Preexisting Diabetes and Breast Cancer Treatment Among Low-Income Women.

IMPORTANCE: Diabetes is associated with poorer prognosis of patients with breast cancer. The association between diabetes and adjuvant therapies for breast cancer remains uncertain. OBJECTIVE: To comprehensively examine the associations of preexisting diabetes with radiotherapy, chemotherapy, and endocrine therapy in low-income women with breast cancer. DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study included women younger than 65 years diagnosed with nonmetastatic breast cancer from 2007 through 2015, followed up through 2016, continuously enrolled in Medicaid, and identified from the linked Missouri Cancer Registry and Medicaid claims data set. Data were analyzed from January 2022 to October 2023. EXPOSURE: Preexisting diabetes. MAIN OUTCOMES AND MEASURES: Logistic regression was used to estimate odds ratios (ORs) of utilization (yes/no), timely initiation (≤90 days postsurgery), and completion of radiotherapy and chemotherapy, as well as adherence (medication possession ratio ≥80%) and persistence (<90-consecutive day gap) of endocrine therapy in the first year of treatment for women with diabetes compared with women without diabetes. Analyses were adjusted for sociodemographic and tumor factors. RESULTS: Among 3704 women undergoing definitive surgery, the mean (SD) age was 51.4 (8.6) years, 1038 (28.1%) were non-Hispanic Black, 2598 (70.1%) were non-Hispanic White, 765 (20.7%) had a diabetes history, 2369 (64.0%) received radiotherapy, 2237 (60.4%) had chemotherapy, and 2505 (67.6%) took endocrine therapy. Compared with women without diabetes, women with diabetes were less likely to utilize radiotherapy (OR, 0.67; 95% CI, 0.53-0.86), receive chemotherapy (OR, 0.67; 95% CI, 0.48-0.93), complete chemotherapy (OR, 0.71; 95% CI, 0.50-0.99), and be adherent to endocrine therapy (OR, 0.71; 95% CI, 0.56-0.91). There were no significant associations of diabetes with utilization (OR, 0.95; 95% CI, 0.71-1.28) and persistence (OR, 1.09; 95% CI, 0.88-1.36) of endocrine therapy, timely initiation of radiotherapy (OR, 1.09; 95% CI, 0.86-1.38) and chemotherapy (OR, 1.09; 95% CI, 0.77-1.55), or completion of radiotherapy (OR, 1.25; 95% CI, 0.91-1.71). CONCLUSIONS AND RELEVANCE: In this cohort study, preexisting diabetes was associated with subpar adjuvant therapies for breast cancer among low-income women. Improving diabetes management during cancer treatment is particularly important for low-income women with breast cancer who may have been disproportionately affected by diabetes and are likely to experience disparities in cancer treatment and outcomes.

Association of Endocrine Therapy Initiation Timeliness With Adherence and Continuation in Low-Income Women With Breast Cancer.

Importance: Though adjuvant endocrine therapy (AET) has proven efficacy in treating hormone receptor-positive (HR-positive) breast cancer, patient adherence to AET and continuation of treatment as recommended by guidelines remain suboptimal, especially for low-income patients. Objective: To quantify timelines for initiating AET and assess their association with short- and long-term adherence and continuation of AET in low-income women with breast cancer. Design, Setting, and Participants: This population-based retrospective cohort study included women younger than 65 years diagnosed with first primary HR-positive breast cancer between January 1, 2007, and December 31, 2013, followed up for 5 years after the first use of AET through December 2018, and identified from the linked Missouri Cancer Registry and Medicaid claims data set. Exposures: Time to initiation (TTI) as days from the date of last treatment (surgery, radiotherapy, or chemotherapy) to the first date of AET prescription fill. Main Outcomes and Measures: The main outcomes were adherence to AET as medication possession ratio of 80% or greater and continuation of AET as no gap in medication supply for at least 90 days. Odds ratios (ORs) of adherence and continuation over 1 to 5 years were estimated using logistic regression adjusted for demographic, clinical, and neighborhood variables. Analyses were performed between September 1, 2020, and May 31, 2022. Results: Among 1711 patients, median TTI was 53 (IQR, 26-117) days. A total of 1029 patients (60.1%) were aged 50 to 64 years old, 1270 (74.2%) were non-Hispanic White, and 1133 (66.2%) were unmarried. In the first year after initiation, 1317 (77.0%) were adherent and 1015 (59.3%) continued AET. Over the full 5 years, 376 (22.0%) were adherent and 409 (23.9%) continued AET. Longer TTI was significantly associated with poorer adherence at every year, with an OR of 0.97 (95% CI, 0.95-0.99) for 1-year adherence and an OR of 0.94 (95% CI, 0.90-0.97) for 5-year adherence per 1-month increase in TTI. Longer TTI was also associated with lower odds of short-term, but not long-term, continuation (OR, 0.97 [95% CI, 0.95-0.99] for 1-year continuation and 0.98 [95% CI, 0.96-0.99] for 2-year continuation). Conclusions and Relevance: In this cohort study, longer time to AET initiation was associated with lower odds of short-term and long-term adherence to AET in Medicaid-insured patients with breast cancer. Therefore, early interventions targeting treatment initiation timelines may positively impact adherence throughout the course of treatment and, therefore, outcomes.

