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Adolescents and young adults (AYAs, 15-39 years) are the largest uninsured population in the Unites States, increasing the likelihood of late-stage cancer diagnosis and poor survival. We evaluated the associations between the Affordable Care Act (ACA), insurance coverage, stage at diagnosis and survival among AYAs with lymphoma. We used data from the California Cancer Registry linked to Medicaid enrollment files on AYAs diagnosed with a primary non-Hodgkin (NHL; n=5959) or Hodgkin (n=5378) lymphoma pre-ACA and in the early and full ACA eras. Health insurance was categorized as continuous Medicaid, discontinuous Medicaid, Medicaid enrollment at diagnosis/uninsurance, other public and private. We used multivariable regression models for statistical analyses. The proportion of AYAs uninsured/Medicaid enrolled at diagnosis decreased from 13.4% pre-ACA to 9.7% with full ACA implementation, while continuous Medicaid increased from 9.3% to 29.6% during this time (P

Author(s): Parikh-Patel, Arti; Morris, Cyllene R; Kizer, Kenneth W; Wun, Ted; Keegan, Theresa HM | Abstract: IntroductionPrevious research suggests cancer patients living in rural areas have lower quality of care, but population-based studies have yielded inconsistent results. This study examines the impact of rurality on care quality for 7 cancer types in California.MethodsBreast, ovarian, endometrial, cervix, colon, lung, and gastric cancer patients diagnosed from 2004 to 2017 were identified in the California Cancer Registry. Multivariable logistic regression and proportional hazards models were used to assess effects of residential location on quality of care and survival. Stratified models examined the impact of treatment at National Cancer Institute designated cancer centers (NCICCs). Quality of care was evaluated using Commission on Cancer measures. Medical Service Study Areas were used to assess urban/rural status. Data were collected in 2004-2019 and analyzed in 2020.Results989,747 cancer patients were evaluated, with 14% living in rural areas. Rural patients had lower odds of receiving radiation after breast conserving surgery compared to urban residents. Colon and gastric cancer patients had 20% and 16% lower odds, respectively, of having optimal surgery. Rural patients treated at NCICCs had greater odds of recommended surgery for most cancer types. Survival was similar among urban and rural subgroups.ConclusionsRural residence was inversely associated with receipt of recommended surgery for gastric and colon cancer patients not treated at NCICCs, and for receiving recommended radiotherapy after breast conserving surgery regardless of treatment location. Further studies investigating the impact of care location and availability of supportive services on urban-rural differences in quality of care are warranted.

ImportanceCalifornia’s tobacco control efforts have been associated with a decrease in cancer mortality, but these estimates are based on smoking prevalence of the general population. Patient-level tobacco use information allows for more precise estimates of the proportion of cancer deaths attributable to smoking.ObjectiveTo calculate the proportion (smoking-attributable fraction) and number (smoking-attributable cancer mortality) of cancer deaths attributable to tobacco use using patient-level data.Design, Setting, and ParticipantsThe smoking-attributable fraction and smoking-attributable cancer mortality were calculated for a retrospective cohort of patients whose cancer was diagnosed from 2014 to 2019 with at least 1 year of follow-up using relative risks from large US prospective studies and patient-level smoking information. Follow-up continued through April 2022. A population-based cohort was identified from the California Cancer Registry. Participants included adults aged 20 years and older with a diagnosis of 1 of the 12 tobacco-related cancers (oral cavity or pharynx, larynx, esophagus, lung, liver, stomach, pancreas, kidney, bladder, colon or rectum, cervix, and acute myeloid leukemia).ExposuresTobacco use defined as current, former, or never.Main Outcomes and MeasuresThe primary outcomes were the smoking-attributable fraction and smoking-attributable cancer mortality for each of the 12 tobacco-related cancers over 2 time periods (2014-2016 vs 2017-2019) and by sex.ResultsAmong 395 459 patients with a tobacco-related cancer, most (285 768 patients [72.3%]) were older than 60 years, the majority (228 054 patients [57.7%]) were non-Hispanic White, 229 188 patients were men (58.0%), and nearly one-half (184 415 patients [46.6%]) had lung or colorectal cancers. Nearly one-half of the deaths (93 764 patients [45.8%]) in the cohort were attributable to tobacco. More than one-half (227 660 patients [57.6%]) of patients had ever used tobacco, and 69 103 patients (17.5%) were current tobacco users, which was higher than the proportion in the general population (11.7%). The overall smoking-attributable fraction of cancer deaths decreased significantly from 47.7% (95% CI, 47.3%-48.0%) in 2014 to 2016 to 44.8% (95% CI, 44.5%-45.1%) in 2017 to 2019, and this decrease was seen for both men and women. The overall smoking-attributable cancer mortality decreased by 10.2%.Conclusions and RelevanceCalifornia still has a substantial burden of tobacco use and associated cancer. The proportion of cancer deaths associated with tobacco use was almost double what was previously estimated. There was a modest but significant decline in this proportion for overall tobacco-associated cancers, especially for women.

Purpose Through screening and HPV vaccination, cervical cancer can mostly be prevented or detected very early, before symptoms develop. However, cervical cancer persists, and many women are diagnosed at advanced stages. Little is known about the degree to which U.S. women may begin their diagnostic workup for cervical cancer in Emergency Departments (ED). We sought to quantify the proportion of women presenting symptomatically in the ED prior to their diagnosis with cervical cancer and to describe their characteristics and outcomes. Methods We identified women diagnosed from 2006 to 2017 with cervical cancer in the California Cancer Registry. We linked this cohort to statewide ED discharge records to determine ED use and symptoms present at the encounter. Multivariable logistic regression models examined associations with ED use and multivariable Cox proportional hazards regression models examined associations with survival. Results Of the more than 16,000 women with cervical cancer in the study cohort, 28% presented symptomatically in the ED prior to diagnosis. Those presenting symptomatically were more likely to have public (odds ratio [OR] 1.16; 95% confidence interval [CI] 1.06–1.27) or no insurance (OR 4.81; CI 4.06–5.71) (vs. private), low socioeconomic status (SES) (OR 1.76; CI 1.52–2.04), late-stage disease (OR 5.29; CI 4.70–5.96), and had a 37% increased risk of death (CI 1.28–1.46). Conclusion Nearly a third of women with cervical cancer presented symptomatically, outside of a primary care setting, suggesting that many women, especially those with low SES, may not be benefiting from screening or healthcare following abnormal results.

Background: Through adequate screening and follow-up, cervical cancer can be prevented or detected at early-stage (stage I), which is related to excellent survival. Current guidelines recommend discontinuing screening for women ≥65 years with history of normal Pap and/or HPV tests, potentially leaving this age group vulnerable. This study examined late-stage disease in a population-based cohort. Methods: Using California Cancer Registry data, we identified 12,442 patients ages ≥21 years with a first primary cervical cancer diagnosed during 2009–2018. Proportions of late-stage disease (stages II–IV) and early- and late-stage 5-year relative survival are presented by the age group. Among patients ages ≥65 years, multivariable logistic regression estimated associations of sociodemographic and clinical characteristics with late-stage cervical cancer. Results: Nearly one fifth of patients (n = 2,171, 17.4%) were ≥65 years. More women ages ≥65 years (71%) presented with late-stage disease than younger women (48% in patients ages Conclusions: There remains a significant burden of advanced cervical cancer in women ≥65. Impact: Efforts should be made to better understand how the current screening paradigm is failing women of 65 years and older. Future work should focus on determining past screening history, lapses in follow-up care, and non-invasive testing approaches.

Background There is evidence indicating that pesticide exposure is a risk factor for non-Hodgkin lymphoma (NHL) development. However, the association between pesticide exposure and NHL survival is not well-established. Methods Using the California Cancer Registry, we identified patients with a first primary diagnosis of NHL from 2010 to 2016 and linked these patients with CalEnviroScreen 3.0 to obtain production agriculture pesticide exposure to 70 chemicals from the state-mandated Pesticide Use Reporting (PUR) by census tract from 2012 to 2014. In addition, data from PUR was integrated into a geographic information system that employs land-use data to estimate cumulative exposure to specific pesticides previously associated with NHL (glyphosate, organophosphorus, carbamate, phenoxyherbicide, and 2,4-dimethylamine salt) between 10 years prior up to 1 year after NHL diagnosis. Multivariable Cox proportional hazards regression models were used to evaluate the association between total pesticide exposure from CalEnviroScreen 3.0 and individual pesticide exposure from geographic land use data and lymphoma-specific and overall survival. Results Among 35,808 NHL patients identified, 44.2% were exposed to pesticide in their census tract of residence. Glyphosate, organophosphorus, carbamate, phenoxyherbicide, and 2,4-dimethylamine salt exposure was observed in 34.1%, 26.0%, 10.6%, 14.0%, and 12.8% of NHL patients, respectively. Total pesticide exposure at the time of diagnosis was not associated with lymphoma-specific or overall survival. In addition, no association was consistently found between glyphosate, organophosphorus, carbamate, phenoxyherbicide, and 2,4 dimethylamine salt exposure and lymphoma-specific or overall survival. Conclusions Although we found no consistent associations between agricultural pesticide exposure at the neighborhood level and worse survival, these results provide a platform for designing future studies to determine the association between pesticide and NHL.

