC‐specific survival using competing risk regression. We also examined the effect of previous cancer type, timing, and stage on overall survival. Of 112,769 patients, 14.1% were previously diagnosed with another cancer––commonly prostate (32.9%) or breast (19.4%) cancer, with many (47.1%) diagnosed, Patients with previous cancer are often excluded from clinical trials despite limited evidence about their prognosis. We examined the effect of previous cancer on overall and colorectal cancer (CRC)‐specific survival of patients newly diagnosed with CRC. Among other findings, we identified that for all CRC stages except IV, in which there was no difference, patients with previous cancer had worse overall survival compared to those without previous cancer.

Background: Many individuals with cancer have survived a prior cancer and for this reason may have been excluded from clinical trials. Recent NCI guidance recommends including these individuals, especially when the risk of the prior malignancy interfering with either safety or efficacy endpoints is very low. Using breast cancer as an example, we determined the potential effect this policy change may have on clinical trial accrual. Patients and Methods: We reviewed protocols of NCI-sponsored breast cancer clinical trials activated in 1991 through 2016. We quantified prevalence of prior cancer-related exclusion criteria and assessed the association with trial characteristics using Fisher’s exact tests. Using SEER data, we estimated the prevalence and timing of prior primary (nonbreast) cancer diagnoses among patients with breast cancer. Results: Among 87 clinical trials (total target enrollment, 137,253 patients), 77% excluded individuals with prior cancer, most commonly (79%) within the preceding 5 years. Among trials with radiographic response or toxicity endpoints, 69% excluded prior cancer. In SEER data, the prevalence of a prior (nonbreast) cancer diagnosis ranged from 5.7% to 7.7%, depending on breast cancer stage, of which 39% occurred within 5 years of the incident breast cancer. For trials excluding prior cancer, the estimated proportion of patients excluded for this reason ranged from 1.3% to 5.8%, with the estimated number of excluded patients ranging from 1 to 288. Conclusions: More than three-fourths of NCI-sponsored breast cancer clinical trials exclude patients with prior cancer, including almost 70% of trials with response or toxicity endpoints. Given that >5% of patients with breast cancer have a history of prior cancer, in large phase III trials this practice may exclude hundreds of patients. Following recent NCI eligibility guidance, the inclusion of patients with prior cancer on breast cancer trials may have a meaningful impact on accrual.

BACKGROUND: Young adults diagnosed with colorectal cancer (CRC) comprise a growing, yet understudied, patient population. We estimated 5-year relative survival of early-onset CRC and examined disparities in survival by race-ethnicity in a population-based sample. METHODS: We used the National Cancer Institute’s Surveillance, Epidemiology, and End Results program of cancer registries to identify patients diagnosed with early-onset CRC (20–49 years of age) between January 1, 1992, and December 31, 2013. For each racial-ethnic group, we estimated 5-year relative survival, overall and by sex, tumor site, and stage at diagnosis. To illustrate temporal trends, we compared 5-year relative survival in 1992–2002 vs 2003–2013. We also used Cox proportional hazards regression models to examine the association of race-ethnicity and all-cause mortality, adjusting for age at diagnosis, sex, county type (urban vs rural), county-level median household income, tumor site, and stage at diagnosis. RESULTS: We identified 33,777 patients diagnosed with early-onset CRC (58.5% White, 14.0% Black, 13.0% Asian, 14.5% Hispanic). Five-year relative survival ranged from 57.6% (Black patients) to 69.1% (White patients). Relative survival improved from 1992–2002 to 2003–2013 for White patients only; there was no improvement for Black, Asian, or Hispanic patients. This pattern was similar by sex, tumor site, and stage at diagnosis. In adjusted analysis, Black (adjusted hazard ratio [aHR], 1.42; 95% confidence interval [CI], 1.36–1.49), Asian (aHR, 1.06; 95% CI, 1.01–1.12), and Hispanic (aHR, 1.16; 95% CI, 1.10–1.21) race-ethnicity were associated with all-cause mortality. CONCLUSION: Our study adds to the well-documented disparities in CRC in older adults by demonstrating persistent racial-ethnic disparities in relative survival and all-cause mortality in patients with early-onset CRC.

