Utilization of long-acting injectable monthly depot buprenorphine for opioid use disorder (OUD) in Kentucky, before and after COVID-19 related buprenorphine access policy changes.

INTRODUCTION: Long-acting injectable buprenorphine (LAI-bup) formulations have advantages over transmucosal buprenorphine (TM-bup), but barriers may limit their utilization. Several policies shifted during the COVID-19 pandemic to promote buprenorphine access. The federal government expanded telemedicine treatment for opioid use disorder and Kentucky (KY) Medicaid lifted prior authorization requirements (PAs) for LAI-bup (i.e., Sublocade®). This retrospective cohort study evaluated changes in LAI-bup access, utilization, and retention before and after these policy changes in KY. METHODS: Individual-level TM-bup and LAI-bup dispensing record data from KY's prescription drug monitoring program examined LAI-bup utilization and retention, without a >30-day gap in coverage, for patients starting a new episode of LAI-bup treatment. Two key time periods were examined: pre-policy changes (Apr 1, 2019 - Dec 31, 2019) and post-policy changes (Apr 1, 2020 - Dec 31, 2020). Data on PA requests among Medicaid managed care organizations and availability of LAI-bup Risk Evaluation and Mitigation Strategy (REMS)-certified pharmacies were also obtained. A multivariable Cox proportional hazard regression model analysis compared pre- versus post-policy period treatment discontinuation. RESULTS: The number of patients initiating LAI-bup increased from 211 to 481 over the two periods. By the end of the post-policy period, 24.3 % of eligible patients were retained on LAI-bup, versus 12.5 % in the pre-policy change period. The adjusted hazard ratio, comparing discontinuation during the post- versus pre-policy change periods, was 0.70 (95 % confidence interval: 0.55-0.89). There were also more REMS-certified pharmacies and providers in the post-policy change period. CONCLUSIONS: LAI-bup access, utilization, and retention increased after several policy changes.

Higher First 30-Day Dose of Buprenorphine for Opioid Use Disorder Treatment Is Associated With Decreased Mortality.

OBJECTIVE: Buprenorphine is a medication for opioid use disorder that reduces mortality. This study aims to investigate the less well-understood relationship between the dose in the early stages of treatment and the subsequent risk of death. METHODS: We used Kentucky prescription monitoring data to identify adult Kentucky residents initiating transmucosal buprenorphine medication for opioid use disorder (January 2017 to November 2019). Average daily buprenorphine dose for days covered in the first 30 days of treatment was categorized as ≤8 mg, >8 to ≤16 mg, and >16 mg. Patients were followed for 365 days after the first 30 days of buprenorphine treatment. Endpoints were opioid-involved overdose death and death from other causes. Causes and dates of death were obtained using Kentucky death certificate records. Associations were evaluated using multivariable Fine and Gray models adjusting for patient baseline characteristics. RESULTS: In the cohort of 49,857 patients, there were 227 opioid-involved overdose deaths and 459 deaths from other causes. Compared with ≤8 mg, the adjusted subdistribution hazard ratio (aSHR) of opioid-involved overdose death decreased by 55% (aSHR, 0.45; 95% confidence interval [CI], 0.34-0.60) and 64% (aSHR, 0.36; 95% CI, 0.25-0.52) for patients receiving doses of >8 to ≤16 mg and >16 mg, respectively. The incidence of death from other causes was lower in patients receiving >8 to ≤16 mg (aSHR, 0.78; 95% CI, 0.62-0.98) and >16 mg (aSHR, 0.62; 95% CI, 0.47-0.80) versus ≤8 mg dose. CONCLUSIONS: Higher first 30-day buprenorphine doses were associated with reduced opioid-involved overdose death and death from other causes, supporting benefit of higher dosing in reducing mortality.

Undiagnosed Cancer Cases in the US During the First 10 Months of the COVID-19 Pandemic.