To assess changes in health insurance coverage for young cancer patients pre- and post- the Affordable Care Act-Dependent Care Expansion (ACA-DCE) implementation in California. Further, we examined differences in insurance coverage by socioeconomic and race/ethnicity. Data were obtained from the California Cancer Registry and Medicaid enrollment files, from 2005 to 2014. We conducted difference-in-difference analyses among 7042 cancer patients aged 22–25 years (“intervention group”) and 25,269 aged 26–34 years (“control group”). We also examined the independent and combined effects of race/ethnicity and neighborhood socioeconomic status (nSES) on insurance coverage. After the ACA-DCE implementation, we observed a 52.7% reduction in the proportion of uninsured and a 35.7% increase in the proportion of privately insured patients. There was also a 17.3% reduction in Medicaid at cancer diagnosis and a 27.5% reduction in discontinuous Medicaid enrollment. However, these benefits were limited to patients of non-Hispanic White, Hispanic and Asian/Pacific Islander race/ethnicity living in higher nSES, with no differences in insurance enrollment among young adults who lived in low nSES or those of Black race/ethnicity. The ACA-DCE broadened insurance coverage for young adults with cancer in California. Yet, only certain subgroups of patients have benefited from this policy.

Background Uninsured adolescents and young adults (AYAs) and those with publicly funded health insurance are more likely to be diagnosed with cancer at later stages. However, prior population-based studies have not distinguished between AYAs who were continuously uninsured from those who gained Medicaid coverage at the time of cancer diagnosis. Methods AYA patients (ages 15–39 years) with nine common cancers diagnosed from 2005 to 2014 were identified using California Cancer Registry data. This cohort was linked to California Medicaid enrollment files to determine continuous enrollment, discontinuous enrollment, or enrollment at diagnosis, with other types of insurance determined from registry data. Multivariable logistic regression was used to evaluate factors associated with later stages at diagnosis. Results The majority of 52 774 AYA cancer patients had private or military insurance (67.6%), followed by continuous Medicaid (12.4%), Medicaid at diagnosis (8.5%), discontinuous Medicaid (3.9%), other public insurance (1.6%), no insurance (2.9%), or unknown insurance (3.1%). Of the 13 069 with Medicaid insurance, 50.1% were continuously enrolled. Compared to those who were privately insured, AYAs who enrolled in Medicaid at diagnosis were 2.2–2.5 times more likely to be diagnosed with later stage disease, whereas AYAs discontinuously enrolled were 1.7–1.9 times and AYAs continuously enrolled were 1.4–1.5 times more likely to be diagnosed with later stage disease. Males, those residing in lower socioeconomic neighborhoods, and AYAs of Hispanic or black race and ethnicity (vs non-Hispanic white) were more likely to be diagnosed at a later stage, independent of insurance. Conclusions Our findings suggest that access to continuous medical insurance is important for decreasing the likelihood of late stage cancer diagnosis.

Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma, with a median age of diagnosis of 66 years. Anthracycline-containing regimens are the most common treatments, but toxicity concerns can limit their use in patients older than 80 years. Understanding treatment patterns and associated survival in adults older than 80 years (vs adults aged 65-80 years) can help determine effective management strategies in this population. We sought to describe the impact of age on treatment regimens used and associated survival in older adults with DLBCL.Data for 17,859 patients aged ≥65 years diagnosed with DLBCL from 2006 to 2017 were obtained from the California Cancer Registry. Detailed treatment information for each patient was extracted from treatment text fields. Multivariable logistic regression models examined characteristics associated with no treatment and multivariable Cox proportional hazards regression models examined the influence of treatment on overall survival and cancer specific survival.Across both examined age groups (65-80 years and older than 80 years), the most common treatment was anthracycline-containing regimens followed by other drug combinations. For patients older than 80 years, fewer received anthracyclines (32.4%) and more received other drug combinations (17.6%) or had no treatment (13.1%) vs those aged 65-80 years (61.6% anthracyclines, 10.4% other combinations, 5% no treatment). Women were less likely to receive treatment, as were those who were older, had more comorbidities, received treatment at non-National Cancer Institute designated cancer centers, or were diagnosed more recently. For patients older than 80 years, anthracyclines and R-CVP conferred a survival advantage compared to other combinations.In this large, population-based group of older adults with DLBCL, patients older than 80 years were less likely to receive initial treatment and more likely to receive other drug combinations despite a survival advantage with more standard anthracycline and nonanthracycline regimen protocols.

6532 Background: Our recent study showed that the implementation of the Affordable Care Act (ACA) was associated with increased health insurance coverage among adolescents and young adults (AYAs, 15–39 years) diagnosed with lymphomas in California and decreased likelihood of late stage at diagnosis. However, AYAs of Black or Hispanic race/ethnicity (vs Whites) and those living in lower socioeconomic (SES) neighborhoods were at higher risk of presenting with advanced stage. We aimed to determine whether the increased insurance coverage under the ACA was associated with improved survival, and to identify the main predictors of survival among AYAs with lymphomas. Methods: We used data from the California Cancer Registry linked to Medicaid enrollment files on AYAs diagnosed with a primary non-Hodgkin (NHL) or Hodgkin (HL) lymphoma during March 2005–September 2010 (pre-ACA), October 2010–December 2013 (early ACA) or 2014–2017 (full ACA). Patients were followed from lymphoma diagnosis until death, loss to follow-up or end of the study (12/31/2018). Health insurance was categorized as continuous Medicaid, discontinuous Medicaid, Medicaid enrollment at diagnosis/uninsured, other public or private. We used multivariable Cox proportional regression to examine the associations between all-cause survival and era of diagnosis, adjusting for sex, age and stage at diagnosis, health insurance, race/ethnicity, neighborhood SES, treatment facility, comorbidities, and marital status. Results: Of 11,221 AYAs, 5,878 were diagnosed with NHL and 5,343 with HL. Most patients were male (56%), White (45%), presented with earlier stage (I/II, 56%), and had private insurance (57%). The proportion of AYAs who received initial care at National Cancer Institute-Designated Cancer Centers (NCI-CCs) increased from 24% pre-ACA to 31% after full ACA implementation (p < 0.001). AYAs diagnosed in the early (aHR = 0.76, 95% CI 0.67–0.88) and full ACA (aHR = 0.55, 95%CI 0.47–0.64) eras had better survival than those diagnosed pre-ACA. Compared to those with private insurance, survival was worse among patients with no insurance (HR = 2.13, 95% CI 1.83–2.49), discontinuous Medicaid (HR = 2.17, 95% CI 1.83–2.56) and continuous Medicaid (HR = 1.93, 95% CI 1.63–2.29) at diagnosis. Regardless of their insurance, older AYAs, males, unmarried, those with later stage (II–IV), residents in lower SES neighborhoods, and those of Black, Hispanic, Asian/Pacific Islander, and American Indian/Alaskan Native race/ethnicity experienced worse survival. Conclusions: Following the ACA implementation in California, AYAs diagnosed with lymphomas experienced increased access to care at NCI-CCs and improved survival. Yet, racial/ethnic and socioeconomic survival disparities persisted. Moving forward, policy actions are required to mitigate structural and social determinants of health disparities in this population.

Objectives Proton beam therapy (PBT) is a type of radiation therapy (RT) used for certain cancer types because it minimizes collateral tissue damage. The high cost and limited availability of PBT have constrained its utilization. This study examined patterns and determinants of PBT use in California. Study design Persons with diagnoses of all cancer types from 2003 to 2016 inclusive who had any type of RT were identified in the California Cancer Registry in this retrospective analysis. Methods Cross-tabulations were performed to summarize the demographic characteristics of the study population, both for individuals who received PBT and for those who received other RT modalities. PBT use patterns over time were assessed. Multivariate logistic regression models assessed the effects of demographics and health insurance type on receipt of PBT. Results Of the 2,499,510 people with a cancer diagnosis during the study period, 578,632 (23%) received some type of RT, and of these, 8609 received PBT (1.5%). PBT was most often used to treat cancers of the prostate (41.3%), breast (14.0%), eye (11.7%), lung (6.1%), and brain (6.0%). PBT use was highest in 2003-2004 and then declined over time. PBT use was significantly associated with being white or male, younger age, higher socioeconomic status, Medicare or dual Medicare-Medicaid insurance, uninsured/self-pay status, and proximity to treatment. Conclusions Significant differences exist in PBT use by demographics and health insurance type. The identified racial and socioeconomic disparities merit further investigation. More granular studies on both use patterns and effectiveness of PBT for specific cancers are needed to draw stronger conclusions about its cost-benefit ratio.