Background Gonadotoxic effects of cancer treatment may increase risk of adverse birth outcomes in adolescent and young adult (AYA, aged 15-39 years) women diagnosed with cancer. We estimated risk of stillbirth (fetal death of gestational age ≥20 weeks or weighing ≥350 grams) in a population-based sample of AYA women. Methods AYA women diagnosed with cancer between January 1, 1995, and December 31, 2015, were identified using the Texas Cancer Registry and linked to live birth and fetal death certificates through December 31, 2016. Among AYA women, cumulative incidence of stillbirth was estimated by gestational age, and Poisson regression models identified factors associated with stillbirth. Standardized fetal mortality ratios (SMR) compared the observed fetal mortality rate in AYA women with the expected fetal mortality rate in the general population. Results A total of 11 628 live births and 68 stillbirths occurred to 8402 AYA women after diagnosis. Cumulative incidence of stillbirth in AYA women was 0.70% (95% confidence interval [CI] = 0.51% to 0.96%) at 40 weeks of gestation. Risk of stillbirth was higher among Hispanic (risk ratio [RR] = 2.64, 95% CI = 1.29 to 5.41) and non-Hispanic Black (RR = 4.13, 95% CI = 1.68 to 10.16) women compared with non-Hispanic White women; there was no association with receipt of chemotherapy or time since diagnosis. Age- and race and ethnicity–adjusted fetal mortality rate in AYA women was similar to the general population (SMR = 0.99, 95% CI = 0.77 to 1.26). Conclusions AYA women may be counseled that overall risk of stillbirth is low, and for most, cancer does not appear to confer additional risk.

PURPOSE: Many women diagnosed with breast cancer have survived previous cancer yet little is known about the impact of previous cancer on overall and cancer-specific survival. METHODS: This population-based cohort study using SEER-Medicare data included women (age ≥66 years) diagnosed with breast cancer between 2005–2015. Separately by breast cancer stage, we estimated effect of previous cancer on overall survival using Cox regression and on cause-specific survival using competing risk regression; all survival analyses adjusted for covariates. RESULTS: Of 138,576 women diagnosed with breast cancer, 8% had a previous cancer of another organ site, most commonly colorectal or uterine cancer or melanoma. Many of these women (46.3%) were diagnosed within 5 years of breast cancer. For all breast cancer stages except IV wherein there was no difference, women with vs. without previous cancer had worse overall survival. This survival disadvantage was driven by deaths due to the previous cancer and other causes. In contrast, women with previous cancer generally had favorable breast-cancer specific survival, although this varied by stage. Overall survival varied by previous cancer type, timing, and stage; previous lung cancer, cancer diagnosed within 1 year of incident breast cancer, and previous cancer at a distant stage were associated with the worst survival. In contrast, women with a previous melanoma had equivalent overall survival to women without previous cancer. CONCLUSION: We observed variable impact of previous cancer on overall and breast-cancer specific survival depending on breast cancer stage at diagnosis and the type, timing, and stage of previous cancer.