Timing of Medicaid Enrollment, Late-Stage Breast Cancer Diagnosis, Treatment Delays, and Mortality.

BACKGROUND: Disrupted and delayed Medicaid coverage has been consistently associated with lower rates of cancer screening and early-stage cancer diagnosis compared with continuous coverage. However, the relationships between Medicaid coverage timing, breast cancer treatment delays, and survival are less clear. METHODS: Using the linked Missouri Cancer Registry-Medicaid claims data, we identified 4583 women diagnosed with breast cancer between 2007 and 2016. We used logistic regression to estimate odds ratios (ORs) of late-stage diagnosis and treatment delays for prediagnosis (>30 days, >90 days, and >1 year before diagnosis) vs peridiagnosis enrollment. Cox proportional hazards models were used to estimate the hazard ratio (HR) of breast cancer-specific mortality for pre- vs postdiagnosis enrollment. RESULTS: Patients enrolled in Medicaid more than 30 days before diagnosis were less likely to be diagnosed at a late stage compared with those enrolled in Medicaid peridiagnosis (OR = 0.69, 95% confidence interval [CI] = 0.60 to 0.79). This result persisted using enrollment 90-day (OR = 0.64, 95% CI = 0.56 to 0.74) and 1-year thresholds (OR = 0.55, 95% CI = 0.47 to 0.65). We did not observe a difference in the likelihood of treatment delays between the 2 groups. After adjustment for sociodemographic factors, there was no statistically significant difference in the risk of breast cancer mortality for patients enrolled more than 30 days prediagnosis relative to patients enrolled peridiagnosis (HR = 0.98, 95% CI = 0.83 to 1.14), but a lower risk was observed for patients enrolled prediagnosis when using 90 days (HR = 0.85, 95% CI = 0.72 to 0.999) or 1 year (HR = 0.79, 95% CI = 0.66 to 0.96) as the threshold. CONCLUSIONS: Women with breast cancer who enroll in Medicaid earlier may benefit from earlier diagnoses, but only longer-term enrollment may have survival benefits.

Predicting coronavirus disease (COVID-19) outcomes in the United States early in the epidemic.

By 21 October 2020, the coronavirus disease (COVID-19) epidemic in the United States (US) had infected 8.3 million people, resulting in 61,364 laboratory-confirmed hospitalizations and 222,157 deaths. Currently, policymakers are trying to better understand this epidemic, especially the human-to-human transmissibility of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in relation to social, populational, air travel related and environmental exposure factors. Our study used 50 US states' public health surveillance datasets (January 1-April 1, 2020) to measure associations of confirmed COVID-19 cases, hospitalizations and deaths with these variables. Using the resulting associations and multivariate regression (Negative Binomial and Poisson), predicted cases, hospitalizations and deaths were generated for each US state early in the epidemic. Factors associated with a significantly increased risk of COVID-19 disease, hospitalization and death included: population density, enplanement, Black race and increased sun exposure; in addition, COVID-19 disease and hospitalization were also associated with morning humidity. Although predictions of the number of cases, hospitalizations and deaths due to COVID-19 were not accurate for every state, those states with a combination of large number of enplanements, high population density, high proportion of Black residents, high humidity or low sun exposure may expect more rapid than expected growth in the number of COVID-19 events early in the epidemic.

Comorbidities and the risk of cardiovascular disease mortality among racially diverse patients with breast cancer.

