Publications by authors named "Tomi Akinyemiju"

98 Publications

Ovarian Cancer Epidemiology, Healthcare Access and Disparities (ORCHiD): methodology for a population-based study of black, Hispanic and white patients with ovarian cancer.

BMJ Open 2021 Oct 4;11(10):e052808. Epub 2021 Oct 4.

Georgetown University Medical Center, Washington, District of Columbia, USA.

Introduction: Less than 40% of patients with ovarian cancer (OC) in the USA receive stage-appropriate guideline-adherent surgery and chemotherapy. Black patients with cancer report greater depression, pain and fatigue than white patients. Lack of access to healthcare likely contributes to low treatment rates and racial differences in outcomes. The Ovarian Cancer Epidemiology, Healthcare Access and Disparities study aims to characterise healthcare access (HCA) across five specific dimensions-Availability, Affordability, Accessibility, Accommodation and Acceptability-among black, Hispanic and white patients with OC, evaluate the impact of HCA on quality of treatment, supportive care and survival, and explore biological mechanisms that may contribute to OC disparities.

Methods And Analysis: We will use the Surveillance Epidemiology and Ends Results dataset linked with Medicare claims data from 9744 patients with OC ages 65 years and older. We will recruit 1641 patients with OC (413 black, 299 Hispanic and 929 white) from cancer registries in nine US states. We will examine HCA dimensions in relation to three main outcomes: (1) receipt of quality, guideline adherent initial treatment and supportive care, (2) quality of life based on patient-reported outcomes and (3) survival. We will obtain saliva and vaginal microbiome samples to examine prognostic biomarkers. We will use hierarchical regression models to estimate the impact of HCA dimensions across patient, neighbourhood, provider and hospital levels, with random effects to account for clustering. Multilevel structural equation models will estimate the total, direct and indirect effects of race on treatment mediated through HCA dimensions.

Ethics And Dissemination: Result dissemination will occur through presentations at national meetings and in collaboration with collaborators, community partners and colleagues across othercancer centres. We will disclose findings to key stakeholders, including scientists, providers and community members. This study has been approved by the Duke Institutional Review Board (Pro00101872). Safety considerations include protection of patient privacy. All disseminated data will be deidentified and summarised.
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http://dx.doi.org/10.1136/bmjopen-2021-052808DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8491419PMC
October 2021

Association of body composition with odds of breast cancer by molecular subtype: analysis of the Mechanisms for Established and Novel Risk Factors for Breast Cancer in Nigerian Women (MEND) study.

BMC Cancer 2021 Sep 25;21(1):1051. Epub 2021 Sep 25.

College of Medicine & Lagos University Teaching Hospital, University of Lagos, Lagos, Lagos State, Nigeria.

Background: The association between obesity and breast cancer (BC) has been extensively studied among US, European and Asian study populations, with often conflicting evidence. However, despite the increasing prevalence of obesity and associated conditions in Africa, the continent with the highest age-standardized BC mortality rate globally, few studies have evaluated this association, and none has examined in relation to molecular subtypes among African women. The current analysis examines the association between body composition, defined by body mass index (BMI), height, and weight, and BC by molecular subtype among African women.

Methods: We estimated odds ratios (ORs) and 95% confidence intervals (95% CI) for the association between measures of body composition and BC and molecular subtypes among 419 histologically confirmed cases of BC and 286 healthy controls from the Mechanisms for Established and Novel Risk Factors for Breast Cancer in Women of Nigerian Descent (MEND) case-control study.

Results: Higher BMI (aOR: 0.79; 95% CI: 0.67, 0.95) and weight (aOR: 0.83; 95% CI: 0.69, 0.98) were associated with reduced odds of BC in adjusted models, while height was associated with non-statistically significant increased odds of BC (aOR: 1.07, 95% CI: 0.90, 1.28). In pre/peri-menopausal, but not post-menopausal women, both higher BMI and weight were significantly associated with reduced odds of BC. Further, higher BMI was associated with reduced odds of Luminal A, Luminal B, and HER2-enriched BC among pre/peri-menopausal women, and reduced odds of triple-negative BC among post-menopausal women.

Conclusions: Higher BMI and weight were associated with reduced odds of BC overall and by molecular subtype among West African women. Larger studies of women of African descent are needed to definitively characterize these associations and inform cancer prevention strategies.
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http://dx.doi.org/10.1186/s12885-021-08775-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8464100PMC
September 2021

Social determinants of health and cancer mortality in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study.

Cancer 2021 Sep 3. Epub 2021 Sep 3.

Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York.

Background: Social determinants of health (SDOHs) cluster together and can have deleterious impacts on health outcomes. Individually, SDOHs increase the risk of cancer mortality, but their cumulative burden is not well understood. The authors sought to determine the combined effect of SDOH on cancer mortality.

Methods: Using the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, the authors studied 29,766 participants aged 45+ years and followed them 10+ years. Eight potential SDOHs were considered, and retained SDOHs that were associated with cancer mortality (P < .10) were retained to create a count (0, 1, 2, 3+). Cox proportional hazard models estimated associations between the SDOH count and cancer mortality through December 31, 2017, adjusting for confounders. Models were age-stratified (45-64 vs 65+ years).

Results: Participants were followed for a median of 10.6 years (interquartile range [IQR], 6.5, 12.7 years). Low education, low income, zip code poverty, poor public health infrastructure, lack of health insurance, and social isolation were significantly associated with cancer mortality. In adjusted models, among those <65 years, compared to no SDOHs, having 1 SDOH (adjusted hazard ratio [aHR], 1.39; 95% CI, 1.11-1.75), 2 SDOHs (aHR, 1.61; 95% CI, 1.26-2.07), and 3+ SDOHs (aHR, 2.09; 95% CI, 1.58-2.75) were associated with cancer mortality (P for trend <.0001). Among individuals 65+ years, compared to no SDOH, having 1 SDOH (aHR, 1.16; 95% CI, 1.00-1.35) and 3+ SDOHs (aHR, 1.26; 95% CI, 1.04-1.52) was associated with cancer mortality (P for trend = .032).

Conclusions: A greater number of SDOHs were significantly associated with an increased risk of cancer mortality, which persisted after adjustment for confounders.
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http://dx.doi.org/10.1002/cncr.33894DOI Listing
September 2021

Association of Life-Course Educational Attainment and Breast Cancer Grade in the MEND Study.

Ann Glob Health 2021 7;87(1):59. Epub 2021 Jul 7.

Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA.

Background: Nigeria reports the highest age-standardized mortality rate for breast cancer (BC) among African countries and disproportionately high rates of high-grade cancer. Histological grade is a strong predictor of mortality, and evidence suggests that educational attainment influences cancer outcomes.

Objective: We characterize the association between educational trends across the life-course and BC grade at diagnosis.

Methods: Data on 224 BC patients enrolled in the Mechanisms for Established and Novel Risk Factors for Breast Cancer in Nigerian Women (MEND) study was analyzed. Participant and parental (mother and father) education was categorized as low (primary school or less) or high (secondary school or greater). Accordingly, the educational trend across the life-course was determined for each participant relative to each parent: stable high, increasing, decreasing, or stable low. BC grade was classified as high (grade 3) or low (grades 1-2).