Importance: The COVID-19 pandemic disrupted the normal course of cancer screening and detection in the US. A nationwide analysis of the extent of this disruption using cancer registry data has not been conducted. Objective: To assess the observed and expected cancer rate trends for March through December 2020 using data from all 50 US states and the District of Columbia. Design, Settings, and Participants: This was a population-based cross-sectional analysis of cancer incidence trends using data on cases of invasive cancer diagnosis reported to the US Cancer Statistics from January 1, 2018, through December 31, 2020. Data analyses were performed from July 6 to 28, 2023. Exposure(s): Age, sex, race, urbanicity, and state-level response to the COVID-19 pandemic at the time of cancer diagnosis. Main Outcomes and Measures: Used time-series forecasting methods to calculate expected cancer incidence rates for March 1 through December 31, 2020, from prepandemic trends (January 2018-February 2020). Measured relative difference between observed and expected cancer incidence rates and numbers of potentially missed cancer cases. Results: This study included 1 297 874 cancer cases reported in the US from March 1 through December 31, 2020, with an age-adjusted incidence rate of 326.5 cases per 100 000 population. Of the observed cases, 657 743 (50.7%) occurred in male patients, 757 106 (58.3%) in persons 65 years or older, and 1 066 566 (82.2%) in White individuals. Observed rates of all-sites cancer incidence in the US were 28.6% (95% prediction interval [PI], 25.4%-31.7%) lower than expected during the height of the COVID-19 pandemic response (March-May 2020); 6.3% (95% PI, 3.8%-8.8%) lower in June to December 2020; and overall, 13.0% (95% PI, 11.2%-14.9%) lower during the first 10 months of the pandemic. These differences indicate that there were potentially 134 395 (95% PI, 112 544-156 680) undiagnosed cancers during that time frame. Prostate cancer accounted for the largest number of potentially missed cases (22 950), followed by female breast (16 870) and lung (16 333) cancers. Screenable cancers saw a total rate reduction of 13.9% (95% PI, 12.2%-15.6%) compared with the expected rate. The rate of female breast cancer showed evidence of recovery to previous trends after the first 3 months of the pandemic, but levels remained low for colorectal, cervical, and lung cancers. From March to May 2020, states with more restrictive COVID-19 responses had significantly greater disruptions, yet by December 2020, these differences were nonsignificant for all sites except lung, kidney, and pancreatic cancer. Conclusions and Relevance: This cross-sectional analysis of cancer incidence trends found a substantial disruption to cancer diagnoses in the US during the first 10 months of the COVID-19 pandemic. The overall and differential findings can be used to inform where the US health care system should be looking to make up ground in cancer screening and detection.

Geographic variation of HPV-associated cancer incidence in Kentucky using spatial scan statistics.

PURPOSE: Populations with high cancer risk that are targeted for screening, education, and vaccination have been shown to increase rates of screening, which ultimately may improve timing of diagnosis and overall outcome for certain cancers. Spatial scan analysis provides a visual representation of areas with higher rates of disease. Limited research has used this methodology to assess HPV-associated cancers. Using, spatial scan statistics, our goal was to identify regions within Kentucky having significantly higher rates of HPV-associated tumors. These regions can be targeted for public health efforts in the form of education, vaccination, screening, and physician recruitment. METHODS: The Kentucky Cancer Registry data from 1995 to 2016 and spatial scan statistics were used to identify county-level clusters with high-incidence of HPV-associated cancers after adjustment for age and sex. Anatomic sites included in this analysis were oropharynx, cervix, anus, penis, and vulva. RESULTS: There was one high-rate cluster of oropharyngeal cancer, which was observed in the Louisville metropolitan region (Relative Risk [RR] = 1.24, p < 0.001). One high-rate cluster of anal and penile cancer incidence in men was identified that partially overlapped with the oropharyngeal cluster. There were five clusters of higher cervical, vulvar, and anal cancer incidence in females, one of which overlapped with the oropharyngeal cluster. CONCLUSION: Overlapping clusters of HPV-associated cancers were identified at the county-level and included both urban and rural counties of Kentucky. Findings can assist in the design of public health interventions to increase screenings, promote vaccination, and recruit physicians in these regions to improve prevention, diagnosis, and early treatment of HPV-associated cancers.