BACKGROUND: Women who have coexisting comorbidities at the time of breast cancer diagnosis have an increased risk of breast cancer and overall mortality. However, the associations between newly diagnosed comorbidities and the risk of cardiovascular disease (CVD) mortality among these patients have not been examined. METHODS: The authors compared the associations between coexisting and newly diagnosed CVD, type 2 diabetes, and hypertension and the risk of CVD mortality among patients with breast cancer identified in the Missouri Cancer Registry. In total, 33,099 women who had incident invasive breast cancer with inpatient and outpatient hospital discharge data within 2 years after breast cancer diagnosis were included: 9.3% were Black. Subdistribution hazard ratios (sdHRs) and 95% CIs were calculated for the risk of CVD-related mortality using adjusted Cox proportional hazards regression models, accounting for a competing risk of breast cancer deaths. RESULTS: Within the first 2 years after breast cancer, the most reported newly diagnosed comorbidity was hypertension (9%), followed by CVD (4%), and type 2 diabetes (2%). CVD mortality was increased in women who had newly diagnosed CVD (sdHR, 2.49; 95% CI, 2.09-2.99), diabetes (sdHR, 2.16; 95% CI, 1.68-2.77), or hypertension (sdHR, 2.06; 95% CI, 1.71-2.48) compared with women who did not have these conditions. Associations were similar by race. The strongest association was among women who received chemotherapy and then developed CVD (sdHR, 3.82; 95% CI, 2.69-5.43). CONCLUSIONS: Monitoring for diabetes, hypertension, and CVD from the time of breast diagnosis may reduce CVD mortality.

Breast Cancer Population Screening Program Results in Early Detection and Reduced Treatment and Health Care Costs for Medicaid.

CONTEXT: The National Breast and Cervical Cancer Early Detection Program has increased access to screening services for low-income females since 1991; however, evaluation information from states implementing the program is sparse. This study evaluates the impact of the Missouri program, Show Me Healthy Women (SMHW), on early detection and treatment cost. OBJECTIVE: To estimate breast cancer treatment and health care services costs by stage at diagnosis among Missouri's Medicaid beneficiaries and assess the SMHW program impact. DESIGN: Analyzed Missouri Medicaid claims linked with Missouri Cancer Registry data for cases diagnosed 2008-2012 (N = 1388) to obtain unadjusted and incremental costs of female breast cancer treatment and follow-up care at 6, 12, and 24 months following diagnosis. Noncancer controls (N = 3840) were matched on age, race, and disability to determine usual health care cost. Regression analyses estimated the impact of stage at diagnosis on expenditures and incremental cost. Show Me Healthy Women participants were compared with other breast cancer patients on stage at diagnosis. A comparison of SMHW participants to themselves had they not been enrolled in the program was analyzed to determine cost savings. RESULTS: Expenditures increased by stage at diagnosis from in situ to distant with unadjusted cost at 24 months ranging from $50 245 for in situ cancers to $152 431 for distant cancers. Incremental costs increased by stage at diagnosis from 6 months at $7346, $11 859, $21 501, and $20 235 for in situ, localized, regional, and distant breast cancers, respectively, to $9728, $17 056, $38 840, and $44 409 at 24 months. A significantly higher proportion of SMHW participants were diagnosed at an early stage resulting in lower unadjusted expenditures and cost savings. CONCLUSIONS: Although breast cancer treatment costs increased by stage at diagnosis, the population screening program's significant impact on early diagnosis resulted in important cost savings over time for Medicaid.

Relationship between insurance status and outcomes for patients with breast cancer in Missouri.

BACKGROUND: The cancer stage at diagnosis, treatment delays, and breast cancer mortality vary with insurance status. METHODS: Using the Missouri Cancer Registry, this analysis included 31,485 women diagnosed with invasive breast cancer from January 1, 2007, to December 31, 2015. Odds ratios (ORs) of a late-stage (stage III or IV) diagnosis and a treatment delay (>60 days after the diagnosis) were calculated with logistic regression. The hazard ratio (HR) of breast cancer mortality was calculated with Cox proportional hazards regression. Mediation analysis was used to quantify the individual contributions of each covariate to mortality. RESULTS: The OR of a late-stage diagnosis was higher for patients with Medicaid (OR, 1.72; 95% confidence interval [CI], 1.56-1.91) or no insurance (OR, 2.30; 95% CI, 1.91-2.78) in comparison with privately insured patients. Medicare (OR, 1.21; 95% CI, 1.10-1.37), Medicaid (OR, 1.60; 95% CI, 1.37-1.85), and uninsured patients (OR, 1.58; 95% CI, 1.18-2.12) had higher odds of a treatment delay. The HR of breast cancer-specific mortality was significantly increased in the groups with public insurance or no insurance and decreased after sequential adjustments for sociodemographic factors (HR, 2.39; 95% CI, 1.96-2.91), tumor characteristics (HR, 1.28; 95% CI, 1.05-1.56), and treatment (HR, 1.23; 95% CI, 1.01-1.50). Late-stage diagnoses accounted for 72.5% of breast cancer mortality in the uninsured. CONCLUSIONS: Compared with the privately insured, women with public or no insurance had a higher risk for advanced breast cancer, a >60-day treatment delay, and death from breast cancer. Particularly for the uninsured, Medicaid expansion and increased funding for education and screening programs could decrease breast cancer disparities.