Findings: About 34% of participants, 71% of fathers, and 85% of mothers had low education. Approximately one-third of participants were diagnosed with high-grade BC. Participants with low-grade BC were more likely to have highly educated fathers (p = 0.04). After adjusting for age, comorbidities, marital status and mammogram screening, participants with highly educated fathers were 60% less likely to have high-grade BC (aOR 0.41; 95% CI 0.20 to 0.84) compared to those with less-educated fathers. Stable high life-course education relative to father was also associated with a significantly lower likelihood of having high-grade BC (aOR 0.36; 95% CI 0.15 to 0.87) compared to stable low life-course education. No significant associations were observed for the participant's education, mother's education, or life-course education relative to mother.

Conclusions: Early-life socioeconomic status (SES) may influence BC grade. This deserves further study to inform policies that may be useful in reducing high-grade BC in Nigeria.
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http://dx.doi.org/10.5334/aogh.3142DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8269775PMC
September 2021

Early Medicaid Expansion and Cancer Mortality.

J Natl Cancer Inst 2021 Jul 14. Epub 2021 Jul 14.

Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.

Background: While Medicaid expansion is associated with decreased uninsured rates and earlier cancer diagnoses, no study has demonstrated an association between Medicaid expansion and cancer mortality. Our primary objective was to quantify the relationship between early Medicaid expansion and changes in cancer mortality rates.

Methods: We obtained county-level data from the National Center for Health Statistics for adults ages 20-64 who died from cancer from 2007-2009 (pre-expansion) and 2012-2016 (post-expansion). We compared changes in cancer mortality rates in early Medicaid expansion states (CA, CT, DC, MN, NJ, and WA) vs. non-expansion states through a difference-in-differences (DID) analysis using hierarchical Bayesian regression. An exploratory analysis of cancer mortality changes associated with the larger-scale 2014 Medicaid expansions was also performed.

Results: In adjusted DID analyses, we observed a statistically significant decrease of 3.07 (95% credible interval = 2.19 to 3.95) cancer deaths per 100,000 in early expansion vs. non-expansion states, which translates to an estimated decrease of 5,276 cancer deaths in the early expansion states during the study period. Expansion-associated decreases in cancer mortality were observed for pancreatic cancer. Exploratory analyses of the 2014 Medicaid expansions showed a decrease in pancreatic cancer mortality (-0.18 deaths per 100,000, 95% confidence interval = -0.32 to -0.05) in states that expanded Medicaid by 2014 compared to non-expansion states.

Conclusion(s): Early Medicaid expansion was associated with reduced cancer mortality rates, especially for pancreatic cancer, a cancer with short median survival where changes in prognosis would be most visible with limited follow-up.
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http://dx.doi.org/10.1093/jnci/djab135DOI Listing
July 2021

Health Care Access Measures and Palliative Care Use by Race/Ethnicity among Metastatic Gynecological Cancer Patients in the United States.

Int J Environ Res Public Health 2021 06 4;18(11). Epub 2021 Jun 4.

Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27701, USA.

Palliative care improves quality-of-life and extends survival, however, is underutilized among gynecological cancer patients in the United States (U.S.). Our objective was to evaluate associations between healthcare access (HCA) measures and palliative care utilization among U.S. gynecological cancer patients overall and by race/ethnicity. We used 2004-2016 data from the U.S. National Cancer Database and included patients with metastatic (stage III-IV at-diagnosis) ovarian, cervical, and uterine cancer (n = 176,899). Palliative care was defined as non-curative treatment and could include surgery, radiation, chemotherapy, and pain management, or any combination. HCA measures included insurance type, area-level socioeconomic measures, distance-to-care, and cancer treatment facility type. We evaluated associations of HCA measures with palliative care use overall and by race/ethnicity using multivariable logistic regression. Our population was mostly non-Hispanic White (72%), had ovarian cancer (72%), and 24% survived <6 months. Five percent of metastatic gynecological cancer patients utilized palliative care. Compared to those with private insurance, uninsured patients with ovarian (aOR: 1.80,95% CI: 1.53-2.12), and cervical (aOR: 1.45,95% CI: 1.26-1.67) cancer were more likely to use palliative care. Patients with ovarian (aOR: 0.58,95% CI: 0.48-0.70) or cervical cancer (aOR: 0.74,95% CI: 0.60-0.88) who reside >45 miles from their provider were less likely to utilize palliative care than those within <2 miles. Ovarian cancer patients treated at academic/research programs were less likely to utilize palliative care compared to those treated at community cancer programs (aOR: 0.70, 95%CI: 0.58-0.84). Associations between HCA measures and palliative care utilization were largely consistent across U.S. racial-ethnic groups. Insurance type, cancer treatment facility type, and distance-to-care may influence palliative care use among metastatic gynecological cancer patients in the U.S.
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http://dx.doi.org/10.3390/ijerph18116040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8200023PMC
June 2021

Association of genetic variants of FBXO32 and FOXO6 in the FOXO pathway with breast cancer risk.

Mol Carcinog 2021 10 1;60(10):661-670. Epub 2021 Jul 1.

Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA.

Forkhead box class O (FOXO) transcription factors play a pivotal role in regulating a variety of biological processes, including organismal development, cell signaling, cell metabolism, and tumorigenesis. Therefore, we hypothesize that genetic variants in FOXO pathway genes are associated with breast cancer (BC) risk. To test this hypothesis, we conducted a large meta-analysis using 14 published genome-wide association study (GWAS) data sets in the Discovery, Biology, and Risk of Inherited Variants in Breast Cancer (DRIVE) study. We assessed associations between 5214 (365 genotyped in DRIVE and 4849 imputed) common single-nucleotide polymorphisms (SNPs) in 55 FOXO pathway genes and BC risk. After multiple comparison corrections by the Bayesian false-discovery probability method, we found five SNPs to be significantly associated with BC risk. In stepwise multivariate logistic regression analysis with adjustment for age, principal components, and previously published SNPs in the same data set, three independent SNPs (i.e., FBXO32 rs10093411 A>G, FOXO6 rs61229336 C>T, and FBXO32 rs62521280 C>T) remained to be significantly associated with BC risk (p = 0.0008, 0.0011, and 0.0017, respectively). Additional expression quantitative trait loci analysis revealed that the FBXO32 rs62521280 T allele was associated with decreased messenger RNA (mRNA) expression levels in breast tissue, while the FOXO6 rs61229336 T allele was found to be associated with decreased mRNA expression levels in the whole blood cells. Once replicated by other investigators, these genetic variants may serve as new biomarkers for BC risk.
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http://dx.doi.org/10.1002/mc.23331DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8475729PMC
October 2021

Association of high-sensitivity C-reactive protein and odds of breast cancer by molecular subtype: analysis of the MEND study.

Oncotarget 2021 Jun 22;12(13):1230-1242. Epub 2021 Jun 22.

Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA.

