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Although the association between in utero exposure to diethylstilbestrol (DES) and clear cell adenocarcinoma of the cervix and vagina (CCA) was first reported among young women, subsequent case reports and cohort studies suggest that an elevated risk for CCA may persist with age. Data from the National Program of Cancer Registries (NPCR) and the Surveillance, Epidemiology and End Results (SEER) Program were used to construct indirect standardized incidence ratios (SIR) comparing CCA risk among women born during the exposure period 1947 through 1971, when DES was prescribed to pregnant women, to the relevant time period for nonexposed women born before or after DES exposure period. CCA incidence among the women born before the DES exposure period (ages 30-54 at diagnosis of CAA) or after the DES exposure period (ages 15-29 at diagnosis) were used to calculate the expected rates for women born during the DES exposure period. Among women aged 15-29 years, CCA risk increased with age and peaked in the 25-29 year age group, but the risk estimates were unstable (SIR = 6.06; 95% CI: 0.97, -251.07, SEER data). Among women aged 40-54 years, CCA risk was greatest in the 40-44 year age group (SIR = 4.55; 95% CI: 1.11, 40.19, SEER data and SIR = 3.94; 95% CI: 1.06, 33.01, NPCR/SEER data) and remained significantly elevated throughout this age group in the combined data set. Risk was not elevated among women aged 30-39 years. The observed risk of CCA, if causally related to DES exposure, reflects a persistent health impact from in utero exposure that is widespread in the general population. When assessing a woman's cancer risks, whether her mother took DES while pregnant may still be a relevant aspect of the medical history for women born during the period of DES use in pregnancy. [ABSTRACT FROM AUTHOR]

Social determinants of health and associated systems, policies, and practices are important drivers of health disparities. American Indian and Alaska Native (AI/AN) populations in the United States have elevated incidence rates of stomach, liver, and colorectal cancers compared with other racial/ethnic groups. In this study, we examined incidence rates of 3 types of gastrointestinal cancer among non-Hispanic AI/AN (NH-AI/AN) and non-Hispanic White (NHW) populations by geographic region and Social Vulnerability Index (SVI) score. Incident cases diagnosed during 2010-2019 were identified from population-based cancer registries linked with the Indian Health Service patient registration databases. Age-adjusted incidence rates (per 100,000 population) for stomach, liver, and colorectal cancers were compared within NH-AI/AN populations and between the NH-AI/AN and NHW populations by SVI score. Rates were higher among NH-AI/AN populations in moderate- and high-SVI-score counties in Alaska, the Southern Plains, and the East than in low-SVI counties. Incidence rates among NH-AI/AN populations were elevated when compared with NHW populations by SVI category. Results indicated that higher social vulnerability may drive elevated cancer incidence among NH-AI/AN populations. Additionally, disparities between NH-AI/AN and NHW populations persist even when accounting for SVI. Exploring social vulnerability can aid in designing more effective interventions to address root causes of cancer disparities among AI/AN populations., (Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objectives: To explore current literature on social determinants of health (SDOH) and cancer among American Indian and Alaska Native (AI/AN) populations., Methods: We searched Ovid MEDLINE ® , CINAHL, and PsycINFO databases for articles published during 2000 to 2020, which included terms for SDOH and cancer occurrence in AI/AN populations. We derived the data extraction elements from the PROGRESS-Plus framework. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-Equity extension guided the evidence map., Results: From 2180 screened articles, 297 were included. Most were observational (93.9%), employed a cross-sectional design (83.2%), were categorized as cancer occurrence and surveillance research (62%), and included no cancer-related risk factors (70.7%). Race, gender, and place were the most frequently included PROGRESS-Plus categories. Religion, relationship features, and characteristics of discrimination were least common. Only 12% of articles mentioned historical/current trauma or historical context., Conclusions: Gaps exist in our understanding of SDOH as drivers of cancer disparities in AI/AN populations. Future studies in health equity science may incorporate historical and cultural factors into SDOH frameworks tailored for AI/AN populations., Competing Interests: No competing financial interests exist., (© Stephanie C. Melkonian et al., 2022; Published by Mary Ann Liebert, Inc.)