Bystander preference for naloxone products: a field experiment.

BACKGROUND: Bystander administration of naloxone is a critical strategy to mitigate opioid overdose mortality. To ensure bystanders' willingness to carry and administer naloxone in response to a suspected overdose, it is critical to select products for community distribution with the highest likelihood of being utilized. This study examines bystanders' preference for and willingness to administer three naloxone products approved by the FDA for bystander use and identify product features driving preference. METHODS: The population was a convenience sample of individuals who attended the Kentucky State Fair, August 18-28, 2022, in Louisville, Kentucky. Participants (n = 503) watched a standardized overdose education and naloxone training video, rated their willingness to administer each of three products (i.e., higher-dose nasal spray, lower-dose nasal spray, intramuscular injection), selected a product to take home, and rated factors affecting choice. RESULTS: After training, 44.4% chose the higher-dose nasal spray, 30.1% chose the intramuscular injection, and 25.5% chose the lower-dose nasal spray. Factors most influencing choice on a 10-point Likert scale were ease of use (9 [7-10]), naloxone dose (8 [5-10]), and product familiarity (5 [5-9]). CONCLUSIONS: Bystanders expressed high willingness to administer all studied formulations of naloxone products. Product choice preference varied as a function of product features. As the number and variety of available products continue to increase, continuous evaluation of formulation acceptability, in addition to including individuals with lived experience who are receiving and administering overdose reversal agents, is critical to support adoption and save lives.

Influence of depression on breast cancer treatment and survival: A Kentucky population-based study.

BACKGROUND: Depression is common among breast cancer patients and can affect concordance with guideline-recommended treatment plans. Yet, the impact of depression on cancer treatment and survival is understudied, particularly in relation to the timing of the depression diagnosis. METHODS: The Kentucky Cancer Registry data was used to identify female patients diagnosed with primary invasive breast cancer who were 20 years of age or older in 2007-2011. Patients were classified as having no depression, depression pre-cancer diagnosis only, depression post- cancer diagnosis only, or persistent depression. The impact of depression on receiving guideline-recommended treatment and survival was examined using multivariable logistic regression and Cox regression, respectively. RESULTS: Of 6054 eligible patients, 4.1%, 3.7%, and 6.2% patients had persistent depression, depression pre-diagnosis only, and depression post-diagnosis only, respectively. A total of 1770 (29.2%) patients did not receive guideline-recommended cancer treatment. Compared to patients with no depression, the odds of receiving guideline-recommended treatment were decreased in patients with depression pre-diagnosis only (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.54-1.04) but not in patients with post-diagnosis only or persistent depression. Depression post-diagnosis only (hazard ratio, 1.51; 95% CI, 1.24-1.83) and depression pre-diagnosis only (hazard ratio, 1.26; 95% CI, 0.99-1.59) were associated with worse survival. No significant difference in survival was found between patients with persistent depression and patients with no depression (p > .05). CONCLUSIONS: Neglecting depression management after a breast cancer diagnosis may result in poorer cancer treatment concordance and worse survival. Early detection and consistent management of depression is critical in improving patient survival.

Changes in transmucosal buprenorphine utilization for opioid use disorder treatment during the COVID-19 pandemic in Kentucky.