To assess changes in health insurance coverage for young cancer patients pre- and post- the Affordable Care Act-Dependent Care Expansion (ACA-DCE) implementation in California. Further, we examined differences in insurance coverage by socioeconomic and race/ethnicity.Data were obtained from the California Cancer Registry and Medicaid enrollment files, from 2005 to 2014. We conducted difference-in-difference analyses among 7042 cancer patients aged 22-25 years ("intervention group") and 25,269 aged 26-34 years ("control group"). We also examined the independent and combined effects of race/ethnicity and neighborhood socioeconomic status (nSES) on insurance coverage.After the ACA-DCE implementation, we observed a 52.7% reduction in the proportion of uninsured and a 35.7% increase in the proportion of privately insured patients. There was also a 17.3% reduction in Medicaid at cancer diagnosis and a 27.5% reduction in discontinuous Medicaid enrollment. However, these benefits were limited to patients of non-Hispanic White, Hispanic and Asian/Pacific Islander race/ethnicity living in higher nSES, with no differences in insurance enrollment among young adults who lived in low nSES or those of Black race/ethnicity.The ACA-DCE broadened insurance coverage for young adults with cancer in California. Yet, only certain subgroups of patients have benefited from this policy.

Background Adolescents and young adults (AYAs) with public or no insurance experience later stage at diagnosis and worse overall survival compared with those with private insurance. However, prior studies have not distinguished the survival impact of continuous Medicaid coverage prior to diagnosis compared with gaining Medicaid coverage at diagnosis. Methods We linked a cohort of AYAs aged 15-39 who were diagnosed with 13 common cancers from 2005 to 2014 in the California Cancer Registry with California Medicaid enrollment files to ascertain Medicaid enrollment, with other insurance determined from registry data. We used Cox proportional hazards regression to evaluate the impact of insurance on survival, adjusting for clinical and demographic characteristics. Results Among 62 218 AYAs, over 65% had private/military insurance, 10% received Medicaid at diagnosis, 13.2% had continuous Medicaid, 4.1% had discontinuous Medicaid, 1.7% had other public insurance, 3% were uninsured, and 2.6% had unknown insurance. Compared with those with private/military insurance, individuals with Medicaid insurance had significantly worse survival regardless of when coverage began (received Medicaid at diagnosis: hazard ratio [95% confidence interval]: 1.51 [1.42-1.61]; continuously Medicaid insured: 1.42 [1.33-1.52]; discontinuous Medicaid: 1.64 [1.49, 1.80]). Analyses of those with Medicaid insurance only demonstrated slightly worse cancer-specific survival among those with discontinuous Medicaid or enrollment at diagnosis compared with those with continuous enrollment, but results were not significant stratified by cancer site. Conclusions and relevance AYAs with Medicaid insurance experience worse cancer-specific survival compared with those with private/military insurance, yet continuous enrollment demonstrates slight survival improvements, providing potential opportunities for future policy intervention.

Introduction: While previous studies propose pesticide exposure to be a risk factor for non-Hodgkin lymphoma (NHL) development, results are inconclusive. In addition, the impact of pesticide exposure on NHL survival is not well-established. Therefore, we identified NHL patients from the California Cancer Registry and linked these patients with the statewide pesticide use reporting database to determine the impact of pesticide exposure on NHL-related incidence and outcomes. Methods: Using the California Cancer Registry, we identified patients with a first primary diagnosis of NHL from 2010-2016 and linked these patients with CalEnviroScreen 3.0 to obtain production agriculture pesticide exposure to 70 chemicals from the state mandated Pesticide Use Reporting (PUR) by census tract from 2012-2014. In addition, data from PUR was integrated into a geographic information system that employs land use data to estimate cumulative exposure to specific pesticides previously associated with NHL (glyphosate, organophosphorus, carbamate, phenoxyherbicide and 2,4-dimethylamine salt) between 10 years prior up to 1 year after NHL diagnosis. SEER*Stat software was used to calculate NHL subtype incidence rates by census tract pesticide use level. Multivariable cox proportional hazards regression models were used to evaluate the impact of total pesticide exposure from CalEnviroScreen 3.0 and individual pesticide exposure from geographic land use data on lymphoma-specific and overall survival. Results: Among 35,808 NHL patients identified, 44.2% were exposed to pesticide in their census tract of residence. Pesticide exposure was higher in Hispanic/Latino (46.5%) and non-Hispanic white (45.6%) then Asian/Pacific Islander (37.2%) and African American (34.9%) patients with NHL. Glyphosate, organophosphorus, carbamate, phenoxyherbicide and 2,4-dimethylamine salt exposure was reported in 34.1%, 26.0%, 10.6%, 14.0% and 12.8% of NHL patients, respectively. Pesticide exposure was not associated with increased NHL incidence by NHL subtype or subgroups defined by sociodemographic factors. Total pesticide exposure at time of diagnosis was not associated with lymphoma-specific or overall survival. In addition, no association was consistently found between glyphosate, organophosphorus, carbamate, phenoxyherbicide and 2,4 dimethylamine salt exposure and lymphoma-specific or overall survival. Conclusion: In this large population-based study of neighborhood agricultural pesticide exposure, pesticide exposure was noted to be prevalent among patients diagnosed with NHL, with high pesticide exposure particularly observed in Hispanics/Latinos and non-Hispanic whites. However, pesticide exposure was not consistently associated with increased NHL incidence or worse NHL lymphoma-specific or overall survival. Disclosures Poh: Acrotech: Honoraria; Incyte: Research Funding; Morphosys: Consultancy. Tuscano: BMS: Research Funding; Seattle Genetics: Research Funding; Takeda: Research Funding; Acrotech: Research Funding; Genentech: Research Funding; Pharmacyclics: Research Funding; Abbvie: Research Funding.

Background and Objective: Since the 1990s, multiple studies have reported on an increased incidence of renal cell carcinomas (RCC), which has been considered incidental to the high use of abdominal diagnostic imaging. This population-based study used data from the California Cancer Registry to (i) update trends in RCC incidence and mortality by several tumor and demographic characteristics after reports of decreased use of diagnostic imaging in recent years, and (ii) examine changes in surgical treatment for early-stage RCC. Methods: Records of patients diagnosed with RCC from 1988 through 2013 and mortality data from the same period were examined. Joinpoint regression was used to estimate annual percent changes in age-adjusted RCC incidence and mortality rates, stratified by sex, race/ethnicity, stage at diagnosis, grade, and tumor size. Trends in the proportion of partial or total/radical nephrectomies were evaluated by Cochran-Armitage tests. Results: A total of 77,363 incident cases of RCC and 28,590 deaths were evaluated. While mortality rates significantly decreased, the incidence of small localized RCC increased in virtually all groups examined after the mid-1990s until 2008-2009, when incidence trends stabilized in all groups concomitant with a decrease in imaging. The proportion of partial nephrectomies among patients with small localized tumors increased from 13.8% in 1988 to 74.6% in 2013. Conclusions: Earlier trends in RCC were consistent with the incidental discovery of small tumors. In parallel with the increase in early-stage RCC, the use of partial nephrectomies increased markedly. Following the decreased use of advanced diagnostic imaging, the trend of increasing RCC incidence appears to have ended in California.

Background Multiple systemic treatments have been developed for stage IV non-small cell lung cancer (NSCLC), but their use and effect on outcomes at the population level are unknown. This study describes the utilization of first-line systemic treatments among stage IV NSCLC patients in California and compares survival among treatment groups. Methods Data on 17 254 patients diagnosed with stage IV NSCLC from 2012 to 2014 were obtained from the California Cancer Registry. Systemic treatments were classified into six groups. The Kaplan-Meier method and multivariable Cox proportional hazards models were used to compare survival between treatment groups. Results Fifty-one percent of patients were known to have received systemic treatment. For patients with nonsquamous histology, pemetrexed regimens were the most common treatment (14.8%) followed by tyrosine kinase inhibitors (11.9%) and platinum doublets (11.5%). Few patients received pemetrexed/bevacizumab combinations (4.5%), bevacizumab combinations (3.6%), or single agents (1.7%). There was statistically significantly better overall survival for those on pemetrexed regimens (hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.80 to 0.92), bevacizumab regimens (HR = 0.73, 95% CI = 0.65 to 0.81), pemetrexed/bevacizumab regimens (HR = 0.68, 95% CI = 0.61 to 0.76), or tyrosine kinase inhibitors (HR = 0.62, 95% CI = 0.57 to 0.67) compared with platinum doublets. The odds of receiving most systemic treatments decreased with decreasing socioeconomic status. For patients with squamous histology, platinum doublets were predominant (33.7%) and were not found to have statistically significantly different overall survival from single agents. Conclusions These population-level findings indicate low utilization of systemic treatments, survival differences between treatment groups, and evident treatment disparities by socioeconomic status.