Breast cancer (BC) in Nigeria is characterized by disproportionately aggressive molecular subtypes. C-reactive protein (CRP) is associated with risk and aggressiveness for several types of cancer. We examined the association of high-sensitivity CRP (hsCRP) with odds of BC by molecular subtype among Nigerian women. Among 296 newly diagnosed BC cases and 259 healthy controls, multivariable logistic regression models were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the association between hsCRP and odds of BC overall and by molecular subtype (luminal A, luminal B, HER2-enriched and triple-negative or TNBC). High hsCRP (> 3 mg/L) was observed in 57% of cases and 31% of controls and was associated with 4 times the odds of BC (aOR: 4.43; 95% CI: 2.56, 7.66) after adjusting for socio-demographic, reproductive, and clinical variables. This association persisted regardless of menopausal status and body mass index (BMI) category. High hsCRP was associated with increased odds of TNBC (aOR: 3.32; 95% CI: 1.07, 10.35), luminal A BC (aOR: 4.03; 95% CI: 1.29, 12.64), and HER2-enriched BC (aOR: 6.27; 95% CI: 1.69, 23.25). Future studies are necessary in this population to further evaluate a potential role for CRP as a predictive biomarker for BC.
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http://dx.doi.org/10.18632/oncotarget.27991DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8238238PMC
June 2021

Comorbidity Profiles and Lung Cancer Screening among Older Adults: U.S. Behavioral Risk Factor Surveillance System 2017 to 2019.

Ann Am Thorac Soc 2021 May 3. Epub 2021 May 3.

Georgetown University Medical Center, 12231, Oncology, Washington, District of Columbia, United States;

Rationale: Although lung cancer screening (LCS) with low-dose computed tomography (LDCT) is now recommended for those meeting standard risk factor-based eligibility criteria, the role of comorbidity in the uptake of LCS with LDCT in an older real-world U.S. population is not well established.

Objective: To examine the relationships between comorbidity, functional status and LCS utilization in the United States.

Methods: Using population-based data from the 2017-2019 Behavioral Risk Factor Surveillance System (BRFSS), we examined the association of comorbid conditions and functional limitations regarding activities of daily living with LCS utilization among participants that met the LCS criteria based on the US Preventive Service Taskforce guidelines. We employed multivariable weighted logistic regression models to evaluate these associations, both overall and within subgroups defined by age (<65 vs. ≥65 years), gender, and smoking history.

Results: Of 11,214 participants that met the eligibility criteria for LCS, 1731 (16%) underwent LCS with LDCT. The majority were white (90%), male (55%), former smokers (52%) and living with at least one chronic comorbid condition (77%). Over 28% had 3 or more comorbid conditions and approximately 40% of participants reported having some form of functional limitations. In the multivariable models, the likelihood of undergoing LCS with LDCT within the past year was positively associated with higher levels of comorbidity (≥5 vs. 0: aOR=2.34, 95% CI=1.22,4.48) but not with functional limitations (≥3 vs. 0: aOR=1.00, 95% CI=0.66, 1.50).

Conclusion: The presence of comorbid conditions is associated with a higher likelihood of undergoing LCS with LDCT. Because poor health status may diminish the benefits of screening, future research is needed to precisely characterize the health status of LCS-eligible individuals.
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http://dx.doi.org/10.1513/AnnalsATS.202010-1276OCDOI Listing
May 2021

Immunotherapy Utilization Among Patients With Metastatic NSCLC: Impact of Comorbidities.

J Immunother 2021 06;44(5):198-203

Department of Population Health Sciences.

In patients with metastatic non-small cell lung cancer (mNSCLC), the extent to which immunotherapy utilization rate varies by comorbidities is unclear. Using the National Cancer Database from 2015 to 2016, we assessed the association between levels of comorbidity and immunotherapy utilization among mNSCLC patients. Burden of comorbidities was ascertained based on the modified Charlson-Deyo score and categorized as an ordinal variable (0, 1, and ≥2). Immunotherapy utilization was determined based on registry data. Multivariable logistic regressions were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the comorbidity score while adjusting for sociodemographic factors, histopathologic subtype, surgery, chemotherapy, radiotherapy, insurance, facility type, and other cancer history. Subgroup analyses were conducted by age and race/ethnicity. Overall, of the 89,030 patients with mNSCLC, 38.6% (N=34,382) had the comorbidity score of ≥1. Most patients were non-Hispanic white (82.3%, N=73,309) and aged 65 years and above (63.2%, N=56,300), with the mean age of 68.4 years (SD=10.6). Only 7.0% (N=6220) of patients received immunotherapy during 2015-2106. Patients with a comorbidity score of ≥2 had a significantly lower rate of immunotherapy utilization versus those without comorbidities (aOR=0.85; 95% CI, 0.78-0.93; P-trend<0.01). In subgroup analysis by age, association patterns were similar among patients younger than 65 and those aged 65-74 years. There were no significant differences in subgroup analysis by race/ethnicity, although statistical significance was only observed for white patients (comorbidity score ≥2 vs. 0: aOR=0.85; 95% CI, 0.77-0.93; P-trend<0.01). In conclusion, mNSCLC patients with a high burden of comorbidities are less likely to receive immunotherapy.
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http://dx.doi.org/10.1097/CJI.0000000000000366DOI Listing
June 2021

A novel evolutionary-concordance lifestyle score is inversely associated with all-cause, all-cancer, and all-cardiovascular disease mortality risk.

Eur J Nutr 2021 Sep 6;60(6):3485-3497. Epub 2021 Mar 6.

Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA.

Purpose: Evolutionary discordance may contribute to the high burden of chronic disease-related mortality in modern industrialized nations. We aimed to investigate the associations of a 7-component, equal-weight, evolutionary-concordance lifestyle (ECL) score with all-cause and cause-specific mortality.

Methods: Baseline data were collected in 2003-2007 from 17,465 United States participants in the prospective REasons for Geographic and Racial Differences in Stroke (REGARDS) study. The ECL score's components were: a previously reported evolutionary-concordance diet score, alcohol intake, physical activity, sedentary behavior, waist circumference, smoking history, and social network size. Diet was assessed using a Block 98 food frequency questionnaire and anthropometrics by trained personnel; other information was self-reported. Higher scores indicated higher evolutionary concordance. We used multivariable Cox proportional hazards regression models to estimate ECL score-mortality associations.

Results: Over a median follow-up of 10.3 years, 3771 deaths occurred (1177 from cardiovascular disease [CVD], 1002 from cancer). The multivariable-adjusted hazard ratios (HR) (95% confidence intervals [CI]) for those in the highest relative to the lowest ECL score quintiles for all-cause, all-CVD, and all-cancer mortality were, respectively, 0.45 (0.40, 0.50), 0.47 (0.39, 0.58), and 0.42 (0.34, 0.52) (all P trend < 0.01). Removing smoking and diet from the ECL score attenuated the estimated ECL score-all-cause mortality association the most, yielding fifth quintile HRs (95% CIs) of 0.56 (0.50, 0.62) and 0.50 (0.46, 0.55), respectively.

Conclusions: Our findings suggest that a more evolutionary-concordant lifestyle may be inversely associated with all-cause, all-CVD, and all-cancer mortality. Smoking and diet appeared to have the greatest impact on the ECL-mortality associations.
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http://dx.doi.org/10.1007/s00394-021-02529-9DOI Listing
September 2021

Temporal changes in allostatic load patterns by age, race/ethnicity, and gender among the US adult population; 1988-2018.

Prev Med 2021 06 26;147:106483. Epub 2021 Feb 26.

Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA. Electronic address:

The objective of this study is to provide an assessment of allostatic load (AL) burden among US adults across race/ethnicity, gender, and age groups over a 30-year time period. We analyzed data from 50,671 participants of the National Health and Nutrition Examination Survey (NHANES) years 1988 through 2018. AL score was defined as the sum total for abnormal measures of the following components: serum albumin, body mass index, serum C - reactive protein, serum creatinine, diastolic blood pressure, glycated hemoglobin, systolic blood pressure, total cholesterol, and serum triglycerides. We performed modified Poisson regression to estimate the adjusted Relative Risks (aRRs) of allostatic load, and generalized linear models to determine adjusted mean differences accounting for NHANES sampling weights. Among US adults aged 18 or older, the prevalence of high AL increased by more than 45% from 1988 to 1991 to 2015-2018, from 33.5% to 48.6%. By the latest period, 2015-2018, Non-Hispanic Black women (aRR: 1.292; 95% CI: 1.290-1.293) and Latina women (aRR: 1.266; 95% CI: 1.265-1.267) had higher risks of AL than non-Hispanic White women. Similar trends were observed among men. Age-adjusted mean AL score among NH-Black and Latinx adults was higher than for NH-Whites of up to a decade older regardless of gender. From 1988 through 2018, Adults aged 40 years old and older had over 2-fold increased risks of high AL when compared to adults 18-29 years old. After 30-years of collective data, racial disparities in allostatic load persist for NH-Black and Latinx adults.
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http://dx.doi.org/10.1016/j.ypmed.2021.106483DOI Listing
June 2021

Racial disparities in palliative care utilization among metastatic gynecological cancer patients living at last follow-up: An analysis of the National Cancer Data Base.

Data Brief 2021 Feb 30;34:106705. Epub 2020 Dec 30.

Department of Population Health, Duke Health System, Durham, NC, United States.

The National Comprehensive Cancer Network recommends palliative care should be integrated in to cancer care starting from cancer diagnosis. However, traditionally palliative care is prioritized for cancer patients at the end-of-life. In our main article titled "Racial and Ethnic Disparities in Palliative Care Utilization Among Gynecological Cancer Patients" we present data describing racial/ethnic disparities among metastatic gynecological cancer patients who were deceased at last follow-up. Here, we expand our population to evaluate racial disparities in palliative care utilization among (1) all metastatic gynecologic cancer patients, regardless of vital status (alive or deceased) ( = 176,899) and (2) among only patients who were alive at last follow-up ( = 66,781). We used data from the 2016 National Cancer Database (NCDB) and included patients between ages 18-90 years with metastatic (stage III-IV) gynecologic cancers including, ovarian, cervical and uterine cancer. Palliative care was defined by NCDB as non-curative treatment, and could include surgery, radiation, chemotherapy, and pain management or any combination. We used multivariable logistic regression to evaluate racial disparities in palliative care use among our two populations of interest. Overall, the mean age of gynecologic cancer patients utilizing palliative care was 66 years. Five percent of all metastatic gynecologic oncology patients utilized palliative care overall; and by cancer site palliative care use was as follows: 4% among ovarian, 9% among cervical, and 11% among uterine cancer patients. Among patients who utilized palliative care, 62% utilized surgery, radiation or chemotherapy only and 12% utilized pain management as a form of palliative care. Among ovarian cancer patients, Hispanic ovarian cancer patients were less likely to utilize palliative care compared to their NH-White counterparts (aOR: 0.79, 95% CI: 0.68-0.91). Among cervical cancer patients, we observed that Hispanic (aOR: 0.65, 95% CI: 0.56-0.75) and Asian (aOR: 0.74, 95% CI: 0.59-0.93) were less likely to utilize palliative care than NH-White cervical cancer patients. We observed no racial disparities in palliative care utilization among uterine cancer patients. When we focused on patients who were alive at last follow-up we found that only 3% of patients utilized palliative care. We also conducted multivariable analyses of racial/ethnic disparities among ovarian and cervical cancer patients who were alive at last follow-up. We were unable to conduct multivariable analyses of uterine cancer patients who were alive at last follow-up due to limited sample size of those who utilized palliative care. We observed no racial/ethnic disparities among this patient population of metastatic gynecologic patients.
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http://dx.doi.org/10.1016/j.dib.2020.106705DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803651PMC
February 2021

Use of therapeutic plasma exchange in heparin-induced thrombocytopenia: A population-based study.

J Clin Apher 2021 Jun 16;36(3):398-407. Epub 2021 Jan 16.

Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.

Background: Heparin-induced thrombocytopenia (HIT) is characterized by anti-heparin/platelet factor 4 immune complexes, which are removed by therapeutic plasma exchange (TPE). Our main objective was to study TPE outcomes in HIT using a large administrative claims database.

Study Design And Methods: We used the National Inpatient Sample (NIS) to identify hospital discharges of adult patients (≥18) with a primary or secondary diagnosis of HIT. Cases were classified into two groups based on TPE use. The primary outcome was in-hospital mortality. Secondary outcomes were thrombotic events, major bleeding, hospital length of stay (LOS), and charges. Multivariable regression analysis, controlling for age and medical comorbidities, was used to examine the association of TPE with study outcomes.

Results: A HIT diagnosis was made in 22 165 discharges, of which 90 (0.4%) received TPE. Corresponding national estimates are 106 435 and 439, respectively. TPE was not associated with decreased in-hospital mortality (OR = 1.72; 95%CI: 0.93-3.17, P = .085). However, TPE was associated with a higher likelihood of major bleeding (OR = 2.35; 95%CI: 1.40-3.68, P = .0009), primarily driven by gastrointestinal bleeding (OR = 2.21; 95%CI: 1.17-4.17, P = .015). TPE was also associated with higher hospital LOS (20.5 vs 10 day, P < .0001) and charges (USD 211181 vs USD 81654, P < .0001).

Conclusion: TPE's association with increased bleeding and a prolonged hospital course indicates that it is being used in HIT cases with a severe clinical phenotype. Future studies are needed to better characterize the HIT phenotype that will most benefit from TPE.
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http://dx.doi.org/10.1002/jca.21876DOI Listing
June 2021

Racial and ethnic disparities in palliative care utilization among gynecological cancer patients.

Gynecol Oncol 2021 02 2;160(2):469-476. Epub 2020 Dec 2.

Department of Population Health, Duke Health System, Durham, North Carolina, United States of America. Electronic address:

Background: Palliative care (PC) is recommended for gynecological cancer patients to improve survival and quality-of-life. Our objective was to evaluate racial/ethnic disparities in PC utilization among patients with metastatic gynecologic cancer.

Methods: We used data from the 2016 National Cancer Database (NCDB) and included patients between ages 18-90 years with metastatic (stage III-IV) gynecologic cancers including, ovarian, cervical and uterine cancer who were deceased at last contact or follow-up (n = 124,729). PC was defined by NCDB as non-curative treatment, and could include surgery, radiation, chemotherapy, and pain management or any combination. We used multivariable logistic regression to evaluate racial disparities in PC use.