PURPOSE: With surging opioid-involved overdoses, maintaining access to opioid use disorder (OUD) treatment is critical during the COVID-19 pandemic. We examined changes in transmucosal buprenorphine prescribing for OUD treatment in Kentucky after the national COVID-19 emergency declaration, with a focus on rural-urban differences. METHODS: Using 2019-2020 prescription monitoring data, we performed segmented regression analysis for an interrupted time series design to evaluate changes in weekly rates (per 100,000 residents) of dispensed prescriptions, unique individuals with dispensed prescriptions, and average days' supply for dispensed prescriptions of transmucosal buprenorphine. FINDINGS: The weekly rates of dispensed prescriptions and unique individuals with dispensed prescriptions were higher for rural residents than urban residents. After the national COVID-19 emergency declaration, rural and urban residents experienced similar immediate drops in the rate of dispensed prescriptions (rural -33.4; urban -24.3) and unique patients with dispensed prescriptions (rural -25.0; urban -17.1), followed by similar sustained increases. Both measures surpassed the prepandemic levels in mid-June 2020. Patients residing in urban areas received averagely longer prescriptions at baseline (urban: 11.0 days; rural: 10.5 days). The average weekly days' supply increased in the week after the national emergency declaration, but the estimated increase was higher (P = .004) for urban (0.8 days) versus rural (0.5 days) residents. CONCLUSIONS: Transmucosal buprenorphine utilization increased during the COVID-19 pandemic after experiencing interruption during the initial weeks of the pandemic. Future studies should evaluate the contribution of the relaxed telemedicine buprenorphine prescribing regulations during the COVID-19 national emergency on initiation and maintenance of buprenorphine treatment.

Sex and race define the effects of adverse childhood experiences on self-reported BMI and metabolic health biomarkers.

BACKGROUND: Adverse childhood experiences (ACEs) are an independent risk factor for chronic diseases, including type 2 diabetes, stroke and ischemic heart disease. However, the effect of ACEs considering sex and race are not often reported in cohorts showing multiracial composition, with power to evaluate effects on underrepresented populations. AIM: To determine how sex and race affected the association of combined and individual ACEs with metabolic health biomarkers in the Southern Community Cohort Study (2012-2015). METHODS: Self-reported data were analyzed from ACE surveys performed during the second follow-up of a cohort comprised by over 60% of Black subjects and with an overall mean age of 60 years. RESULTS: BMI steadily increased with cumulative ACEs among Black and White women, but remained relatively stable in White men with ≥ 4 ACEs. Contrary, Black men showed an inverse association between ACE and BMI. Secondary analysis of metabolic outcomes showed that physical abuse was correlated with a 4.85 cm increase in waist circumference in Black subjects. Total cholesterol increased among individuals with more than 4 ACEs. In addition, increases in HbA1c were associated with emotional and maternal abuse in Black women and sexual abuse in White women. CONCLUSIONS: BMI is strongly associated with cumulative ACEs in women regardless the race, while waist circumference is strongly associated with ACEs in Black individuals, which combined with reduced BMI may indicate increased central adiposity in Black men. Our study suggests that sex and race influence the contribution of certain ACEs to impair metabolic health.

Ranked determinants of telemedicine diabetic retinopathy screening performance in the United States primary care safety-net setting: an exploratory CART analysis.

BACKGROUND: Diabetic retinopathy (DR) is a leading cause of blindness worldwide, despite easy detection and effective treatment. Annual screening rates in the USA remain low, especially for the disadvantaged, which telemedicine-based DR screening (TDRS) during routine primary care has been shown to improve. Screening rates from such programs have varied, however, pointing to inconsistent implementation and unaddressed barriers. This work seeks to identify and prioritize modifiable barriers for targeted intervention. METHODS: In this final phase of an exploratory mixed-methods study, we developed, validated, and administered a 62-item survey to multilevel stakeholders involved with TDRS in primary care safety-net clinics. Survey items were aligned with previously identified determinants of clinic-level screening and mapped to the Consolidated Framework for Implementation Research (CFIR). Classification and Regression Tree (CART) analyses were used to identify and rank independent variables predictive of individual-level TDRS screening performance. RESULTS: Overall, 133 of the 341 invited professionals responded (39%), representing 20 safety-net clinics across 6 clinical systems. Respondents were predominately non-Hispanic White (77%), female (94%), and between 31 and 65 years of age (79%). Satisfaction with TDRS was high despite low self-reported screening rates. The most important screening determinants were: provider reinforcement of TDRS importance; explicit instructions by providers to staff; effective reminders; standing orders; high relative priority among routine diabetic measures; established TDRS workflows; performance feedback; effective TDRS champions; and leadership support. CONCLUSIONS: In this survey of stakeholders involved with TDRS in safety-net clinics, screening was low despite high satisfaction with the intervention. The best predictors of screening performance mapped to the CFIR constructs Leadership Engagement, Compatibility, Goals & Feedback, Relative Priority, Champions, and Available Resources. These findings facilitate the prioritization of implementation strategies targeting determinants of TDRS performance, potentially increasing its public health impact.