Author(s): Maguire, Frances B; Morris, Cyllene R; Parikh-Patel, Arti; Cress, Rosemary D; Keegan, Theresa H M; Li, Chin-Shang; Lin, Patrick S; Kizer, Kenneth W | Abstract: Population-based cancer registries have treatment information for all patients making them an excellent resource for population-level monitoring. However, specific treatment details, such as drug names, are contained in a free-text format that is difficult to process and summarize. We assessed the accuracy and efficiency of a text-mining algorithm to identify systemic treatments for lung cancer from free-text fields in the California Cancer Registry.The algorithm used Perl regular expressions in SAS 9.4 to search for treatments in 24,845 free-text records associated with 17,310 patients in California diagnosed with stage IV non-small cell lung cancer between 2012 and 2014. Our algorithm categorized treatments into six groups that align with National Comprehensive Cancer Network guidelines. We compared results to a manual review (gold standard) of the same records.Percent agreement ranged from 91.1% to 99.4%. Ranges for other measures were 0.71-0.92 (Kappa), 74.3%-97.3% (sensitivity), 92.4%-99.8% (specificity), 60.4%-96.4% (positive predictive value), and 92.9%-99.9% (negative predictive value). The text-mining algorithm used one-sixth of the time required for manual review.SAS-based text mining of free-text data can accurately detect systemic treatments administered to patients and save considerable time compared to manual review, maximizing the utility of the extant information in population-based cancer registries for comparative effectiveness research.

Background: Management of advanced-stage non–small cell lung cancer (NSCLC) has changed significantly over the past two decades with the development of numerous systemic treatments, including targeted therapies. However, a high proportion of advanced-stage patients are untreated. The role that health insurance plays in receipt of systemic treatments is unclear. Methods: Using California Cancer Registry data (2012–2014), we developed multivariable Poisson regression models to assess the independent effect of health insurance type on systemic treatment utilization among patients with stage IV NSCLC. Systemic treatment information was manually abstracted from treatment text fields. Results: A total of 17,310 patients were evaluated. Patients with Medicaid/other public insurance were significantly less likely to receive any systemic treatments [risk ratio (RR), 0.78; 95% confidence interval (CI), 0.75–0.82], bevacizumab combinations (RR, 0.57; 95% CI, 0.45–0.71), or tyrosine kinase inhibitors (RR, 0.70; 95% CI, 0.60–0.82) compared with the privately insured. Patients with Medicare or dual Medicare–Medicaid insurance were not significantly different from the privately insured in their likelihood of receiving systemic treatments. Conclusions: Substantial disparities in the use of systemic treatments for stage IV NSCLC exist by source of health insurance in California. Patients with Medicaid/other public insurance were significantly less likely to receive systemic treatments compared with their privately insured counterparts. Impact: Source of health insurance influences care received. Further research is warranted to better understand barriers to treatment that patients with Medicaid face.

Copyright © 2017 the Author(s). Published by Wolters Kluwer Health, Inc. Escalating costs and concerns about quality of cancer care have increased calls for quality measurement and performance accountability for providers and health plans. The purpose of the present cross-sectional study was to assess variability in the quality of cancer care by health insurance type in California. Persons with breast, ovary, endometrium, cervix, colon, lung, or gastric cancer during the period 2004 to 2014 were identified in the California Cancer Registry. Individuals were stratified into 5 health insurance categories: private insurance, Medicare, Medicaid, dual Medicare and Medicaid eligible, and uninsured. Quality of care was evaluated using Commission on Cancer quality measures. Logistic regression models were generated to assess the independent effect of health insurance type on stage at diagnosis, quality of care and survival after adjusting for age, sex, race/ethnicity, and socioeconomic status (SES). A total of 763,884 cancer cases were evaluated. Individuals with Medicaid or Medicare-Medicaid dual-eligible coverage and the uninsured had significantly lower odds of receiving recommended radiation and/or chemotherapy after diagnosis or surgery for breast, endometrial, and colon cancer, relative to those with private insurance. Dual eligible patients with gastric cancer had 21% lower odds of having the recommended number of lymph nodes removed and examined compared to privately insured patients. After adjusting for known demographic confounders, substantial and consistent disparities in quality of cancer care exist according to type of health insurance in California. Further study is needed to identify particular factors and mechanisms underlying the identified treatment disparities across sources of health insurance.

Daphne Y Lichtensztajn,1 Brenda M Giddings,2 Cyllene R Morris,2 Arti Parikh-Patel,2 Kenneth W Kizer2 1Greater Bay Area Cancer Registry, Cancer Prevention Institute of California, CA, USA; 2California Cancer Reporting and Epidemiologic Surveillance Program, Institute for Population Health Improvement, UC Davis Health, CA, USA Background: The presence of comorbid medical conditions can significantly affect a cancer patient’s treatment options, quality of life, and survival. However, these important data are often lacking from population-based cancer registries. Leveraging routine linkage to hospital discharge data, a comorbidity score was calculated for patients in the California Cancer Registry (CCR) database.Methods: California cancer cases diagnosed between 1991 and 2013 were linked to statewide hospital discharge data. A Deyo and Romano adapted Charlson Comorbidity Index was calculated for each case, and the association of comorbidity score with overall survival was assessed with Kaplan–Meier curves and Cox proportional hazards models. Using a subset of Medicare-enrolled CCR cases, the index was validated against a comorbidity score derived using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data.Results: A comorbidity score was calculated for 71% of CCR cases. The majority (60.2%) had no relevant comorbidities. Increasing comorbidity score was associated with poorer overall survival. In a multivariable model, high comorbidity conferred twice the risk of death compared to no comorbidity (hazard ratio 2.33, 95% CI: 2.32–2.34). In the subset of patients with a SEER-Medicare-derived score, the sensitivity of the hospital discharge-based index for detecting any comorbidity was 76.5. The association between overall mortality and comorbidity score was stronger for the hospital discharge-based score than for the SEER-Medicare-derived index, and the predictive ability of the hospital discharge-based score, as measured by Harrell’s C index, was also slightly better for the hospital discharge-based score (C index 0.62 versus 0.59, P

e18143 Background: Studies have shown that having public or no insurance at sarcoma diagnosis is associated with higher stage disease and poor survival. However, previous studies have not differentiated sarcoma patients who enrolled in Medicaid at diagnosis from those previously insured, groups with differing access to care. Therefore, we examined the impact of insurance on stage at diagnosis and overall survival for AYAs with soft tissue sarcoma (STS), osteosarcoma (OS) and Ewing sarcoma (EWS). Methods: Using Medicaid enrollment data linked to the California Cancer Registry, we identified AYAs with STS (n = 1782), OS (n = 458), and EWS (n = 348), diagnosed during 2005-14. Insurance was classified as Medicaid [1. Continuous (≥5 months prior to diagnosis), 2. Discontinuous, 3. At diagnosis (no coverage prior to diagnosis)], private, and uninsured. Logistic and Cox proportional hazards regression determined the association of insurance with metastatic stage (vs localized) and overall survival, respectively adjusting for sociodemographic factors, baseline comorbidities, type of facility, treatment (survival) and stage (survival). Results: Only 17.5% of sarcoma patients had continuous Medicaid prior to diagnosis, with 11% of STS, 17% of EWS and 19% of OS patients obtaining Medicaid at diagnosis. AYAs with Medicaid at diagnosis [Odds Ratio (OR) 3.03, 95% Confidence Interval (CI) 2.27-4.03; vs private] and discontinuous Medicaid (OR 2.25, CI 1.48-3.41) had a higher likelihood of metastatic disease. STS patients with Medicaid at diagnosis [Hazard Ratio (HR) 1.83, CI 1.44-2.33; vs private) and discontinuous Medicaid (HR 1.45, CI 1.01-2.08) had worse survival. Medicaid at diagnosis (HR 1.68, CI 1.07-2.63) also was associated with worse survival in OS patients, but this association was not observed in EWS patients. Conclusions: Lacking insurance prior to diagnosis is associated with metastatic disease at presentation and worse survival in AYA patients with sarcoma. Health insurance remained associated with worse survival even after adjusting for stage, highlighting the importance of continuous health insurance to improve outcomes for this patient population.

© 2016 American Journal of Preventive Medicine Introduction Colorectal cancer (CRC) incidence and mortality rates have decreased dramatically since 1990, both nationally and in California, except among Hispanic men. This study examined trends in CRC incidence, mortality, and survival to determine likely contributing factors for the differential trends between Hispanic and non-Hispanic white men in California. Methods California Cancer Registry data were used to identify 23,157 Hispanic and 114,944 white men diagnosed with CRC between 1990 and 2012. Joinpoint trends in incidence, mortality, and 5-year relative survival were examined by age, stage at diagnosis, and tumor location. Data used in the study were extracted from the California Cancer Registry database and analyzed in 2015. Results Both incidence and mortality rates decreased substantially among white men between 1990 and 2012, but no corresponding decrease was observed among Hispanic men. Both groups experienced similar trends in survival and stage at diagnosis over time. White men had greater declines in CRC incidence and mortality in all age groups, particularly those aged >50 years. Hispanic men had a significantly higher proportion (65%) of tumors in the distal colon than white men (59%). Conclusions CRC incidence and mortality rates have decreased among white men since 1990, but not among Hispanic men. Results from this study suggest lower screening rates may be an important reason why CRC rates in California did not decline in Hispanic men. Effective strategies aimed at both Hispanics and their healthcare providers are needed to increase CRC screening among Hispanic men and reduce their CRC burden.