Usability Assessment of the Missouri Cancer Registry's Published Interactive Mapping Reports: Round Two.

BACKGROUND: Health-related data's users have trouble understanding and interpreting combined statistical and mapping information. This is the second round of a usability study conducted after we modified and simplified our tested maps based on the first round's results. OBJECTIVE: To explore if the tested maps' usability improved by modifying the maps according to the first round's results. METHODS: We recruited 13 cancer professionals from National American Central Cancer registries (NACCR) 2016 conference. The study involved three phases per participant: A pretest questionnaire, the multi-task usability test, and the System Usability Scale (SUS). Software was used to record the computer screen during the trial and the users' spoken comments. We measured several qualitative and quantitative usability metrics. The study's data was analyzed using spreadsheet software. RESULTS: In the current study, unlike the previous round, there was no significant statistical relationship between the subjects' performance on the study test and the experience in GIS tools (P = .17 previously was .03). Three out of the four (75%) of our subjects with a bachelor's degree or less accomplished the given tasks effectively and efficiently. This study developed a comparable satisfaction results to the first round study, despite that the previous round's participants were highly educated and more experienced with GIS. CONCLUSION: By considering the round one's results and by updating our maps, we made the tested maps simpler to be used by subjects who have little experience in using GIS technology, and have little spatial and statistical knowledge.

Randomized Controlled Trial of Primary Health Care Strategies for the Promotion of Leisure-Time Physical Activity Among Older Brazilians.

BACKGROUND: Physical activity promotion within primary health care is in the spotlight. However, few studies have evaluated the long-term effectiveness of possible interventions. This study aimed to compare the effectiveness of 3 primary health care interventions in increasing leisure-time physical activity among older Brazilians. METHODS: Experimental study with 142 older residents of an ongoing urban cohort in São Paulo (Brazil). Participants were randomized into 3 groups: minimal intervention group, physician-based counseling group, and individual counseling and referral for physical activity programs group (CRG). We used the long version of the International Physical Activity Questionnaire to assess leisure-time physical activity at baseline, 4 years after baseline without any intervention, 3 months after intervention, and 6 months after intervention. Statistical analysis included repeated analysis of variance. RESULTS: At baseline, 31% of the individuals were active, and this figure remained stable for a period of 4 years. Three months after the interventions, there was a significant increase in leisure-time physical activity for CRG compared with the minimal intervention (P < .001) and physician-based counseling (P < .02) groups, and these differences persisted after 6 months (P < .001 and P < .05, respectively). CONCLUSION: Results indicate that interventions with CRG are effective in producing sustained changes in physical activity among older Brazilians.

Five Fruit and Vegetable a Day Does Not Reflect the Upward Trend of Obesity in the U.S.