Background A growing number of women newly diagnosed with breast cancer have survived a previous cancer. Although little is known about their prognosis, this population is frequently excluded from clinical trials. Additional evidence about the survival of this population is needed, so that trial sponsors and investigators can create evidence-based trial eligibility criteria. Among women newly diagnosed with breast cancer, we examined the impact of previous cancer on overall and cancer-specific survival. Methods This population-based cohort study included patients age ≥66 years and diagnosed with breast cancer between 2005-2015 in linked SEER-Medicare data. Separately by breast cancer stage, we estimated overall survival using Cox regression and cause-specific survival using competing risk regression for women with and without previous cancer, adjusting for numerous covariates and competing risk of death from previous cancer, other causes, or the incident breast cancer. Results Of 138,576 women diagnosed with incident breast cancer, 10,822 (8%) had a previous cancer of another organ site. Many of these (n=5,014, 46.3%) were diagnosed ≤5 years of breast cancer. For all breast cancer stages except IV in which there was no significant survival difference, women with vs. without previous cancer had worse overall survival. This survival disadvantage was driven by deaths due to the previous cancer and other causes. In contrast, women with previous cancer generally had favorable breast-cancer specific survival; however this varied somewhat by stage and over time. Conclusions Many women newly diagnosed with breast cancer are already cancer survivors. These women had generally worse overall survival, worse survival from other causes, but their disease-specific survival varied depending on their breast cancer stage and over time. Citation Format: Sandi L Pruitt, Hong Zhu, Daniel Heitjan, David E Gerber, Bhumika Maddineni, Danyi Xiong, Ethan Halm, Caitlin Murphy. Survival among female breast cancer patients who have survived a previous cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS11-31.

Background Accrual to cancer clinical trials is suboptimal. Few data exist regarding whether financial reimbursement might increase accruals. Objective The objective of this study was to assess perceptions about reimbursement to overcome barriers to trial accrual. Research design This was a cross-sectional survey. Subjects Oncologists identified from the American Medical Association Physician Masterfile. Measures We report descriptive statistics, associations of physician characteristics with perceptions of reimbursement, domains, and subthemes of free-text comments. Results Respondents (n=1030) were mostly medical oncologists (59.4%), ages 35-54 (67%), and male (75%). Overall, 30% reported discussing trials with >25% of patients. Barriers perceived were administrative/regulatory, physician/staff time, and eligibility criteria. National Cancer Institute cooperative group participants and practice owners were more likely to endorse higher reimbursement. Respondents indicated targeted reimbursement would help improve infrastructure, but also noted potential ethical problems with reimbursement for discussion (40.7%) and accrual (85.9%). Free-text comments addressed reimbursement sources, recipients, and concerns about the real and apparent conflict of interest. Conclusions Though concerns about a potential conflict of interest remain paramount and must be addressed in any new system of reimbursement, oncologists believe reimbursement to enhance infrastructure could help overcome barriers to trial accrual.

Persons newly diagnosed with pancreas cancer and who have survived a previous cancer are often excluded from clinical trials, despite limited evidence about their prognosis. We examined the association between previous cancer and overall survival.This US population-based cohort study included older adults (aged ≥66 years) diagnosed with pancreas cancer between 2005 and 2015 in the linked Surveillance, Epidemiology, and End Results-Medicare data. We used Cox proportional hazards models to estimate stage-specific effects of previous cancer on overall survival, adjusting for sociodemographic, treatment, and tumor characteristics.Of 32,783 patients, 18.7% were previously diagnosed with another cancer. The most common previous cancers included prostate (29.0%), breast (18.9%), or colorectal (9.7%) cancer. More than half of previous cancers (53.9%) were diagnosed 5 or more years prior to pancreas cancer diagnosis or at an in situ or localized stage (47.8%). The proportions of patients surviving 1, 3, and 5 years after pancreas cancer were nearly identical for those with and without previous cancer. Median survival in months was as follows for those with and without previous cancer respectively: 7 versus 8 (Stage 0/I), 10 versus 10 (Stage II), 7 versus 7 (Stage III), and 3 versus 2 (Stage IV). Cox models indicated that patients with previous cancer had very similar or statistically equivalent survival to those with no previous cancer.Given nearly equivalent survival compared to those without previous cancer, cancer survivors newly diagnosed with pancreas cancer should be considered for inclusion in pancreas cancer clinical trials.