Introduction: Adolescent and young adult (AYAs: 15-39) patients with cancer have not had the same relative improvement in survival as other age groups over the last decades. Studies have shown that having public insurance or being uninsured at diagnosis is associated with more advanced disease at presentation and worse overall survival. However, previous studies have not differentiated patients who joined Medicaid at diagnosis from those with continuous enrollment which may have different implications for access to care prior to diagnosis. Therefore, we examined the impact of insurance status, including Medicaid enrollment at diagnosis, on stage at diagnosis for AYAs with non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL) only] and on survival for AYAs with NHL, HL, acute myeloblastic leukemia (AML), and acute lymphoblastic leukemia (ALL). Methods: Using Medicaid enrollment data linked to the California Cancer Registry, we identified AYAs with NHL, HL, ALL, and AML diagnosed from 2005 to 2014. Insurance type was classified as: continuous Medicaid, discontinuous Medicaid prior to diagnosis, Medicaid at diagnosis, other public (Medicare, Indian/Public Health Service, county), private/military, and uninsured. Multivariable logistic regression and Cox proportional hazards regression were used to determine the impact of insurance type on stage at diagnosis (for NHL and HL) and overall survival, respectively. Results are represented as adjusted odds ratios (OR) and hazard ratios (HR) with associated 95% confidence intervals (CI). Results: Of the 11,667 AYA patients in our study, 4,435 had NHL, 4,161 had HL, 1,522 had AML and 1,549 had ALL. Patients with HL had the highest proportion of private insurance (66%) followed by those with NHL (60%), AML (50%) and ALL (37%). Of the 4,059 patients enrolled in Medicaid, 41% had continuous Medicaid, 15% had discontinuous Medicaid and 43% received Medicaid at diagnosis. Only 2-4% of patients, depending on primary diagnosis, remained uninsured after cancer diagnosis. The majority of AYAs with HL and NHL were diagnosed with stage I/II disease (59% and 52% respectively). Compared to AYAs with private insurance, NHL and HL patients with discontinuous Medicaid and Medicaid at diagnosis had a higher likelihood of later stage disease (III-IV vs I/II) at diagnosis (NHL: discontinuous OR 1.45, CI 1.10-1.92; at diagnosis OR 1.69, CI 1.38-2.06; HL: discontinuous OR 1.63, CI 1.19-2.23; at diagnosis OR 1.68, CI 1.35-2.09) after adjusting for sociodemographic factors, baseline comorbidities and type of facility. In addition, NHL patients with continuous Medicaid (OR 1.23, CI 1.01, 1.51) and HL patients with other public insurance (OR 1.56, CI 1.05-2.32) had a higher odds of late stage disease. Type of health insurance was associated with overall survival in multivariable models (Table). NHL patients with Medicaid (continuous HR 1.74, CI 1.39-2.17; discontinuous HR 2.52, CI 1.94-3.27; at diagnosis HR 1.88, CI 1.53-2.31), other public (HR 1.83, CI 1.16-2.87) and no insurance (HR 1.87, CI 1.09-3.20) had worse survival than NHL patients with private insurance. Similarly, HL patients with Medicaid (continuous HR 2.10, CI 1.42-3.12; discontinuous HR 1.89, CI 1.08-3.29; at diagnosis HR 2.43, CI 1.699-3.48) and no insurance (HR 1.87, CI 1.09-3.20) experienced worse survival. For AML, health insurance was not significantly associated with survival. For ALL, only continuous Medicaid (HR 1.32, CI 1.05-1.67) and other public (HR 1.32, CI 1.05-1.67) insurance were associated with worse survival, though discontinuous Medicaid trended toward significance (p=0.06). Conclusion: Our study demonstrates that a significant proportion of patients previously thought to have public insurance were discontinuously insured with Medicaid or uninsured at time of diagnosis, only receiving Medicaid after diagnosis. While important, insurance enrollment at diagnosis does not provide the same pre-diagnosis access to services as those with continuous enrollment. Indeed, for NHL and HL, we observed the strongest associations between discontinuous Medicaid and Medicaid at diagnosis and late stage disease. However, Medicaid, regardless of type of enrollment, was associated with worse survival in AYAs with NHL, HL and ALL relative to private insurance. Therefore, future studies should focus on factors influencing worse outcomes for AYA patients with public insurance. Disclosures No relevant conflicts of interest to declare.

OBJECTIVE We sought to evaluate the impact of socioeconomic status (SES) on the likelihood of undergoing radical prostatectomy (RP) or external beam radiation therapy (XRT) and the ensuing effect on cancer-specific survival (CSS) after treatment for men with low-risk prostate cancer. METHODS Using the California Cancer Registry database, we identified 123,953 men diagnosed with localized, Gleason ≤7 prostate cancer from 1996 to 2005. Patients were separated into quintiles based on socioeconomic status and were stratified by race, age, year of diagnosis, and treatment. Logistic regression and Kaplan-Meier analyses were used to determine the likelihood of undergoing RP or XRT and cancer-specific survival. RESULTS In the final cohort, 39,234 patients (31.7%) and 42,431 patients (34.3%) underwent RP and XRT as initial therapy. Men of lower SES were less likely to undergo RP or XRT. Men undergoing RP in the lowest SES were twice as likely to die of prostate cancer (HR 1.99, 95% CI 1.28-3.09, P = .002) than men in the highest SES. This difference was even more profound when adjusted for race (HR 2.20, 95% CI 1.38-3.50, P = .001). Similarly, men in the lowest SES who underwent XRT were also approximately twice as likely to die of prostate cancer (HR 2.24, 95% CI 1.71-2.94, P

The objective of this retrospective cohort study was to evaluate cancer risk among rheumatoid arthritis (RA) patients in California.The study cohort derived from statewide patient discharge records was followed via linkage with cancer registry data over the period 1991-2002. Age and sex adjusted standardized incidence ratios (SIRs) and 95% confidence intervals were calculated to compare observed to expected numbers of cancers based on age, race, and sex specific incidence rates in the California population.Among the 84,475 RA patients, who were observed for 405,540 person-years, 5,533 incident cancers were diagnosed during the observation interval. The risk of developing lymphohematopoietic cancer was significantly higher in the cohort for both sexes. Males had significantly higher risks of lung, liver, and esophageal cancer, but a lower risk of prostate cancer. Females were at significantly decreased risk for several cancers including breast, ovary, uterus, cervix, and melanoma, with the risk reduction ranging from 15 to 57% lower than the general population. Hispanics had increased risks of leukemia, vagina/vulva, lung, and liver cancers.Studies investigating the mechanisms that underlie the reported associations between RA and specific cancer types are needed.

The authors conducted a study to determine whether differences in prostate cancer survival between White men and Black men are reduced or eliminated after accounting for differences in prognostic factors. Using population-based statewide cancer registry data, the authors analyzed data from a cohort of 122,375 non-Hispanic White men and Black men from California who were newly diagnosed with prostate cancer between 1995 and 2004 and followed through 2004. Compared with White men, Black men were characterized by younger age at diagnosis, more distant stage, less treatment with surgery or radiation therapy, higher tumor grades, lower neighborhood socioeconomic status, and more recent year of diagnosis. Adjusted only for age, the hazard ratio for prostate cancer death (Blacks vs. Whites) was 1.61 (95% confidence interval (CI): 1.50, 1.72). Additional adjustment for potentially modifiable factors (stage and treatment) eliminated most of the racial difference in survival (adjusted hazard ratio = 1.10, 95% CI: 1.03, 1.18). The racial difference in survival was completely eliminated after further adjustment for other factors (grade, socioeconomic status, and year of diagnosis) (adjusted hazard ratio = 0.99, 95% CI: 0.92, 1.06). Thus, the large difference in prostate cancer survival between White men and Black men was completely explained by known prognostic factors, with potentially modifiable disparities playing the largest role.

BACKGROUND. There are very limited data concerning survival from prostate cancer among Asian subgroups living in the U.S., a large proportion of whom reside in California. There do not appear to be any published data on prostate cancer survival for the more recently immigrated Asian subgroups (Korean, South Asian [SA], and Vietnamese). METHODS. A study of prognostic factors and survival from prostate cancer was conducted in non-Hispanic whites and 6 Asian subgroups (Chinese, Filipino, Japanese, Korean, SA, and Vietnamese), using data from all men in California diagnosed with incident prostate cancer during 1995–2004 and followed through 2004 (n = 116,916). Survival was analyzed using Cox proportional hazards models. RESULTS. Whites and Asians demonstrated significant racial differences in all prognostic factors: age, summary stage, primary treatment, histologic grade, socioeconomic status, and year of diagnosis. Every Asian subgroup had a risk factor profile that put them at a survival disadvantage compared with whites. Overall, the 10-year risk of death from prostate cancer was 11.9%. However, in unadjusted analyses Japanese men had significantly better survival than whites; Chinese, Filipino, Korean, and Vietnamese men had statistically equal survival; and SA men had significantly lower survival. On multivariate analyses adjusting for all prognostic factors, all subgroups except SA and Vietnamese men had significantly better survival than whites; the latter 2 groups had statistically equal survival. CONCLUSIONS. Traditional prognostic factors for survival from prostate cancer do not explain why most Asian men have better survival compared with whites, but they do explain the poorer survival of SA men compared with whites. Cancer 2007. © 2007 American Cancer Society.