OBJECTIVE: After almost three decades of U.S. surveillance in fruit and vegetable (F&V) intake and obesity, it is important to evaluate their usefulness for monitoring prevention and health promotion efforts in public health. We used U.S. surveillance data to evaluate whether the 16-year trends of F&V intake, measured by the prevalence of eating five or more servings of fruits and vegetables a day (FV5/day) is related to obesity trend as measured by its prevalence in the same period. We also evaluated whether trends in the prevalence of FV5/day by important sociodemographic factors (age, race/ethnicity, etc.) could explain the findings. STUDY DESIGN: A secondary analysis of U.S. adults (≥ 18 years) from the Behavioral Risk Factor Surveillance System (BRFSS) (1994-2009). METHODS: We categorized survey subjects for their F&V intake derived from the BRFSS six-question food frequency questionnaire into two groups: < FV5/day vs. ≥ FV5/day. Obesity was defined as BMI ≥ 30. We used logistic regressions to compute predicted prevalence of FV5/day and obesity, and to estimate the odds ratio of FV5/day by obesity and levels of sociodemographic, stratified by year. RESULTS: Between 1994 and 2009, the prevalence of FV5/day hovered around 25% among U.S. adults, while the obesity prevalence steadily increased from 14.8% to 27.4%. As measured through odds ratio, an inverse association between FV5/day and obesity was only observed in 55+, but not in other age, racial/ethnic or education groups. CONCLUSIONS: Between 1994 and 2009, we could not confirm a decrease in the prevalence of FV5/day associated with an increase in obesity prevalence, except for age 55+ group. Known disparities in FV5/day and obesity across sociodemographic factors persisted over the study period. FV5/day may be an inappropriate measure of total calories derived from eating fruits and vegetables. Its use to measure impact of public health strategies to improve nutrition and prevent obesity may be questionable.

The effect of metabolic risk factors on cancer mortality among blacks and whites.

BACKGROUND: Previous data showed that metabolic syndrome (MS) and its components are associated with cancer mortality. However, whether the association varies by race is unclear. To examine the association between metabolic risk factors and cancer death in non-Hispanic whites (whites) and non-Hispanic blacks (blacks) in the US. METHODS: We used data from National Health and Nutrition Examination Survey III (NHANES III) [1988-1994], a nationwide survey conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention in the US. We included a total of 18,001 participants aged ≥20 years in the study. We ascertained cancer death from NHANES III mortality follow-up study, which linked with the National Death Index and provides follow-up from the date of baseline NHANES III [1988-1994] through December 2006. MS was defined as the presence of at least three of five risk factors [i.e., elevated triglycerides (TG) (≥150 mg/dL), impaired fasting blood glucose (≥100 mg/dL), increased waist circumference (≥88 cm for women and ≥102 cm for men), elevated blood pressure (BP) (≥130 mmHg systolic BP or ≥85 mmHg diastolic BP) and, reduced high density lipoprotein (HDL) cholesterol (<50 mg/dL)]. The interaction between race and MS and its components against total cancer mortality was first tested. Cox proportional hazards regression was then used to estimate the hazard ratios (HR) and 95% confidence intervals (CI) for total cancer mortality in relation to each MS individual component, and a MS composite score in whites and blacks, separately. RESULTS: We found a statistically significant interaction between MS and race as well as MS components and race in their effect on cancer death. In adjusted models, elevated BP was significantly associated with a 41% increased risk of total cancer death in blacks (HR 1.41; 95% CI, 1.10-1.80) while in whites, the risk of cancer death increased 29% with central obesity (HR 1.29; 95% CI, 1.05-1.59), 26% with low HDL (HR 1.26; 95% CI, 1.04-1.52), and 45% with impaired fasting glucose (HR 1.45; 95% CI, 1.19-1.76). CONCLUSIONS: The relationship between metabolic risk factors and total cancer mortality differed by race in the US. In blacks, high BP was associated with an increased risk for cancer death while in whites, central obesity, low HDL, and especially impaired fasting glucose were positively associated with cancer death.

Improving Visualization of Female Breast Cancer Survival Estimates: Analysis Using Interactive Mapping Reports.

BACKGROUND: The Missouri Cancer Registry collects population-based cancer incidence data on Missouri residents diagnosed with reportable malignant neoplasms. The Missouri Cancer Registry wanted to produce data that would be of interest to lawmakers as well as public health officials at the legislative district level on breast cancer, the most common non-skin cancer among females. OBJECTIVE: The aim was to measure and interactively visualize survival data of female breast cancer cases in the Missouri Cancer Registry. METHODS: Female breast cancer data were linked to Missouri death records and the Social Security Death Index. Unlinked female breast cancer cases were crossmatched to the National Death Index. Female breast cancer cases in subcounty senate districts were geocoded using TIGER/Line shapefiles to identify their district. A database was created and analyzed in SEER*Stat. Senatorial district maps were created using US Census Bureau's cartographic boundary files. The results were loaded with the cartographic data into InstantAtlas software to produce interactive mapping reports. RESULTS: Female breast cancer survival profiles of 5-year cause-specific survival percentages and 95% confidence intervals, displayed in tables and interactive maps, were created for all 34 senatorial districts. The maps visualized survival data by age, race, stage, and grade at diagnosis for the period from 2004 through 2010. CONCLUSIONS: Linking cancer registry data to the National Death Index database improved accuracy of female breast cancer survival data in Missouri and this could positively impact cancer research and policy. The created survival mapping report could be very informative and usable by public health professionals, policy makers, at-risk women, and the public.