Results: The study population was primarily NH-White (74%), ovarian cancer patients (74%), insured by Medicare (47%) or privately insured (36%), and had a Charlson-Deyo score of zero (77%). Over one-third of patients were treated at a comprehensive community cancer program. Overall, 7% of metastatic gynecologic deceased cancer patients based on last follow-up utilized palliative care: more specifically, 5% of ovarian, 11% of cervical, and 12% of uterine metastatic cancer patients. Palliative care utilization increased over time starting at 4% in 2004 to as high as 13% in 2015, although palliative care use decreased to 7% in 2016. Among metastatic ovarian cancer patients, NH-Black (aOR:0.87, 95% CI:0.78-0.97) and Hispanic patients (aOR:0.77, 95% CI:0.66-0.91) were less likely to utilize PC when compared to NH-White patients. Similarly, Hispanic cervical cancer patients were less likely (aOR:0.75, 95% CI:0.63-0.88) to utilize PC when compared to NH-White patients.

Conclusions: PC is highly underutilized among metastatic gynecological cancer patients. Racial disparities exist in palliative care utilization among patients with metastatic gynecological cancer.
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http://dx.doi.org/10.1016/j.ygyno.2020.11.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8221248PMC
February 2021

Patterns of de-novo metastasis and breast cancer-specific mortality by race and molecular subtype in the SEER population-based dataset.

Breast Cancer Res Treat 2021 Apr 11;186(2):509-518. Epub 2020 Nov 11.

Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.

Purpose: To examine patterns of de-novo metastases (mets) and association with breast cancer-specific mortality across subtypes and racial groups.

Methods: Non-Hispanic (NH) Black and NH-White patients ages 40 years and older with primary breast cancer (BC) between 2010 and 2015 were examined. Multilevel logistic regression and Cox proportional hazards models were used to assess (1) odds of de-novo mets to specific sites by subtype, and (2) association of subtype with risk of BC mortality among patients with de-novo mets by race.

Results: A total of 204,941 BC patients were included in analysis. The most common de-novo mets site was to the bone, and overall prevalence of de-novo mets was higher among NH-Black (6.4%) versus NH-White (4.1%) patients. The odds of de-novo mets to any site were lower for TNBC (OR 0.68, 95% CI 0.62-0.73) and HR+/HER2- (OR 0.50, 95% CI 0.47-0.53) subtypes, but higher for HR-/HER2+ (OR 1.16, 95% CI 1.06-1.28) relative to HR+/HER2+ . De-novo mets to the brain only was associated with the highest mortality risk across all subtypes, ranging from a 13-fold increase (hazard ratio 13.45, 95% CI 5.03-35.96) for HR-/HER2+ to a 39-fold increase (hazard ratio 39.04, 95% CI 26.2-58.14) for HR+/HER2-.

Conclusion: Site and fatality of de-novo mets vary by subtype and by race. This information may help improve risk stratification and post-diagnostic surveillance to ultimately reduce BC mortality.
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http://dx.doi.org/10.1007/s10549-020-06007-4DOI Listing
April 2021

Variants in , and in vitamin D pathway genes are associated with breast cancer risk: a large-scale analysis of 14 GWASs in the DRIVE study.

Am J Cancer Res 2020 1;10(7):2160-2173. Epub 2020 Jul 1.

Duke Cancer Institute, Duke University Medical Center Durham 27710, NC, USA.

Vitamin D has a potential anticarcinogenic role, possibly through regulation of cell proliferation and differentiation, stimulation of apoptosis, immune modulation and regulation of estrogen receptor levels. Because breast cancer (BC) risk varies among individuals exposed to similar risk factors, we hypothesize that genetic variants in the vitamin D pathway genes are associated with BC risk. To test this hypothesis, we performed a larger meta-analysis using 14 published GWAS datasets in the Discovery, Biology, and Risk of Inherited Variants in Breast Cancer (DRIVE) Study. We assessed associations between 2,994 (237 genotyped in the DRIVE study and 2,757 imputed from the 1000 Genomes Project) single nucleotide polymorphisms (SNPs) in 33 vitamin D pathway genes and BC risk. In unconditional logistic regression analysis, we found 11 noteworthy SNPs to be associated with BC risk after multiple comparison correction by the Bayesian false-discovery probability method (<0.80). In stepwise logistic regression analysis, with adjustment for age, principal components and previously published SNPs in the same study populations, we identified three independent SNPs ( rs1047920 C>T, rs11826 C>T and rs3914238 C>T) to be associated with BC risk ( = 0.0014, 0.0020 and 0.0022, respectively). Additional expression quantitative trait loci analysis revealed that the rs73276407 A allele, in a high LD with the rs1047920 T allele, was associated with decreased mRNA expression levels, while the rs11826 T allele was significantly associated with elevated mRNA expression levels. Once replicated by other investigators and additional mechanistic studies, these genetic variants may serve as new biomarkers for susceptibility to BC.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7407344PMC
July 2020

Association of Allostatic Load with All-Cause andCancer Mortality by Race and Body Mass Index in theREGARDS Cohort.

Cancers (Basel) 2020 Jun 26;12(6). Epub 2020 Jun 26.

Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35233, USA.

Among 29,701 Black and White participants aged 45 years and older in the Reasons forGeographic and Racial Difference in Stroke (REGARDS) study, allostatic load (AL) was defined asthe sum score of established baseline risk-associated biomarkers for which participants exceeded aset cutoff point. Cox proportional hazard regression was utilized to determine the association of ALscore with all-cause and cancer-specific mortality, with analyses stratified by body-mass index, agegroup, and race. At baseline, Blacks had a higher AL score compared with Whites (Black mean ALscore: 2.42, SD: 1.50; White mean AL score: 1.99, SD: 1.39; < 0.001). Over the follow-up period,there were 4622 all-cause and 1237 cancer-specific deaths observed. Every unit increase in baselineAL score was associated with a 24% higher risk of all-cause (HR: 1.24, 95% CI: 1.22, 1.27) and a 7%higher risk of cancer-specific mortality (HR: 1.07, 95% CI: 1.03, 1.12). The association of AL withoverall- and cancer-specific mortality was similar among Blacks and Whites and across age-groups,however the risk of cancer-specific mortality was higher among normal BMI than overweight orobese participants. In conclusion, a higher baseline AL score was associated with increased risk ofall-cause and cancer-specific mortality among both Black and White participants. Targetedinterventions to patient groups with higher AL scores, regardless of race, may be beneficial as astrategy to reduce all-cause and cancer-specific mortality.
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http://dx.doi.org/10.3390/cancers12061695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352652PMC
June 2020

Association of Sedentary Behavior With Cancer Mortality in Middle-aged and Older US Adults.

JAMA Oncol 2020 08;6(8):1210-1217

Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, New York.

Importance: Sedentary behavior is associated with several health outcomes, including diabetes, cardiovascular disease, and all-cause mortality. Less is known about the association between objectively measured sedentary behavior and cancer mortality, as well as the association with physical activity.

Objective: To examine the association between accelerometer-measured sedentary behavior (total volume and accrual in prolonged, uninterrupted bouts) and cancer mortality.

Design, Setting, And Participants: A prospective cohort study conducted in the contiguous US included 8002 black and white adults aged 45 years or older enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. The present analysis was performed from April 18, 2019, to April 21, 2020.