To identify geographic variations in colorectal cancer by stage at diagnosis in California using a descriptive analysis coupled with a spatial analysis and to discuss methodological considerations concerning the spatial statistical method. We analyzed 59,076 colorectal cancer cases diagnosed in California from 1996 to 2000 by logistic regression and by a spatial scan statistic to identify areas with a higher and lower relative risk of late-stage colorectal cancer. In California, 57% of overall cases of colorectal cancer were diagnosed at a late stage. Californians diagnosed with late-stage colorectal cancer were more likely to be Hispanic and living in areas of lower socioeconomic status. The spatial scan identified two areas where the observed number of late-stage cancer was different than the number expected from the distribution in the rest of the state. Spatial scan analyses can complement descriptive statistics, but results must be interpreted with consideration of factors that affect the ability to detect meaningful differences such as the number of events observed, accuracy in geocoding rural versus urban addresses, and the difficulty of adjusting for covariates.

Although autoimmune diseases can have a significant impact on the quality of life, there has been a relative paucity of data with respect to the functional status of patients with primary biliary cirrhosis (PBC).We conducted a case-control study of 182 patients ("cases") with PBC as well as 225 age- and sex-matched friend control subjects using a standardized instrument obtained from the National Health and Nutrition Examination Survey.In all, 126 of 182 cases (69%) and 141 of 225 friend controls (62.6%) responded to this survey, a response rate comparable to or better than in similar previous studies of such instruments. Patients with PBC had a significantly reduced functional status score compared to their controls (p0.001). Interestingly, a lower level of education and the presence of arthritis and hypertension were significantly associated with these lower levels of functional capabilities. These data were subjected to multivariate analysis and confirmed. Age was not associated with impaired functional status in either the patients or controls.Studies of this nature have potential implications for the well-being and management of patients with PBC, and focus on issues that can be addressed to help maintain functional status in this chronic disease.

PURPOSE: Primary biliary cirrhosis is an autoimmune disease with female predominance that leads to liver failure. The goal of this study was to identify reproductive risk factors associated with this disease. METHODS: We compared 182 cases of PBC with 225 age- and sex-matched friend controls to examine the role of reproductive factors. The survey instrument was developed using standardized questions obtained from the National Health and Nutrition Examination Survey (NHANES) III. RESULTS: A total of 126/182 cases (69%) and 141/225 (62.6%) friend controls responded to the survey. More cases than controls reported ever having genitourinary infection [adjusted odds ratio (OR) = 2.12, 95% confidence interval (CI) 1.01, 4.42] among those without a personal or family history of autoimmune disease. The most notable finding was that cases reported significantly more pregnancies than controls (p = 0.008). The adjusted OR for each additional pregnancy among those without a personal or family history of autoimmune disease was 1.40 (95% CI 1.14, 1.7). More controls (24.4%) than cases (16.0%) were nulliparous. Cases reported having five or more children (16.0%) with double the frequency of controls (8.2%). CONCLUSIONS: The association reported herein, between primary biliary cirrhosis and gravidity, is particularly significant because of the overwhelming female predominance.

Although the etiology of primary biliary cirrhosis (PBC) remains unknown, environmental factors may act to trigger the disease in genetically susceptible hosts. To assess specific risk factors, we conducted a survey using standardized NHANES questions to 241 PBC patients in the United States, 261 of their siblings, and 141 friends without PBC. The overall response rate was 199 of 241 (83%) among PBC cases, 171 of 261 (67%) among siblings, and 141 of 225 (62. 7%) among friend controls. The female-to-male ratio among cases in this sample was approximately 10:1; the mean age was 53 years, and 97% were Caucasian. Other autoimmune diseases reported most frequently by PBC cases included Sjogren's syndrome (17.4%) and Raynaud's syndrome (12.5%). Approximately 6% of cases reported at least one family member with PBC. Adjusted odds ratios (OR) were elevated for cases compared with friends for other autoimmune diseases (OR = 4.92, 95% confidence interval [CI] = 2.38, 10.18), smoking (OR = 2.04, 95% CI = 1.10, 3.78), tonsillectomy (OR = 1.86, 95% CI = 1.02, 3.39), and vaginal or urinary tract infection (UTI) in females only (OR = 2.12, 95% CI = 1.10, 4.07). Similarly elevated ORs were observed for these risk factors when cases were compared with their siblings. The higher rate of UTI among cases is particularly interesting in light of previous data, and raises the possibility of an infectious etiology for PBC and of molecular mimicry as an etiologic mechanism. The significance of smoking in the multivariate models supports the findings of previous studies and raises the issue of the influence of smoking on a Th1 response.

Recent data have suggested that the prevalence of many autoimmune diseases is higher than originally suspected. Indeed, the incidence of some autoimmune diseases may be increasing. Part of the problem in these latter two issues is that there is a dearth of well-designed and controlled epidemiologic studies, and often confounding variables in diverse populations and geographic areas that are not well controlled. Primary biliary cirrhosis (PBC) is a highly directed, organ-specific autoimmune disease that results in the destruction of intrahepatic bile ducts. It is primarily a disease of middle-aged women. Although there is no obvious association with MHC class I or class II alleles, the relative risk of a family member of a first-degree relative within a family having a member with PBC is a hundred-fold that of the general population. Unfortunately, most epidemiologic studies have been descriptive, providing incidence and prevalence rates with many methodologic problems, including lack of an appropriate case definition, varying criteria for inclusion of cases, and inaccurate estimate of the time period to which the rate applies. Because PBC is a very definable disease with significant clinical and serologic overlaps among patients throughout the world, we believe that a review of the geoepidemiology of PBC is not only specifically of value to workers interested in autoimmune liver disease, but also of generic interest in the study of autoimmune disease. In this review, we discuss the nature of the existing epidemiologic data and the possible roles of genetic and environmental factors in the etiology of the disease and compare such data to similar observations for multiple sclerosis, systemic lupus erythematosus, and rheumatoid arthritis.

Colorectal cancer has declined markedly in California for all major racial/ethnic groups, including Asian/Pacific Islanders as a whole. Analyzing cancer data for Asian/Pacific Islanders collectively masks important differences that exist between individual Asian subgroups. This study examines secular, sex-, age-, and socioeconomic-specific trends in colorectal cancer incidence among six Asian subgroups-Chinese, Japanese, Filipino, Korean, Vietnamese, and South Asian-to determine whether these groups experienced a decline in colorectal cancer incidence and to assess possible differences in colorectal cancer incidence trends among these groups.Cases of invasive colorectal cancer diagnosed among Japanese, Chinese, Filipinos, Koreans, Vietnamese, and South Asians between 1988 and 2007 were identified using the California Cancer Registry database. Secular, sex-, age-, and socioeconomic-specific trends in the age-adjusted colorectal cancer incidence rates for each Asian subgroup were examined using joinpoint analysis to estimate the annual percent change (APC).Among males, Koreans (APC, 3.6 %) were the only group that experienced a significant increase in colorectal cancer incidence. Among females, Koreans (APC, 2.7 %), South Asians (APC, 2.8 %), and Filipinos (APC, 1.6 %) experienced significant increases. Stratification by age at diagnosis revealed that Korean males (APC, 3.4 %) and females (APC, 2.9 %) as well as Filipino females (APC, 1.8 %) aged 50 years and older experienced a significant increase in colorectal cancer incidence. Korean males aged less than 50 years (APC, 3.4 %) also experienced a significant increase. Japanese (APC, -1.2 %) and Chinese (APC, -1.6 %) males aged 50 years and older experienced a significant decrease in colorectal cancer incidence. Stratification by socioeconomic status (SES) revealed that Korean males (APC, 2.5 %) and females (APC, 2.9 %) as well as Filipino females (APC, 2.1 %) in the lowest SES category experienced a significant increase in colorectal cancer incidence. Korean males (APC, 5.2 %) and females (APC, 3.1 %) as well as Filipino males (APC, 1.5 %) in the highest SES category also experienced a significant increase. Japanese males (APC, -2.5 %) and females (APC, -2.0 %) as well as Chinese males (APC, -2.8 %) and females (APC, -2.9 %) in the lowest SES category experienced a significant decrease. Chinese males in the middle (APC, -3.4 %) and highest (APC, -3.5 %) SES categories also experienced significant decreases in colorectal cancer incidence.In contrast to the decreasing trends in colorectal cancer incidence reported among all major racial/ethnic groups including Asian/Pacific Islanders, colorectal cancer is actually increasing among some Asian subgroups in California including Korean males and females, as well as South Asian and Filipino females. Furthermore, the colorectal cancer incidence trends for these Asian subgroups differ with respect to age at diagnosis and socioeconomic status. These findings suggest that more efforts need to be made to target these populations with culturally sensitive cancer prevention and screening programs. More research is needed to examine the differences in the colorectal cancer burden among these populations.