Ovarian Cancer Survival in Missouri, 1996-2014.

We evaluated relative survival (RS) for ovarian cancer (OC) overall, by demographic and by clinicopathological characteristics in Missouri. Survival data from the Missouri Cancer Registry were obtained for cases diagnosed 1996-2014. An improved OC survival, especially in late stage, was observed in the study period. Our findings showed demographic, especially race-associated, and geographical variations of OC survival. OC survival also differed by first course treatment received and histology. These differences indicate disparities in OC care.

Usability Assessment of the Missouri Cancer Registry's Published Interactive Mapping Reports: Round One.

BACKGROUND:  Many users of spatial data have difficulty interpreting information in health-related spatial reports. The Missouri Cancer Registry and Research Center (MCR-ARC) has produced interactive reports for several years. These reports have never been tested for usability. OBJECTIVE:  The aims of this study were to: (1) conduct a multi-approach usability testing study to understand ease of use (user friendliness) and user satisfaction; and (2) evaluate the usability of MCR-ARC's published InstantAtlas reports. METHODS:   An institutional review board (IRB) approved mixed methodology usability testing study using a convenience sample of health professionals. A recruiting email was sent to faculty in the Master of Public Health program and to faculty and staff in the Department of Health Management and Informatics at the University of Missouri-Columbia. The study included 7 participants. The test included a pretest questionnaire, a multi-task usability test, and the System Usability Scale (SUS). Also, the researchers collected participants' comments about the tested maps immediately after every trial. Software was used to record the computer screen during the trial and the participants' spoken comments. Several performance and usability metrics were measured to evaluate the usability of MCR-ARC's published mapping reports. RESULTS: Of the 10 assigned tasks, 6 reached a 100% completion success rate, and this outcome was relative to the complexity of the tasks. The simple tasks were handled more efficiently than the complicated tasks. The SUS score ranged between 20-100 points, with an average of 62.7 points and a median of 50.5 points. The tested maps' effectiveness outcomes were better than the efficiency and satisfaction outcomes. There was a statistically significant relationship between the subjects' performance on the study test and the users' previous experience with geographic information system (GIS) tools (P=.03). There were no statistically significant relationships between users' performance and satisfaction and their education level, work type, or previous experience in health care (P>.05). There were strong positive correlations between the three measured usability elements. CONCLUSIONS: The tested maps should undergo an extensive refining and updating to overcome all the discovered usability issues and meet the perspectives and needs of the tested maps' potential users. The study results might convey the perspectives of academic health professionals toward GIS health data. We need to conduct a second-round usability study with public health practitioners and cancer professionals who use GIS tools on a routine basis. Usability testing should be conducted before and after releasing MCR-ARC's maps in the future.

Trend analysis and survival of primary gallbladder cancer in the United States: a 1973-2009 population-based study.

Primary gallbladder cancer is an aggressive and uncommon cancer with poor outcomes. Our study examines epidemiology, trend, and survival of gallbladder cancer in the United States from 1973 to 2009. We utilized the Surveillance Epidemiology and End Results database (SEER). Frequency and rate analyses on demographics, stage, and survival were compared among non-Hispanic whites, Hispanics, African American, and Asian/Pacific Islanders. A total of 18,124 cases were reported in SEER from 1973 to 2009 comprising 1.4% of all reported gastrointestinal cancers. Gallbladder cancer was more common in females than males (71 vs. 29%, respectively). The age-adjusted incidence rate was 1.4 per 100,000, significantly higher in females than males (1.7 vs. 1.0). Trend analysis showed that the incidence rate has been decreasing over the last three decades for males. However, among females, the incidence rate had decreased from 1973 to mid-90s but has remained stable since then. Trend analysis for stage at diagnosis showed that the proportion of late-stage cases has been increasing significantly since 2001 after a decreasing pattern since 1973. Survival has improved considerably over time, and survival is better in females than males and in Asian/Pacific Islanders than other racial groups. The highest survival was in patients who received both surgery and radiation. Trend analysis revealed a recent increase of the incidence of late-stage gallbladder cancer. Highest survival was associated with receiving both surgery and radiation.