Background Although early‐onset colorectal cancer (EOCRC) incidence rates (IRs) are increasing, geographic and intra‐racial IR disparities are not well defined. Methods 2000‐2015 Surveillance, Epidemiology, and End Results (SEER) program CRC IR Analysis (170,434 cases) was performed from ages 30 to 60 in four US regions, 18 individual registries, metropolitan and nonmetropolitan locations and stratified by race. Analyses were conducted in 1‐year and 5‐year age increments. Results Wide US regional EOCRC IR variations exist: For example, age 45 IRs in the south are 26.8/100,000, 36.0% higher than the West, 19.7/100,000 (p, This analysis of SEER 18 early‐onset colorectal cancer data reveals marked disparities by geography and within racial groups (intra‐racial) across the United States. This data can be used to target public health interventions and guide future studies on etiology.

Background: Proportion of time covered (PTC, or “covered time”) is a longitudinal measure of adherence to preventive health services, the use of which has increased in recent years. This measure is helpful for evaluating the success of delivering screening interventions over time. However, there are challenges and nuances in computing and interpreting PTC. Methods: In this manuscript, we describe some desired properties of PTC measures, challenges in achieving those, and potential solutions using hypothetical examples. Results: We propose a modified PTC measure (mPTC) to complement the standard, existing PTC measure. The mPTC measure focuses on screening completion rather than initiation when a screening modality requires more than one step; is affected less by loss to follow-up, death, or cancer during covered time than the standard PTC measure; and is not sensitive to screening episode results. We propose weighting strategies to ensure that the average PTC and mPTC are more heavily influenced by individuals who were observed for longer and are thus more informative. We further describe how PTC and mPTC measures can incorporate test indication to focus specifically on screening. Conclusions: We recommend that studies of covered time present ample descriptive information, calculate both PTC and mPTC, describe how symptoms and indication are handled, and present multiple complementary measures, such as the proportion never screened and the proportion in need of screening. Impact: Common approaches, terminology, and reporting practices for covered time measures have the potential to improve the study of longitudinal cancer screening adherence.

Background: Colorectal cancer screening with fecal immunochemical testing (FIT) can reduce colorectal cancer–related mortality. Effectiveness of FIT may be compromised when patients do not adhere to a regular schedule. However, having no standard measure of repeat FIT presents challenges for assessing effectiveness across populations and settings. We compared three measures of repeat FIT in a large, integrated health care system in Dallas, Texas. Methods: We identified 18,257 patients age-eligible (50–60 years) for FIT in January 1–December 31, 2010 and followed over four rounds of screening. Measures included: (i) repeat FIT in prior screeners, or completion of FIT within 9–15 months of the previous; (ii) yes–no patterns, whereby patients were assigned yes or no in 9–15 month windows; and 3) proportion of time covered (PTC), or the amount of time patients were up-to-date with screening relative to time eligible. Results: Repeat FIT varied by measure. Using a prior screeners measure, 15.8% of patients with a normal FIT in round 1 completed repeat FIT in round 2. Repeat FIT was notably higher (52.3%) using PTC. The most common yes–no pattern was YNNN or “one-and-done,” and only 9.4% of patients completed two consecutive FITs across all rounds (YYNN). Conclusions: Different measures of repeat FIT yielded a range of estimates, making comparison across studies difficult. Researchers should weigh the advantages and disadvantages of each measure and select the most appropriate to their research question. Impact: Our study highlights the need for future research of repeat FIT measures that best approximate screening effectiveness.