Effect of a Multimodal Analgesic Protocol on Short-Term and Long-Term Opioid Use After Orthopaedic Trauma.

OBJECTIVE: To determine whether the use of a multimodal analgesic protocol reduced short-term and long-term opioid use in patients hospitalized after orthopaedic trauma. DESIGN: Retrospective pre-post intervention study. SETTING: Regional, academic, Level 1 trauma center in Central Kentucky. PATIENTS/PARTICIPANTS: Patients were hospitalized after orthopaedic injury before (n = 393) and after (n = 378) the implementation of a multimodal analgesic protocol. INTERVENTION: The intervention involved a multimodal analgesic protocol consisting of acetaminophen, ibuprofen/ketorolac, gabapentinoids, skeletal muscle relaxants, and standardized doses of opioids plus standardized pain management education before hospital discharge. MAIN OUTCOME MEASUREMENTS: End points included discharge opioid prescription, days' supply and daily morphine milligram equivalent (MME), and long-term opioid use after hospitalization. Opioid use in the 90 days before and after hospitalization was assessed using state prescription drug monitoring program data. RESULTS: Discharge opioid prescription rates were similar in the intervention and control cohorts [79.9% vs. 78.4%, odds ratio (OR) 1.30 (0.83-2.03), P = 0.256]. Patients in the intervention cohort received a shorter days' supply [5.7 ± 4.1 days vs. 8.1 ± 6.2 days, rate ratio 0.70 (0.65-0.76), P < 0.001] and lower average daily MME [34.8 ± 24.9 MME vs. 51.5 ± 44.0 MME, rate ratio 0.68 (0.62-0.75), P < 0.001]. The incidence of long-term opioid use was also significantly lower in the intervention cohort [7.7% vs. 12.0%, OR 0.53 (0.28-0.98), P = 0.044]. CONCLUSIONS: Implementation of a multimodal analgesic protocol was associated with reductions in both short-term and long-term opioid use, including long-term opioid therapy, after orthopaedic trauma. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Longitudinal Examination of Prenatal Tobacco Switching Behaviors and Birth Outcomes, Including Electronic Nicotine Delivery System (ENDS) and Dual Use.

INTRODUCTION: In the US, approximately 8% of pregnant women smoke, and 5-11.9% currently use ENDS products. The health effects of ENDS use are debated; however, most contain nicotine which is known to cause adverse perinatal outcomes. Studies have shown adult ENDS users significantly alter use behaviors over time (switch to conventional cigarettes-only or dual use) thus complicating efforts to examine health effects of ENDS use. The purpose of this study was to describe switching behaviors and associated birth outcomes among infants of women using conventional cigarettes only, ENDS-only, or both. METHODS: This was a multisite, longitudinal study of biologically confirmed perinatal tobacco users, with nicotine product use assessed each trimester. For the purpose of analysis, participants were defined as switchers, no-switchers, or quitters. Birth outcomes were abstracted from electronic medical records. Analysis included descriptive statistics, linear and multivariate logistic regression adjusted for age, preterm birth, smoking behavior in the first trimester, and an interaction between smoking switching behavior and smoking behavior in the first trimester. Analysis was conducted using SAS v9.4 with significance determined as p < 0.05. RESULTS: At enrollment, 48.6% of participants used only conventional cigarettes, 41.7% were dual users, and 10% used ENDS-only. While almost two-thirds of participants used the same tobacco product throughout pregnancy, 26% reported switching behaviors that were complex and not easily clustered. No differences were found in birth outcomes between switchers and no-switchers; however, a difference emerged in birth weight between no-switchers and quitters. DISCUSSION: Given the limited data on health effects of ENDS use, and the known harmful consequences of perinatal nicotine use, capturing and classifying product switching behaviors is imperative to inform public health, and remains a challenge requiring further research.