Exposures: Sedentary time, light-intensity physical activity (LIPA), and moderate- to vigorous-intensity physical activity (MVPA) were measured using a hip-mounted accelerometer worn for 7 consecutive days.

Main Outcomes And Measures: Cancer mortality.

Results: Of the 8002 study participants, 3668 were men (45.8%); mean (SD) age was 69.8 (8.5) years. Over a mean (SD) follow-up of 5.3 (1.5) years, 268 participants (3.3%) died of cancer. In multivariable-adjusted models, including MVPA, greater total sedentary time was associated with a greater risk of cancer mortality (tertile 2 vs tertile 1: hazard ratio [HR], 1.45; 95% CI, 1.00-2.11; tertile 3 vs tertile 1: HR, 1.52; 95% CI, 1.01-2.27). Longer sedentary bout duration was not significantly associated with greater cancer mortality risk: after adjustment for MVPA (tertile 2 vs tertile 1: HR, 1.26; 95% CI, 0.90-1.78; tertile 3 vs tertile 1: HR, 1.36; 95% CI, 0.96-1.93). Replacing 30 minutes of sedentary time with LIPA was significantly associated with an 8% (per 30 minutes: HR, 0.92; 95% CI, 0.86-0.97) lower risk of cancer mortality; MVPA was significantly associated with a 31% (per 30 minutes: HR, 0.69; 95% CI, 0.48-0.97) lower risk of cancer mortality.

Conclusions And Relevance: In this cohort study, greater sedentary time, as measured with accelerometry, appeared to be independently associated with cancer mortality risk. Replacing sedentary time with either LIPA or MVPA may be associated with a lower risk of cancer mortality. These findings suggest that the total volume of sedentary behavior is a potential cancer mortality risk factor and support the public health message that adults should sit less and move more to promote longevity.
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http://dx.doi.org/10.1001/jamaoncol.2020.2045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7303924PMC
August 2020

Mobile Technologies and Cervical Cancer Screening in Low- and Middle-Income Countries: A Systematic Review.

JCO Glob Oncol 2020 04;6:617-627

Department of Oncology, Georgetown University School of Medicine, Washington, DC.

Purpose: Cervical cancer screening is not well implemented in many low- and middle-income countries (LMICs). Mobile health (mHealth) refers to utilization of mobile technologies in health promotion and disease management. We aimed to qualitatively synthesize published articles reporting the impact of mHealth on cervical cancer screening-related health behaviors.

Methods: Three reviewers independently reviewed articles with the following criteria: the exposure or intervention of interest was mHealth, including messages or educational information sent via mobile telephone or e-mail; the comparison was people not using mHealth technology to receive screening-related information, and studies comparing multiple different mHealth interventional strategies were also eligible; the primary outcome was cervical cancer screening uptake, and secondary outcomes included awareness, intention, and knowledge of screening; appropriate research designs included randomized controlled trials and quasi-experimental or observational research; and the study was conducted in an LMIC.

Results: Of the 8 selected studies, 5 treated mobile telephone or message reminders as the exposure or intervention, and 3 compared the effects of different messages on screening uptake. The outcomes were diverse, including screening uptake (n = 4); health beliefs regarding the Papanicolaou (Pap) test (n = 1); knowledge of, attitude toward, and adherence to colpocytologic examination (n = 1); interest in receiving messages about Pap test results or appointment (n = 1); and return for Pap test reports (n = 1).

Conclusion: Overall, our systematic review suggests that mobile technologies, particularly telephone reminders or messages, lead to increased Pap test uptake; additional work is needed to unequivocally verify whether mhealth interventions can improve knowledge regarding cervical cancer. Our study will inform mHealth-based interventions for cervical cancer screening promotion in LMICs.
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http://dx.doi.org/10.1200/JGO.19.00201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7193780PMC
April 2020

Correction: Association of baseline inflammatory biomarkers with cancer mortality in the REGARDS cohort.

Oncotarget 2020 Feb 18;11(7):758. Epub 2020 Feb 18.

Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA.

[This corrects the article DOI: 10.18632/oncotarget.27108.].
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http://dx.doi.org/10.18632/oncotarget.27480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7041933PMC
February 2020

Race, Socioeconomic Status, and Health-Care Access Disparities in Ovarian Cancer Treatment and Mortality: Systematic Review and Meta-Analysis.

JNCI Cancer Spectr 2019 Dec 9;3(4):pkz084. Epub 2019 Oct 9.

See the Notes section for the full list of authors' affiliations.

Background: Ovarian cancer remains a leading cause of death from gynecological malignancies. Race, socioeconomic status (SES), and access to health care are important predictors of quality treatment and survival. We provide a systematic review and meta-analysis on the role of these predictors on disparities in ovarian cancer treatment and mortality.

Methods: Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched PubMed, EMBASE, and Scopus for relevant articles published between January 2000 and March 2017. We selected studies published in the United States that evaluated the role of race, SES, or health-care access on disparities in ovarian cancer treatment or survival. Pooled relative risk (RR) and 95% confidence intervals (CIs) were calculated for each outcome using a random-effects model.

Results: A total of 41 studies met the inclusion criteria for systematic review. In meta-analysis, there was a 25% decrease (RR = 0.75, 95% CI = 0.66 to 0.84) in receipt of adherent ovarian cancer treatment and 18% increased risk (RR = 1.18, 95% CI = 1.11 to 1.26) of mortality for blacks compared to whites. Receipt of adherent ovarian cancer treatment was 15% lower (RR = 0.85, 95% CI = 0.77 to 0.94) in the lowest vs highest SES group and 30% lower (RR = 0.70, 95% CI = 0.58 to 0.85) among patients at lower vs higher hospital volumes.

Conclusion: We found consistent and strong evidence for continued lack of quality ovarian cancer treatment and higher mortality among ovarian cancer patients who are black, are of low SES, and/or have poor access to care. Interventions focused on these groups targeting specific barriers to care are needed to reduce disparities in ovarian cancer treatment and mortality.
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http://dx.doi.org/10.1093/jncics/pkz084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6899434PMC
December 2019

A Prospective Study of Community Mediators on the Risk of Sepsis After Cancer.

J Intensive Care Med 2020 Dec 4;35(12):1546-1555. Epub 2019 Nov 4.

Department of Epidemiology, 9968University of Alabama at Birmingham, Birmingham, AL, USA.

Background: Few studies have examined whether community factors mediate the relationship between patients surviving cancer and future development of sepsis. We determined the influence of community characteristics upon risk of sepsis after cancer, and whether there are differences by race.

Methods: We performed a prospective analysis using data from the REasons for Geographic and Racial Differences in Stroke cohort years 2003 to 2012 complemented with county-level community characteristics from the American Community Survey and County Health Rankings. We categorized those with a self-reported prior cancer diagnosis as "cancer survivors" and those without a history of cancer as "no cancer history." We defined sepsis as hospitalization for a serious infection with ≥2 systemic inflammatory response syndrome criteria. We examined the mediation effect of community characteristics on the association between cancer survivorship and sepsis incidence using Cox proportional hazards models adjusted for age, sex, race, and total number of comorbidities. We repeated analysis stratified by race.