Background: In 2018, the US Preventive Services Task Force (USPSTF) recommended prostate cancer screening for men aged 55 to 69 years who express a preference for being screened after being informed about and understanding prostate-specific antigen (PSA) test benefits and risks. USPSTF recommended against screening men aged ≥70 years. We aim to generate county-level prevalence estimates, masked by national and state estimates, to identify counties with high PSA screening prevalence., Methods: We fitted multilevel logistic regression mixed models for 4 age groups (≥40, 40 to 54, 55 to 69, ≥70 years), using data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) (n = 116,654) and other sources. We evaluated consistency between our model-based state and BRFSS direct state estimates with Spearman and Pearson correlation coefficients., Results: PSA screening prevalence increased with increasing age groups: 7.7% for men aged 40 to 54 years, 27.2% for men aged 55 to 69 years, and 33.7% among men age ≥70 years, and was largely clustered in the South and Appalachia. Many county estimates among men aged ≥70 years exceeded 40%, especially in the South. Correlation coefficients were 0.94 for men aged ≥40, and ≥0.85 for men aged 40 to 54 years, 55 to 69 years, and ≥70 years., Conclusions: PSA screening was highest among men ≥70 years, for whom it is not recommended, and in the South among all age groups. Screening varied substantially within states., Impact: In 2018, on average, more than 1 in 4 men aged 55 to 69 years and 1 in 3 men aged ≥70 years underwent PSA screening in the prior year, suggesting potential overuse among some men., Competing Interests: Conflict of interest: The authors declare no potential conflicts of interest., (© Copyright 2021 by the American Board of Family Medicine.)

Background: More than one-half of breast cancer cases are diagnosed among women aged younger than 62 years, which may result in employment challenges. This study examined whether cancer-related employment disruption was associated with increased financial hardship in a national US study of women with breast cancer., Methods: Women with breast cancer who were enrolled in the Sister or Two Sister Studies completed a survivorship survey in 2012. Employment disruption was defined as stopping work completely or working fewer hours after diagnosis. Financial hardship was defined as: 1) experiencing financial problems paying for cancer care, 2) borrowing money or incurring debt, or 3) filing for bankruptcy because of cancer. Prevalence ratios and 95% confidence intervals for the association between employment disruption and financial hardship were estimated using multivariable Poisson regression with robust variance., Results: We analyzed data from women employed at diagnosis (n = 1628). Women were a median age of 48 years at diagnosis and 5.6 years from diagnosis at survey completion. Overall, 27.3% of women reported employment disruption (15.4% stopped working; 11.9% reduced hours), and 21.0% experienced financial hardship (16.0% had difficulty paying for care; 12.6% borrowed money or incurred debt; 1.8% filed for bankruptcy). In adjusted analysis, employment disruption was associated with nearly twice the prevalence of financial hardship (prevalence ratio = 1.93, 95% confidence interval = 1.58 to 2.35)., Conclusions: Women experiencing employment disruptions after breast cancer may be more vulnerable to financial hardship. Findings highlight the need to target risk factors for employment disruption, facilitate return to work or ongoing employment, and mitigate financial consequences after cancer., (© The Author(s) 2021. Published by Oxford University Press.)

Background: The U.S. Preventive Services Task Force recommends biennial screening mammography for average-risk women aged 50-74 years. County-level information on population measures of mammography use can inform targeted intervention to reduce geographic disparities in mammography use. County-level estimates for mammography use nationwide are rarely presented., Methods: We used data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS; n = 130,289 women), linked it to the American Community Survey poverty data, and fitted multilevel logistic regression models with two outcomes: mammography within the past 2 years (up-to-date), and most recent mammography 5 or more years ago or never (rarely/never). We poststratified the data with U.S. Census population counts to run Monte Carlo simulations. We generated county-level estimates nationally and by urban-rural county classifications. County-level prevalence estimates were aggregated into state and national estimates. We validated internal consistency between our model-based state-specific estimates and urban-rural estimates with BRFSS direct estimates using Spearman correlation coefficients and mean absolute differences., Results: Correlation coefficients were 0.94 or larger. Mean absolute differences for the two outcomes ranged from 0.79 to 1.03. Although 78.45% (95% confidence interval, 77.95%-78.92%) of women nationally were up-to-date with mammography, more than half of the states had counties with >15% of women rarely/never using a mammogram, many in rural areas., Conclusions: We provided estimates for all U.S. counties and identified marked variations in mammography use. Many states and counties were far from the 2020 target (81.1%)., Impact: Our results suggest a need for planning and resource allocation on a local level to increase mammography uptake., (©2018 American Association for Cancer Research.)

Background: The U.S. Preventive Services Task Force recommends routine screening for colorectal cancer for adults ages 50 to 75 years. We generated small-area estimates for being current with colorectal cancer screening to examine sociogeographic differences among states and counties. To our knowledge, nationwide county-level estimates for colorectal cancer screening are rarely presented. Methods: We used county data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS; n = 251,360 adults), linked it to the American Community Survey poverty data, and fitted multilevel logistic regression models. We post-stratified the data with the U.S. Census population data to run Monte Carlo simulations. We generated county-level screening prevalence estimates nationally and by race/ethnicity, mapped the estimates, and aggregated them into state and national estimates. We evaluated internal consistency of our modeled state-specific estimates with BRFSS direct state estimates using Spearman correlation coefficients. Results: Correlation coefficients were ≥0.95, indicating high internal consistency. We observed substantial variations in current colorectal cancer screening estimates among the states and counties within states. State mean estimates ranged from 58.92% in Wyoming to 75.03% in Massachusetts. County mean estimates ranged from 40.11% in Alaska to 79.76% in Florida. Larger county variations were observed in various race/ethnicity groups. Conclusions: State estimates mask county variations. However, both state and county estimates indicate that the country is far behind the "80% by 2018" target. Impact: County-modeled estimates help identify variation in colorectal cancer screening prevalence in the United States and guide education and enhanced screening efforts in areas of need, including areas without BRFSS direct-estimates. Cancer Epidemiol Biomarkers Prev; 27(3); 245-53. ©2018 AACR ., (©2018 American Association for Cancer Research.)