Characterize prevalence of intimate partner violence (IPV) among breast and cervical survivors receiving care in an urban safety-net healthcare system; Examine the relationship between IPV and clinical characteristics, receipt of cancer treatment, and guideline-recommended survivorship care. From 2010 to 2017, breast and cervical cancer survivors were identified and recruited from a large, integrated, safety-net hospital system. Electronic health records (EHR; to measure survivorship care), cancer registry (to measure clinical characteristics), and patient telephone surveys (to measure IPV) were triangulated among 312 survivors. Bivariate and multivariable models assessed the relationship between victimization and clinical characteristics, cancer treatment, and guideline-recommended survivorship care. Among the 312 participants, 54% identified as IPV+. Among breast cancer, IPV+ cancer participants were twice more likely to develop estrogen receptor negative ER- and/or progesterone receptor negative PR- tumor receptors compared with IPV- cancer participants (AOR = 2.31; 95% CI, 1.20, 4.44). IPV+ breast cancer participants were less likely to have surgery and less likely to have hormone therapy as a first course of treatment compared with IPV- participants. There was no relationship between IPV and adherence to guideline-recommended cancer survivorship care. This study expands our current knowledge on how victimization, and specifically IPV, impact health among specialty care. Future research should determine the feasibility of implementing Trauma-Informed Care in oncology practices to better optimize care. At integrated hospital systems, IPV+ cancer participants should utilize social workers, within their oncology clinics, to connect to victim services.

Screening with fecal occult blood tests (FOBT) reduces colorectal cancer mortality. Failure to complete repeat tests may compromise screening effectiveness. We conducted a systematic review of repeat FOBT across diverse health care settings. We searched MEDLINE, Embase, and the Cochrane Library for studies published from 1997 to 2017 and reported repeat FOBT over ≥2 screening rounds. Studies (n = 27 reported in 35 articles) measured repeat FOBT as (i) proportion of Round 1 participants completing repeat FOBT in Round 2; (ii) proportion completing two, consecutive FOBT; or (iii) proportion completing ≥3 rounds. Among those who completed FOBT in Round 1, 24.6% to 89.6% completed repeat FOBT in Round 2 [median: 82.0%; interquartile range (IQR): 73.7%–84.6%]. The proportion completing FOBT in two rounds ranged from 16.4% to 80.0% (median: 46.6%; IQR: 40.5%–50.0%), and in studies examining ≥3 rounds, repeat FOBT ranged from 0.8% to 64.1% (median: 39.2%; IQR: 19.7%–49.4%). Repeat FOBT appeared higher in mailed outreach (69.1%–89.6%) compared with opportunistic screening (24.6%–48.6%). Few studies examined correlates of repeat FOBT. In summary, we observed a wide prevalence of repeat FOBT, and prevalence generally declined in successive screening rounds. Interventions that increase and maintain participation in FOBT are needed to optimize effectiveness of this screening strategy.

In contrast to the decreasing incidence of colorectal cancer (CRC) in older populations, the incidence has nearly doubled in younger adults since the early 1990s. Approximately 1 in 10 new diagnoses of CRC are now made in individuals 50 years or younger. Patients’ risk of CRC has been calculated largely by age and family history, yet 3 of 4 patients with early-onset CRC have no family history of the disease. Rapidly increasing incidence rates in younger persons could result from generational differences in diet, environmental exposures, and lifestyle factors. We review epidemiologic trends in CRC, data on genetic and non-genetic risk factors, and new approaches for determining CRC risk. These may identify individuals likely to benefit from early screening and specialized surveillance.

Background:Incidence rates of gastric cancer are increasing in young adults (age Methods:We used population-based data from the California and Texas Cancer Registries from 1995 to 2016 to estimate age-adjusted incidence rates of EOGC among Hispanic and non-Hispanic White persons by year, sex, tumor stage, census tract poverty level, metro versus nonmetro county, and state. We used logistic regression models to identify factors associated with distant stage diagnosis.Results:Of 3,047 persons diagnosed with EOGC, 73.2% were Hispanic White. Incidence rates were 1.29 [95% confidence interval (CI), 1.24–1.35] and 0.31 (95% CI, 0.29–0.33) per 100,000 Hispanic White and non-Hispanic White persons, respectively, with consistently higher incidence rates among Hispanic persons at all levels of poverty. There were no statistically significant associations between ethnicity and distant stage diagnosis in adjusted analysis.Conclusions:There are ethnic disparities in EOGC incidence rates that persist across poverty levels.Impact:EOGC incidence rates vary by ethnicity and poverty; these factors should be considered when assessing disease risk and targeting prevention efforts.