Endometrial cancer surgeries have been traditionally performed via laparotomy to accomplish a total abdominal hysterectomy (TAH) and surgical staging of retroperitoneal lymph nodes. The Gynecologic Oncology Group (GOG) protocol 33 helped establish that endometrial cancer should be a surgicopathologically staged disease because of the 22% incidence of extrauterine disease in clinical stage 1 patients.1 This GOG study also defined the risk and pattern of spread of nodal metastases in endometrial cancer.1,2 Consequently, surgical assessment of the pelvic and paraaortic lymph nodes is the standard of care for most patients with operable endometrial cancer. Childers and Surwit3 were the first authors to report the use of laparoscopically assisted vaginal hysterectomy (LAVH) with laparoscopic staging of pelvic and paraaortic lymph nodes in 1992 for treatment of early-stage endometrial cancer. Since that time, numerous reports have supported the equivalency of laparoscopic nodal staging compared with traditional open surgical staging for endometrial cancer4–9 that parallels the acceptable surgical standards defined by GOG. Numerous authors have reported their institutional experience with laparoscopic surgery for endometrial cancer6–8,10–15 These reports tend to emphasize the similarities between patients who undergo LAVH and patients who undergo TAH procedures. Characteristics such as age, weight, histology, and thoroughness of surgical staging were often equivalent in these reports, with advantages in the LAVH group such as decreased postoperative stays, decreased hospital charges/costs, and improved quality of life, However, it may reflect the experiences of a limited number of expert laparoscopic surgeons rather than what might be expected among all surgeons who manage endometrial cancer patients. Certainly, even proponents of laparoscopic surgery readily admit to a substantial learning curve necessary to obtain these beneficial outcomes, 9,16–18 which leads to a bias regarding patient selection for laparoscopic surgery. We were interested to see if endometrial cancer patients who underwent laparoscopic surgery were similar to those who received a traditional abdominal procedure. We used the California Cancer Registry (CCR), which is a large, well-validated tumor registry linked to another large database that contains rich details about California hospital discharges, to examine these issues. This population-based study broadly reflects actual community experience rather than narrower institutional reports. This combined database allowed us to compare patient demographics, medical comorbidities, cancer characteristics, and hospital outcomes in the endometrial cancer patients who underwent a laparoscopy versus laparotomy procedure.

BACKGROUND. Aggregated cancer statistics for Asians mask important differences in cancer burden among Asian subgroups. The purpose of this study was to describe the relative patterns of cervical cancer incidence, mortality, and survival among Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese women in California, using data from the California Cancer Registry. METHODS. All cervical cancer cases diagnosed among the 6 subgroups and non-Hispanic whites (NHW) from 1990 to 2004 were identified and used to calculate incidence and mortality rates and trends. The Kaplan-Meier method was used to calculate 5- and 10-year survival probabilities by subgroup, and Cox proportional hazards methodology was used to calculate survival differences adjusted for race and ethnicity, age, stage at diagnosis, socioeconomic status, and treatment factors. RESULTS. Vietnamese and Korean women experienced greater cervical cancer incidence and mortality than NHW women, whereas rates among Chinese, Japanese, and South Asians were comparable or lower. Five-year unadjusted survival probabilities were greatest for South Asians (86%) and Koreans (86%), followed by Vietnamese (82%), Chinese (79%), and Filipinos (79%), as compared with NHW (78%) and Japanese (72%). The adjusted risk of cervical cancer death was significantly lower for South Asians, Koreans, Vietnamese, and Filipinos than for NHW women, but not for Chinese and Japanese. CONCLUSIONS. Cervical cancer incidence rates vary substantially across the major Asian subgroups. Despite higher incidence and mortality rates compared with NHW women, Vietnamese, Koreans, and Filipinos have better survival outcomes. Further studies are needed to examine the factors behind these survival differences. Cancer 2008;113(10 suppl):2955–63. Published 2008 by the American Cancer Society.

We conducted a retrospective cohort study to examine cancer risk in a large cohort of systemic lupus erythematosus (SLE) patients in California.The cohort consisted of individuals with SLE derived from statewide patient discharge data during the period 1991-2002. SLE patients were followed using cancer registry data to examine patterns of cancer development. Standardized incidence ratios (SIRs) and 95% CI were calculated to compare the observed to expected numbers of cancers based on age-, race-, and sex-specific incidence rates in the California population.The 30,478 SLE patients were observed for 157,969 person-years. A total of 1,273 cancers occurred within the observation interval. Overall cancer risk was significantly elevated (SIR = 1.14, 95% CI = 1.07-1.20). SLE patients had higher risks of vagina/vulva (SIR = 3.27, 95% CI = 2.41-4.31) and liver cancers (SIR = 2.70, 95% CI = 1.54-4.24). Elevated risks of lung, kidney, and thyroid cancers and several hematopoietic malignancies were also observed. Individuals had significantly lower risks of several screenable cancers, including breast, cervix, and prostate.These data suggest that risks of several cancer types are elevated among SLE patients. Detailed studies of endogenous and exogenous factors that drive these associations are needed.

BACKGROUND. Rural residence has been associated with increased risk of late stage cancer diagnosis, but it is unknown if this is related to lower socioeconomic status (SES) of rural residents or to other factors. This study examined the impacts of SES and urban/rural status on colorectal cancer (CRC) stage at diagnosis in California. METHODS. Cases of CRC among persons ≥50 years of age diagnosed from 1988–2000 were obtained from the California Cancer Registry. A composite census based SES measure was used in the analysis, and the RUCA (Rural Urban Commuting Areas) classification scheme was used to categorize the residence at diagnosis as urban, large town, or small town. Multivariate logistic regression was used to examine the association between SES, urban/rural status, and late stage at diagnosis. RESULTS. In multivariate models, SES had the strongest association with stage at diagnosis among individuals living in urban areas. As SES level increased, odds of late stage at diagnosis decreased. Individuals in the highest SES category had lower odds of being diagnosed at late stage when compared with those in the lowest SES category (O.R. = 0.91, 95% C.I. = 0.87, 0.94). For individuals who lived in large towns and small rural towns, SES was not significantly associated with stage at diagnosis. We found no significant differences in stage at diagnosis by urban/rural status within SES categories. CONCLUSIONS. These data suggest that the relationship between SES and the risk of late stage colorectal cancer varies among rural and urban populations. Further research into the factors that influence access to and utilization of colorectal cancer screening in rural areas is needed. Cancer 2006. © 2006 American Cancer Society.

BACKGROUND Patients with ovarian cancer often report having symptoms for months before diagnosis, but such findings are subject to recall bias. The aim of this study was to provide an objective evaluation of symptoms that precede a diagnosis of ovarian cancer. METHODS Medicare provider claims linked to records in the California Surveillance, Epidemiology, and End Results data base were utilized to extract diagnosis and procedure codes for 1985 women age 68 years or older who resided in California with ovarian cancer, 6024 elderly women with localized breast cancer, and 10,941 age-matched, Medicare-enrolled women without cancer. Prevalence of rates of symptom-related diagnoses and procedure codes in Medicare claims records were obtained during 3-month periods up to 36 months before diagnosis of ovarian cancer. RESULTS From 1 month to 3 months before patients were diagnosed with ovarian cancer, the frequency and adjusted odds ratios (ORs) with 95% confidence intervals (95%CIs) for 4 “target symptom” code groups were: abdominal pain (frequency, 30.6%; OR, 6.0; 95%CI, 5.1–6.9), abdominal swelling (frequency, 16.5%; OR, 30.9; 95%CI, 21.4–44.8), gastrointestinal symptoms (frequency, 8.4%; OR, 2.3; 95%CI, 1.8–3.0), and pelvic pain (frequency, 5.4%; OR, 4.3; 95%CI, 2.8–6.7). The adjusted odds for abdominal swelling codes was elevated 10–12 months before diagnosis (OR, 2.4; 95%CI, 1.2–4.6) for abdominal pain codes 7–9 months before diagnosis (OR, 1.3; 95%CI, 1.1–1.7). Abdominal imaging (frequency, 7.0%; OR, 1.3; 95%CI, 1.0–1.7) and pelvic imaging/CA125 (frequency, 3.7%; OR, 2.4; 95%CI, 1.7–3.4) showed an elevated frequency and adjusted odds 4–6 months before diagnosis. Patients with claims codes for “target symptoms” 4–36 months before diagnosis were more likely to have abdominal imaging (61.1%) or gastrointestinal procedures (30.8%) than pelvic imaging/CA125 (25.3%). CONCLUSIONS Patients with ovarian cancer were more likely than patients with breast cancer and women in a cancer-free control group to have target symptom codes (particularly abdominal swelling and pain) > 6 months before diagnosis. The evaluation of women with unexplained “target symptoms” should include pelvic imaging and/or CA125. Cancer 2005. © 2005 American Cancer Society.