Can organizational efforts lead to less secondary traumatic stress? A longitudinal investigation of change.

Objectives: Current best practice approaches suggest that to address secondary traumatic stress (STS) a two-pronged perspective that considers individual and organizational factors over time is warranted. However, research documenting the impact of organizational efforts on individual experience with STS is lacking. In this study, it was hypothesized that as an organization becomes more STS informed, there would be decreases in reported levels of STS and burnout (BO) in individuals over time; and these changes would be associated with higher levels of implementation activity and increased use of interventions to improve physical and psychological safety. Methods: This study uses data from 2,345 responses, representing 7 groups involved in an organizational change process aimed at creating STS informed organizations in a department of health and human services. The Secondary Traumatic Stress Informed Organizational Assessment (STSI-OA), the Secondary Traumatic Stress Scale (STSS), and the Professional Quality of Life-5 BO subscales measured variables of interest. Using a longitudinal design, baseline, post, and follow-up data were collected. Results: One-way ANOVAs revealed significant improvements in STSI-OA, STSS, and BO scores across time (p-value < .05). Linear mixed models reveal that significant declines in STSS scores were associated with improved STSI-OA scores (p = <.001), after adjusting for age, gender, time, and level of implementation activity. Implications: These results support the hypothesis that organizational efforts can improve an individual's perceived level of distress, and that focused attention to the issue of secondary trauma in an organization can improve organizational and individual outcomes using a data-driven change approach. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

High-fat feeding disrupts daily eating behavior rhythms in obesity-prone but not in obesity-resistant male inbred mouse strains.

Abnormal meal timing, like skipping breakfast and late-night snacking, is associated with obesity in humans. Disruption of daily eating rhythms also contributes to obesity in mice. When fed a high-fat diet, male C57BL/6J mice have disrupted eating behavior rhythms and they become obese. In contrast to obesity-prone C57BL/6J mice, some inbred strains of mice are resistant to high-fat diet-induced obesity. In this study, we sought to determine whether there are distinct effects of high-fat feeding on daily eating behavior rhythms in obesity-prone and obesity-resistant male mice. Male obesity-prone (C57BL/6J and 129X1/SvJ) and obesity-resistant (SWR/J and BALB/cJ) mice were fed low-fat diet or high-fat diet for 6 wk. Consistent with previous studies, obesity-prone male mice gained more weight and adiposity during high-fat diet feeding than obesity-resistant male mice. The amplitude of the daily rhythm of eating behavior was markedly attenuated in male obesity-prone mice fed high-fat diet, but not in obesity-resistant males. In contrast, high-fat feeding did not differentially affect locomotor activity rhythms in obesity-prone and obesity-resistant male mice. Together, these data suggest that regulation of the daily rhythm of eating may underlie the propensity to develop diet-induced obesity in male mice.

Implementation and sustainment of a statewide telemedicine diabetic retinopathy screening network for federally designated safety-net clinics.

CONTEXT: Diabetic retinopathy (DR) is the leading cause of incident blindness among working-age adults in the United States. Federally designated safety-net clinics (FDSC) often serve as point-of-contact for patients least likely to receive recommended DR screenings, creating opportunity for targeted interventions to increase screening access and compliance. STUDY DESIGN AND METHODS: With such a goal, we implemented and assessed the longitudinal performance of an FDSC-based telemedicine DR screening (TDRS) network of 22 clinical sites providing nonmydriatic fundus photography with remote interpretation and reporting. Retrospective analysis of patient encounters between February 2014 and January 2019 was performed to assess rates of pathology and referral. A generalized estimating equation logistic regression model was used for subset analysis from audits of pre- and post-implementation screening rates. Finally, patient surveys were conducted and assessed as a measure of intervention acceptability. RESULTS: Of the 13,923 individual telescreening encounters (4327 female, 4220 male, and 5376 unspecified; mean [SD] age, 54.9 [12.5] years) studied, 10,540 were of adequate quality to identify 3532 (33.5%) patients with ocular pathology: 2319 (22.0%) patients had some level of DR with 1604 (15.2%) requiring specialist referral, and 808 (7.7%) patients required referral for other ocular pathologies. The mean screening rate for audited clinics in the year prior to program implementation was 29.9% (641/2147), which increased to 47.7% (1012/2124) in the program's first year, doubling patients' odds of being screened (OR 2.2; 95% CI: 1.3-3.7; P = .003). These gains were sustained over four years following implementation (OR 1.9; 95% CI: 1.1-3.1; P = .018) despite varied clinic screening performance (4-year averaged range, 22.9-55.1%). Odds of early detection likewise doubled for patients with consecutive screenings (OR 2.2, 95% CI: 2.0-2.4; P < .001). Finally, surveyed patients preferred TDRS to specialist exams (82.5%; 776/941) and would recommend the service to friends (92.7%; 868/936). CONCLUSION AND RELEVANCE: A statewide, FDSC-centered TDRS network was successfully established and sustained in a medically underserved region of the United States. Our results suggest that large TDRS networks in FDSCs can increase screening access and compliance for otherwise unscreened populations, but outcomes can vary greatly among clinics. Further work to optimize program implementation is needed to maximize this model's impact.