The effectiveness of hepatocellular carcinoma (HCC) surveillance is mitigated by underuse in clinical practice, highlighting a need for interventions. We evaluated the effectiveness of mailed HCC surveillance outreach to promote HCC surveillance in patients with cirrhosis.We conducted a multicenter pragmatic randomized clinical trial comparing mailed outreach for surveillance ultrasound (n = 1436) and usual care with visit-based surveillance (n = 1436) among patients with cirrhosis at 3 health systems (tertiary care referral center, safety net health system, and Veterans Affairs medical center) from April 2018 to December 2019. The primary outcome of this interim analysis was guideline concordant semiannual HCC surveillance over a 12-month period and a secondary outcome was proportion time covered by surveillance. All patients were included in intention-to-screen analyses.Compared with usual care, the outreach arm had significantly higher semiannual surveillance (35.1% vs 21.9%) and lower no-surveillance (29.8% vs 43.5%) (P.001), resulting in significant increases in the proportion of time covered by surveillance (41.3% vs 31.0%; P.001). The intervention increased HCC surveillance across most predefined subgroups; however, there were site-level differences in the intervention effect, with significant increases in semiannual surveillance at the Veterans Affairs and safety net health systems but not at the tertiary care referral center.Mailed outreach significantly increased semiannual HCC surveillance vs usual care in patients with cirrhosis, with a consistent intervention effect across most examined subgroups. Continued follow-up is ongoing to determine if these increases in surveillance translate into improved downstream outcomes includi.ng early HCC detection and curative treatment receipt. (ClinicalTrials.gov, Numbers: NCT02582918 and NCT03756051).

National data on COVID-19 vaccine breakthrough infections is inadequate but urgently needed to determine U.S. policy during the emergence of the Delta variant. We address this gap by comparing SARS CoV-2 infection by vaccination status from February 1, 2021 to August 13, 2021 in the Veterans Health Administration, covering 2.7% of the U.S. population. Vaccine protection declined by mid-August 2021, decreasing from 91.9% in March to 53.9% (p

We examined prescription medication use and identified correlates of polypharmacy-taking multiple medications-in adolescent and young adult cancer survivors (AYAs), who experience early-onset chronic conditions.Our cross-sectional study pooled data (2008-2017) from the national Medical Expenditure Panel Survey. We estimated prevalence of polypharmacy (≥ 5 unique prescription medications over an approximate 1-year period) in AYAs (age 18-39 years with a history of cancer) and age- and sex-matched controls, overall and by sociodemographics, clinical factors, and health indicators. We compared survivors' and controls' medication use across therapeutic classes. To identify correlates of polypharmacy among AYAs, we included factors with p 0.20 in bivariable analysis in a multivariable logistic regression model.AYAs (n = 601) had a higher prevalence of polypharmacy than controls (n = 2,402), overall (31.5% vs. 15.9%, p .01) and by all sociodemographics, clinical factors, and health indicators. A majority of AYAs with multiple chronic conditions (58.8%, 95% CI 47.3-70.4) or disability (61.3%, 95% CI 52.6-70.0) had polypharmacy. Patterns of AYAs' medication use across therapeutic classes were consistent with their chronic conditions. Nearly one-third used opioid/narcotic analgesics (32.2% vs. 13.7% of controls, p 0.01). Among AYAs, multiple chronic conditions (aOR 4.68, 95% CI 2.23-9.83) and disability (aOR 3.70, 95% CI 2.23-6.14) were correlated with polypharmacy.Chronic conditions and disabilities, including aftereffects of cancer treatment, may drive polypharmacy in AYAs. Future research should examine adverse outcomes of polypharmacy and opioid/narcotic use in AYAs.AYAs with chronic conditions or disabilities should be monitored for polypharmacy.