Results: There were 28 840 eligible participants, of which 2860 (9.92%) were cancer survivors, and 25 289 (90.08%) were no cancer history participants. The only observed community-level mediation effects were from income (% mediated 0.07%; natural indirect effect [NIE] on hazard scale] = 1.001, 95% confidence interval [95% CI]: 1.000-1.005) and prevalence of adult smoking (% mediated = 0.21%; NIE = 1.002, 95% CI: 1.000-1.004). We observed similar effects when stratified by race.

Conclusion: Cancer survivors are at increased risk of sepsis; however, this association is weakly mediated by community poverty and smoking prevalence.
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http://dx.doi.org/10.1177/0885066619881122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7196500PMC
December 2020

Hospitalization outcomes and racial disparities in cervical cancer patients: An analysis of the national inpatient sample data from 2002 to 2014.

Cancer Epidemiol 2019 12 18;63:101620. Epub 2019 Oct 18.

Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham AL, United States; O'Neal Comprehensive Cancer Center at University of Alabama at Birmingham, Birmingham AL, United States. Electronic address:

Background: Little is known about outcomes in patients after being hospitalized for care of cancer or comorbid conditions and the disparity between African-American and White cervical cancer patients.

Methods: Using the national inpatient sample (HCUP-NIS) database of the Healthcare Cost and Utilization Project between 2002-2014, we included 5217 African-American and 21,752 White patients hospitalized with a primary diagnosis of cervical cancer. We examined racial differences in hospitalization outcomes; length of stay (LOS) in hospital, mortality in hospital, post-operative complications in patients who underwent hysterectomy and discharge disposition. Patients were matched on age at primary diagnosis, insurance status, residential region, and median income of residential area, modified Deyo comorbidity index, stage of disease and treatment. Categorical outcomes were analyzed by conditional logistic regression accounting for matched study design and odds ratios (95%CI) were reported. LOS was analyzed using t-test and beta estimate for difference in means was reported.

Results: The LOS was significantly lower for Whites compared to African-American cervical cancer patients when matched on demographic only (β=-0.41, p-value<0.0005, presentation + demographic (β=-0.41, p-value<0.0006) and treatment + presentation + demographic variables (β=-0.46, p-value<0.0001). White cervical cancer patients were commonly discharged to other intermediate nursing facility (OR = 1.30, 95%CI = 1.20-1.41, matched on demographic only; OR = 1.31, 95%CI = 1.21-1.43, matched on presentation + demographic; and OR = 1.32, 95%CI = 1.22-1.43), matched on treatment + presentation + demographic). Similar trends were seen in both older (≥65 years) and younger (<65 years) patients, when stratified by age.

Conclusion: Disparities in hospitalization outcomes in cervical patients are not observed when different characteristics of African-American and White cervical patients are accounted for and matched.
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http://dx.doi.org/10.1016/j.canep.2019.101620DOI Listing
December 2019

Global, Regional, and National Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life-Years for 29 Cancer Groups, 1990 to 2017: A Systematic Analysis for the Global Burden of Disease Study.

JAMA Oncol 2019 12;5(12):1749-1768

Department of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.

Importance: Cancer and other noncommunicable diseases (NCDs) are now widely recognized as a threat to global development. The latest United Nations high-level meeting on NCDs reaffirmed this observation and also highlighted the slow progress in meeting the 2011 Political Declaration on the Prevention and Control of Noncommunicable Diseases and the third Sustainable Development Goal. Lack of situational analyses, priority setting, and budgeting have been identified as major obstacles in achieving these goals. All of these have in common that they require information on the local cancer epidemiology. The Global Burden of Disease (GBD) study is uniquely poised to provide these crucial data.

Objective: To describe cancer burden for 29 cancer groups in 195 countries from 1990 through 2017 to provide data needed for cancer control planning.

Evidence Review: We used the GBD study estimation methods to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life-years (DALYs). Results are presented at the national level as well as by Socio-demographic Index (SDI), a composite indicator of income, educational attainment, and total fertility rate. We also analyzed the influence of the epidemiological vs the demographic transition on cancer incidence.

Findings: In 2017, there were 24.5 million incident cancer cases worldwide (16.8 million without nonmelanoma skin cancer [NMSC]) and 9.6 million cancer deaths. The majority of cancer DALYs came from years of life lost (97%), and only 3% came from years lived with disability. The odds of developing cancer were the lowest in the low SDI quintile (1 in 7) and the highest in the high SDI quintile (1 in 2) for both sexes. In 2017, the most common incident cancers in men were NMSC (4.3 million incident cases); tracheal, bronchus, and lung (TBL) cancer (1.5 million incident cases); and prostate cancer (1.3 million incident cases). The most common causes of cancer deaths and DALYs for men were TBL cancer (1.3 million deaths and 28.4 million DALYs), liver cancer (572 000 deaths and 15.2 million DALYs), and stomach cancer (542 000 deaths and 12.2 million DALYs). For women in 2017, the most common incident cancers were NMSC (3.3 million incident cases), breast cancer (1.9 million incident cases), and colorectal cancer (819 000 incident cases). The leading causes of cancer deaths and DALYs for women were breast cancer (601 000 deaths and 17.4 million DALYs), TBL cancer (596 000 deaths and 12.6 million DALYs), and colorectal cancer (414 000 deaths and 8.3 million DALYs).

Conclusions And Relevance: The national epidemiological profiles of cancer burden in the GBD study show large heterogeneities, which are a reflection of different exposures to risk factors, economic settings, lifestyles, and access to care and screening. The GBD study can be used by policy makers and other stakeholders to develop and improve national and local cancer control in order to achieve the global targets and improve equity in cancer care.
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http://dx.doi.org/10.1001/jamaoncol.2019.2996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6777271PMC
December 2019

Association of baseline inflammatory biomarkers with cancer mortality in the REGARDS cohort.

Oncotarget 2019 Aug 6;10(47):4857-4867. Epub 2019 Aug 6.

Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA.

This study examines the association between inflammatory biomarkers and risk of cancer mortality by race. Data were obtained from 1,856 participants in the prospective REGARDS cohort who were cancer-free at baseline, and analyzed in relation to cancer mortality prospectively. Biomarkers were log-transformed and categorized into tertiles due to non-normal distributions, and Cox proportional hazard regression models were utilized to compute hazard ratios with 95% confidence intervals using robust sandwich methods. Individuals in the highest tertile of IL-6 had over a 12-fold increased risk of cancer mortality (HR: 12.97, 95% CI: 3.46-48.63); those in the highest tertile of IL-8 had over a 2-fold increased risk of cancer mortality (HR: 2.21, 95% CI: 0.86-5.71), while those in the highest tertile of IL-10 had over a 3-fold increased risk of cancer mortality (HR: 3.06, 95% CI: 1.35-6.89). In race-stratified analysis, each unit increase in IL-6 was associated with increased risk of cancer mortality among African-Americans (HR: 3.88, 95% CI: 1.17-12.88) and Whites (5.25, 95% CI: 1.24-22.31). If replicated in larger, racially diverse prospective cohorts, these results suggest that cancer patients may benefit from clinical or lifestyle approaches to regulate systemic inflammation as a cancer prevention strategy.
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http://dx.doi.org/10.18632/oncotarget.27108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6690671PMC
August 2019

Current smoking and quit-attempts among US adults following Medicaid expansion.