Financial distress among cancer survivors in Appalachian Kentucky.

BACKGROUND: Rural residence may exacerbate cancer-related financial distress. Limited research has focused on Appalachian cancer survivors' experience with financial distress. AIMS: The primary aim of this study was to estimate the prevalence of financial distress among cancer survivors residing in Appalachian Kentucky with a specific focus on the impact of rurality and to elucidate the risk factors impacting financial distress among this population. METHODS AND RESULTS: Appalachian Kentucky residents were sampled for receipt of a health survey based on county-level rurality. Analyses describe the prevalence and predictors of financial distress among cancer survivors. Subsequent analyses were conducted with Health Information National Trends Survey (HINTS) data to compare local versus national estimates of financial distress. Almost two-thirds of Appalachian survivors reported financial distress compared to one-third of the HINTS sample. Appalachian survivors residing in the most rural counties reported higher distress; this finding was not supported in the national sample. In multivariable analyses, gender, current age, and household income were associated with financial distress among Appalachians; only income was significant among the national sample. CONCLUSION: Appalachian cancer survivors have higher than national estimates of financial distress; rurality and socioeconomics are drivers of this disparity.

Thyroid Cancer Incidence in India Between 2006 and 2014 and Impact of Overdiagnosis.

CONTEXT/OBJECTIVE: Increases of thyroid cancer (TC) incidence emerged in the past several decades in several countries. This study aimed to estimate time trends of TC incidence in India and the proportion of TC cases potentially attributable to overdiagnosis by sex, age, and area. DESIGN: TC cases aged 0 to 74 years reported to Indian cancer registries during 2006 through 2014 were included. Age-standardized incidence rates (ASR) and TC overdiagnosis were estimated by sex, period, age, and area. RESULTS: Between 2006 to 2008 and 2012 to 2014, the ASRs for TC in India increased from 2.5 to 3.5/100,000 women (+37%) and from 1.0 to 1.3/100,000 men (+27%). However, up to a 10-fold difference was found among regions in both sexes. Highest ASRs emerged in Thiruvananthapuram (14.6/100,000 women and 4.1/100,000 men in 2012-2014), with 93% increase in women and 64% in men compared with 2006 to 2008. No evidence of overdiagnosis was found in Indian men. Conversely, overdiagnosis accounted for 51% of TC in Indian women: 74% in those aged < 35 years, 50% at ages 35 to 54 years, and 30% at ages 55 to 64 years. In particular, 80% of TC overdiagnosis in women emerged in Thiruvananthapuram, whereas none or limited evidence of overdiagnosis emerged in Kamrup, Dibrugarh, Bhopal, or Sikkim. CONCLUSIONS: Relatively high and increasing TC ASRs emerged in Indian regions where better access to health care was reported. In India, as elsewhere, new strategies are needed to discourage opportunistic screening practice, particularly in young women, and to avoid unnecessary and expensive treatments. Present results may serve as a warning also for other transitioning countries.