Very little is known about cancer survival patterns among the growing South Asian community in the United States.Breast cancer survival patterns were evaluated among South Asians using California Cancer Registry data from 1988 to 1998, and breast cancer survival among South Asians was compared to non-Hispanic Whites and other Asian subgroups. The analysis included all female, invasive, histologically confirmed breast cancer cases diagnosed from 1988 to 1998. The outcome of interest was death due to breast cancer. The Kaplan-Meier method was used to calculate 5- and 10-year survival probabilities.South Asians were less likely to be diagnosed with early stage carcinomas relative to non-Hispanic Whites, Chinese and Japanese individuals. In unadjusted analyses, South Asians experienced poorer survival than non-Hispanic Whites at later survival times. The 5- and 10-year unadjusted survival probabilities for South Asians were 84% and 76%, respectively, compared to those for non-Hispanic Whites, which were 87% and 80%, respectively. There was no significant difference in survival between South Asians and non-Hispanic Whites after multivariate adjustment.These data suggest the need for targeted efforts to improve early stage diagnosis among South Asian women. Further research into the factors that influence survival among South Asians is also needed.

OBJECTIVES To estimate misclassification of ethnicity and cancer incidence in Southeast Asian children using the population-based California Cancer Registry. METHODS Asian race/ethnicity was evaluated using lists of Asian surnames. Average annual incidence rates (per million) for 1988 to 1992 were calculated for non-Hispanic white, black, Hispanic, and Asian children (age

Self-reported cancer data from the California Teachers Study were validated by using California Cancer Registry data. The California Teachers Study cohort consists of 133,479 active and retired California teachers. In 1995-1996, data from a mailed questionnaire were linked to the California Cancer Registry data. Sensitivity and specificity of 11 types of cancer were calculated. Multivariate analyses were conducted to evaluate correlates of false-positive and false-negative reporting. Sensitivities showed great variation by cancer site. The highest sensitivities were observed for breast (96.4%) and thyroid (92.9%) cancers, whereas the lowest sensitivities were those for cervical (44.3%), endometrial (69.1%), and other skin (53.6%) cancers. The sensitivities for in situ cancers (at the time of diagnosis) were considerably lower than those for invasive cancers in about half of the cancer types surveyed. The specificities for individual cancer sites ranged from 90% to 99%; the highest were those for lung cancer, leukemia, and Hodgkin's disease (all 99.9%). The lowest specificity was for other skin cancer (90.2%). In situ stage at diagnosis and older age were significantly associated with false-positive reporting. Age and non-White race were associated with false-negative reporting. These findings suggest that the feasibility of using self-reported data without verification in epidemiologic studies of cancer varies by site.

OBJECTIVE To estimate the prevalence of human immunodeficiency virus (HIV) infection, sexually transmitted diseases, and hepatitis and the associated sexual and drug-using behavior among women residing in low-income neighborhoods in 5 northern California counties. METHODS From April 4, 1996, to January 6, 1998, women aged 18 to 29 years were recruited door-to-door from randomly selected street blocks within 1990 census block groups below the 10th percentile for median household income for each county. RESULTS Of 24,223 dwellings enumerated, contact was made with residents from 19,546 (80.7%). Within contacted dwellings, 3,560 eligible women were identified and 2,545 enrolled (71.5%). Weighted estimates for disease prevalence were HIV infection, 0.3% (95% confidence interval, 0.1%-0.4%); syphilis, 0.7% (0.3%-1.1%); gonorrhea, 0.8% (0.3%-1.3%); chlamydia, 3.3% (2.4%-4.8%); herpes simplex virus, type 1, 73.7% (71.6%-76.9%); herpes simplex virus, type 2, 34.4% (29.9%-39.0%); hepatitis A, 33.5% (28.3%-38.7%); chronic hepatitis B, 0.8% (0.3%-1.2%); and hepatitis C, 2.5% (1.4%-3. 6%). Condom use at last sexual intercourse with a new partner was reported by 44.0% (33.9%-54.1%). Injection drug use in the last 6 months was reported by 1.8% (1.0%-2.7%). CONCLUSIONS The Young Women's Survey provided population-based estimates of the prevalence of 8 infectious diseases and related risk behavior within a population for whom data are often difficult to collect. Population-based data are needed for appropriate targeting and planning of primary and secondary disease prevention.

Methods: The California Cancer Registry was used to identify diagnosed cases of 19 common malignancies during a 6-year period. Cases were linked to a hospital discharge database to identify incident VTE events in the year before the cancer diagnosis date. The standardized incidence ratio (SIR) of unprovoked VTE was determined by using the age-, race-, and sex-specific incidence rates in California.

It is unclear how frequently unprovoked venous thromboembolism (VTE) reflects the presence of an occult cancer.The California Cancer Registry was used to identify diagnosed cases of 19 common malignancies during a 6-year period. Cases were linked to a hospital discharge database to identify incident VTE events in the year before the cancer diagnosis date. The standardized incidence ratio (SIR) of unprovoked VTE was determined by using the age-, race-, and sex-specific incidence rates in California.Among 528,693 cancer cases, 596 (0.11%) were associated with a diagnosis of unprovoked VTE within 1 year of the cancer diagnosis, compared with 443.0 expected cases (SIR, 1.3; 95% confidence interval, 1.2-1.5; P.001). Among cases with metastatic-stage cancer, the SIR was 2.3 (95% confidence interval, 2.0-2.6; P.001), whereas for all other stages, the SIR was 1.07 (95% confidence interval, 0.97-1.18; P = .09). The incidence of preceding VTE was increased over that expected only during the 4-month period immediately preceding the cancer diagnosis date (P.001). Only 7 cancer types were associated with a significantly elevated SIR: acute myelogenous leukemia; non-Hodgkin lymphoma; and renal cell, ovarian, pancreatic, stomach, and lung cancer (SIR range, 1.8-4.2).In the year preceding the diagnosis of cancer, the number of cases with unprovoked VTE was modestly higher than expected, and almost all of the unexpected VTE cases were associated with a diagnosis of metastatic-stage cancer within 4 months. Given the timing and advanced stage of the unexpected cases, it is unlikely that earlier diagnosis of these cancers would have significantly improved long-term survival.

Although South Asians (SA) form a large majority of the Asian population of U.S., very little is known about cancer in this immigrant population. SAs comprise people having origins mainly in India, Pakistan, Bangladesh and Sri Lanka. We calculated age-adjusted incidence and time trends of cancer in the SA population of California (state with the largest concentration of SAs) between 1988–2000 and compared these rates to rates in native Asian Indians as well as to those experienced by the Asian/Pacific Islander (API) and White, non-Hispanic population (NHW) population of California.

Background. It is not clear how frequently unprovoked venous thromboembolism (VTE) reflects the presence of an underlying occult malignancy. Objective: To compare the expected and observed incidence of unprovoked VTE during a one year period immediately preceding the diagnosis of common types of cancer Design: Retrospective population-based cohort study using the California Cancer Registry linked with the California Patient Discharge Data Set. Setting: All non-federal hospitals in California. Patients: All cases over the age of 17 that were diagnosed with one of 19 common cancers between Jan. 1993 and Dec. 1995. Measurement. VTE was identified and classified as provoked (after surgery, pregnancy, trauma, medical hospitalization etc.) or unprovoked using an array of validated specific ICD-9-CM codes. VTE cases first diagnosed before the cancer diagnosis of cancer were labeled as having preceding VTE, and VTE cases diagnosed at the time of the cancer diagnosis were labeled as having concurrent VTE cases. Cancer cases with common malignant histologies were identified using the registry. The standardized incidence ratio (SIR) of unprovoked VTE was determined by calculating the expected incidence in the cancer cohorts using the 1995 and 1996 age, race and sex specific incidence rates of unprovoked VTE among California residents. Results. There were 250585 cancer cases; mean age was 66 years, 52% were women, 35% had metastatic or unknown stage cancer at the time of diagnosis; A total of 385 cancer cases had VTE in the preceding year, and 221 of these cases (0.09%) had unprovoked VTE, compared to 216 expected cases, SIR= 1.02 (95% CI= 0.9–1.2, p=NS). 50% of the cases with preceding unprovoked VTE had metastatic or unknown stage cancer (p Limitations. This was a retrospective study that relied on administrative data to identify cases and outcomes. The extent of any evaluation for cancer that might have occurred among the cases with preceding unprovoked VTE could not be determined. Conclusions: In this large population based cohort of cancer cases, the incidence of unprovoked VTE in the year prior to the diagnosis of cancer was not significantly higher than expected in the general population. Approximately 10% to 15% of the cases diagnosed with preceding unprovoked VTE had features suggesting a causal link between thromboembolism and the undiagnosed cancer. Many patients were diagnosed concurrently with cancer and VTE during the same hospitalization.