Prev Med Rep 2019 Sep 18;15:100923. Epub 2019 Jun 18.

Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States.

The objective of this study was to estimate the influence of the Affordable Care Act (ACA) Medicaid Expansion on current smoking and quit attempts in expanded and non-expanded states. We analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) between 2003 through 2015 to evaluate changes in current smoking and quit attempts using multivariable logistic regression and generalized estimating equations (GEE), adjusting for socioeconomic factors. Time periods evaluated were: 2003-2009 (pre-expansion) and 2011-2015 (post-expansion), and in supplemental analysis, also 2011-2017. Overall, smoking prevalence among adults in expanded and non-expanded states were 16% and 17% ( < 0.001), respectively, and quit attempt prevalence for expanded and non-expanded states were 56% and 57% ( = 0.05), respectively. In adjusted models comparing post- versus pre- expansion periods, current smoking declined by 6% in both expanded (RR: 0.94, 95% CI: 0.93-0.94) and non-expanded (RR: 0.94, 95% CI: 0.94-0.95) states. Quit attempts increased by 4% (RR: 1.04, 95% CI: 1.04-1.05) in expanded states, and by 3% (RR: 1.03, 95% CI: 1.02-1.03) in non-expanded states. States that imposed barriers to utilization of smoking cessation services e.g. prior authorization, saw only a 3% increase in quit attempts regardless of expansion status, while expanded states that did not impose barriers experienced a 6% (RR: 1.06, 95% CI: 1.05-1.06) increase in quit attempts. Reducing administrative barriers to smoking cessation programs may enhance further declines in smoking rates among US adults.
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http://dx.doi.org/10.1016/j.pmedr.2019.100923DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6664091PMC
September 2019

Collaborative Molecular Epidemiology Study of Metabolic Dysregulation, DNA Methylation, and Breast Cancer Risk Among Nigerian Women: MEND Study Objectives and Design.

J Glob Oncol 2019 06;5:1-9

University of Kentucky, Lexington, KY.

Purpose: To elucidate the role of metabolic dysregulation and associated DNA methylation changes on breast cancer risk and aggressive subtypes among Nigerian women. We describe the design and methods of a collaborative molecular epidemiology study of breast cancer in Nigerian hospitals.

Methods: The Mechanisms for Novel and Established Risk Factors for Breast Cancer in Women of Nigerian Descent (MEND) study was designed as a matched case-control study of 350 patients, age 18 to 75 years, with newly diagnosed, treatment-naïve breast cancer and 350 age-matched healthy controls from surrounding geographic areas. Patients with breast cancer seen for initial diagnosis at four large tertiary hospitals in southwest Nigeria and one affiliated private hospital were recruited. Healthy female controls were selected from a cohort of 4,000 healthy women recruited as part of the Human Heredity and Health (H3) in Africa Chronic Kidney Disease Case-Control Study in Nigeria. Tumor and adjacent normal tissue, and blood and saliva samples were collected for molecular and epigenetic assays.

Results: Although recruitment is ongoing, a total of 416 patients have been recruited to date, with tumor and blood samples obtained from at least 310 patients. Data on age-matched (± 6 months) controls have also been obtained and harmonized. Lipid assays for 350 pathologically verified cases and 350 age-matched controls is underway, and pathologic characterization of tumors (including immunohistochemistry for subtyping) is ongoing. Data on DNA methylation for tumors and adjacent normal tissue are expected by the end of the study period.

Conclusion: The MEND study will provide a unique, high-quality source of data to evaluate the contribution of metabolic dysregulation such as obesity, diabetes, hypertension, and metabolic syndrome to the biology of breast cancer among Nigerian women and foster collaborative studies relevant for women of African descent globally.
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http://dx.doi.org/10.1200/JGO.18.00226DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6613666PMC
June 2019

Medicaid Expansion and Breast Cancer Screening in Appalachia and Non-Appalachia, United States, BRFSS 2003 to 2015.

Cancer Control 2019 Jan-Dec;26(1):1073274819845874

1 Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA.

Background: Prior data suggests that breast cancer screening rates are lower among women in the Appalachian region of the United States. This study examined the changes in breast cancer screening before and after the implementation of the Affordable Care Act Medicaid expansion, in Appalachia and non-Appalachia states.

Methods: Data from the Behavioral Risk Factor Surveillance System between 2003 and 2015 were analyzed to evaluate changes in breast cancer screening in the past 2 years among US women aged 50-74 years. Multivariable adjusted logistic regression and generalized estimating equation models were utilized, adjusting for sociodemographic, socioeconomic, and health-care characteristics. Data were analyzed for 2 periods: 2003 to 2009 (pre-expansion) and 2011 to 2015 (post-expansion) comparing Appalachia and non-Appalachia states.

Results: The prevalence for of self-reported breast cancer screening in Appalachia and non-Appalachia states were 83% and 82% ( P < .001), respectively. In Appalachian states, breast cancer screening was marginally higher in non-expanded versus expanded states in both the pre-expansion (relative risk [RR]: 1.002, 95% confidence interval [CI]: 1.002-1.003) and post-expansion period (RR: 1.001, 95% CI: 1.001-1.002). In non-Appalachian states, screening was lower in non-expanded states versus expanded states in both the pre-expansion (RR: 0.98, 95% CI: 0.97-0.98) and post-expansion period (RR: 0.95, 95% CI: 0.95-0.96). There were modest 3% to 4% declines in breast cancer screening rates in the pos-texpansion period regardless of expansion and Appalachia status.

Conclusions: Breast cancer screening rates were higher in Appalachia versus non-Appalachia US states and higher in expanded versus nonexpanded non-Appalachia states. There were modest declines in breast cancer screening rates in the post-expansion period regardless of expansion and Appalachia status, suggesting that more work may be needed to reduce administrative, logistical, and structural barriers to breast cancer screening services.
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http://dx.doi.org/10.1177/1073274819845874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6509986PMC
November 2019

Targeting risk factors for reducing the racially disparate burden in breast cancer.

Front Biosci (Schol Ed) 2019 03 1;11:136-160. Epub 2019 Mar 1.

Department of Biology, International Consortium for Advancing Research on Triple Negative Breast Cancer, Georgia State University, Atlanta, GA 30303, USA,

African-American (AA) women are more likely to die from breast cancer (BC), at any age, compared to European-American women. Although breakthroughs in pre-clinical studies have resulted in potentially actionable targets in AA BC, drugs that were rationally designed for these targets have performed poorly in clinical trials. Challenges with interpatient and intratumoral heterogeneity, lack of drug sensitivity and specificity, suboptimal biomarker cut-offs, lack of drug response predictive biomarkers, drug side effects, high costs of drug development, and under-representation of AAs in clinical trials complicate the development of targeted therapies for AA BC patients. Accumulating evidence suggests that racial disparities exist in non-genetic risk factors that can alter genetic and epigenetic programs to promote breast tumorigenesis. Herein, we present a "roadmap" that addresses non-genetic risk factors that are suspected to contribute to the racial disparity in BC mortality. Increased targeting of these non-genetic risk factors may proffer a safer and more economical route to alleviating the racially disparate burden in BC.
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http://dx.doi.org/10.2741/S531DOI Listing
March 2019
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