Effectiveness of a scaled up physical activity intervention in Brazil: A natural experiment.

Physical inactivity causes 5.3 million deaths annually worldwide. We evaluated the impact on population leisure-time physical activity (LTPA) of scaling up an intervention in Brazil, Academia das Cidades program (AC-P). AC-P is a health promotion program classified as physical activity classes in community settings which started in the state of Pernambuco state in 2008. We surveyed households from 80 cities of Pernambuco state in 2011, 2012 and 2013, using monitoring data to classify city-level exposure to AC-P. We targeted 2370 individuals in 2011; 3824 individuals in 2012; and 3835 individuals in 2013. We measured participation in AC-P and whether respondents had seen an AC-P activity or heard about AC-P. We measured LTPA using the International Physical Activity Questionnaire. We estimated the odds of reaching recommended LTPA by levels of exposure to the three AC-P measures. For women, the odds of reaching recommended LTPA were 1.10 for those living in cities with AC-P activity for less than three years, and 1.46 for those living in cities with AC-P activity for more than three years compared to those living in cities that had not adopted AC-P. The odds of reaching recommended LTPA increased with AC-P participation and knowledge about AC-P. AC-P exposure is associated with increased population LTPA. Extending AC-P to all cities could potentially impact non-communicable diseases in Brazil.

Estimated and Interactively Visualized Female Breast Cancer Incidence Rates in Missouri Senate Districts: 2008-2012.

OBJECTIVES: To measure and interactively visualize female breast cancer (FBC) incidence rates in Missouri by age, race, stage and grade, and senate district of residence at diagnosis from 2008 to 2012. METHODS: An observational epidemiological study. The FBC cases in counties split by senate districts were geocoded. Population database was created. A database was created within SEER*Stat. The incidence rates and the 95% Confidence Interval (CI) were age standardized using US 2000 Standard Population. The Census Bureau's Cartographic Boundary Files were used to create maps showing Missouri senate districts. Incidence results were loaded along with the maps into InstantAtlas™ software to produce interactive reports. RESULTS: Cancer profiles were created for all 34 Missouri senate districts. An area profile and a double map that included interactive maps, graphs, and tables for the 34 Missouri senate districts were built. CONCLUSION: The results may provide an estimation of social inequality within the state and could provide clues about the impact of level of coverage and accessibility to screening and health care services on disease prevention and early diagnosis.

Increased risk for colorectal cancer under age 50 in racial and ethnic minorities living in the United States.

Colorectal cancer (CRC) is the second most common cause of cancer death in USA. We analyzed CRC disparities in African Americans, Hispanics, Asians/Pacific Islanders, and American Indians/Alaska Natives compared to non-Hispanic Whites. Current guidelines recommend screening for CRC beginning at age 50. Using SEER (Surveillance, Epidemiology, and End Results) database 1973-2009 and North American Association of Central Cancer Registries (NAACCR) 1995-2009 dataset, we performed frequency and rate analysis on colorectal cancer demographics and incidence based on race/ethnicity. We also used the SEER database to analyze stage, grade, and survival based on race/ethnicity. Utilizing SEER database, the median age of CRC diagnosis is significantly less in Hispanics (66 years), Asians/Pacific Islanders (68 years), American Indians/Alaska Natives (64 years), and African Americans (64 years) compared to non-Hispanic whites (72 years). Twelve percent of Asians/Pacific Islanders, 15.4% Hispanics, 16.5% American Indians/Alaska Natives, and 11.9% African Americans with CRC are diagnosed at age <50 years compared to only 6.7% in non-Hispanic Whites (P < 0.0001). Minority groups have more advanced stages at diagnosis compared to non-Hispanic Whites. Trend analysis showed age-adjusted incidence rates of CRC diagnosed under the age of 50 years have significantly increased in all racial and ethnic groups but are stable in African Americans. These results were confirmed through analysis of NAACCR 1995-2009 dataset covering nearly the entire USA. A significantly higher proportion of minority groups in USA with CRC are diagnosed before age 50 compared to non-Hispanic Whites, documenting that these minority groups are at higher risk for early CRC. Further studies are needed to identify the causes and risk factors responsible for young onset CRC among minority groups and to develop intervention strategies including earlier CRC screening, among others.