Background: Evidence shows underutilization of cancer genetics services. To explore the reasons behind this underutilization, this study evaluated characteristics of women who were referred for genetic counseling and/or had undergone BRCA1/2 testing., Methods: An ovarian cancer risk perception study stratified 16,720 eligible women from the Henry Ford Health System into average-, elevated-, and high-risk groups based on family history. We randomly selected 3,307 subjects and interviewed 2,524 of them (76.3% response rate)., Results: Among the average-, elevated-, and high-risk groups, 2.3, 10.1, and 20.2%, respectively, reported genetic counseling referrals, and 0.8, 3.3, and 9.5%, respectively, reported having undergone BRCA testing. Personal breast cancer history, high risk, and perceived ovarian cancer risk were associated with both referral and testing. Discussion of family history with a doctor predicted counseling referral, whereas belief that family history influenced risk was the strongest BRCA testing predictor. Women perceiving their cancer risk as much higher than other women their age were twice as likely (95% confidence interval: 2.0-9.6) to report genetic counseling referral., Conclusion: In a health system with ready access to cancer genetic counseling and BRCA testing, women who were at high risk underutilized these services. There were strong associations between perceived ovarian cancer risk and genetic counseling referral, and between a belief that family history influenced risk and BRCA testing.

Purpose: Screening has been shown to lower the morbidity and mortality for breast, cervical, and colorectal cancers. Despite the availability of cancer screening, nearly 70,000 women die each year from these cancers. We conducted a study in 2008 within a privately-insured patient population of women who were members of an integrated health care system in Southeastern Michigan, for whom information on ovarian cancer risk as well as personal and family history of cancer was available., Methods: We used a population-based, weighted stratified random sample of women from a single health care institution to assess the proportion with up-to-date breast, cervical, and colorectal screening. Multivariable analyses were conducted to identify predictors of screening behavior., Results: In our study, women reported cervical and breast cancer screening above 90% and colorectal cancer screening above 75%., Conclusions: The results of our study hold promise that Healthy People 2020 cancer screening objectives might be obtainable as access to health insurance is expanded among US residents.

Introduction: Understanding the characteristics of early and late survey responders has implications for recruitment efforts and for informing potential response bias. The main objective of this analysis was to examine survey responder status (ie, early vs late response) by sociodemographic characteristics and by salience of study variables among respondents., Methods: We analyzed data from a survey on family cancer history and perceived cancer risk among women at a large managed health-care organization. For baseline and 12-month follow-up surveys, we defined early versus late responder status according to the 95th percentile of the number of days it took to obtain completed interviews., Results: We found no significant associations between responder status and sociodemographic characteristics at baseline or follow-up. At baseline, early responders were significantly more likely than late responders to have a personal history of breast cancer (5.2% vs 3.4%, P = .04) and to have been referred for genetic counseling (4.6% vs 2.0%, P = .004). The association between personal history of breast cancer and responder status persisted at follow-up; only 3.5% of late responders at baseline were also late responders at follow-up. Follow-up survey nonresponse rates did not vary by baseline responder status., Conclusion: Survey topic salience is associated with early response and is important for recruitment. However, once recruited, late responders do not remain late responders at follow-up, suggesting that extra efforts made to recruit late responders are worthwhile. Health-related agencies that conduct surveys should consider survey salience in survey administration and recruitment strategies.

Background: In 2005, the United States Preventive Services Task Force (USPSTF) released guidelines which outlined specific family history patterns associated with an increased risk for BRCA1/2 mutations, and recommended at-risk individuals be referred for genetic counseling and evaluation for BRCA testing. The purpose of this study was to assess the prevalence of individuals with a USPSTF increased-risk family history pattern, the frequency with which specific patterns were met, and resulting healthcare actions among women from the Henry Ford Health System., Methods: As part of a study evaluating ovarian cancer risk perception and screening, 2,524 randomly selected participants completed a detailed interview (response rate 76%) from an initial eligible cohort of 16,720 women., Results: Approximately 6% of participants had a family history fulfilling one or more of the USPSTF patterns. Although 90% of these women had shared their family history with their provider, less than 20% had been referred for genetic counseling and only 8% had undergone genetic testing. Caucasian women with higher income and education levels were more likely to receive referrals. Among the 95 participants in the total study cohort who reported BRCA testing, 78% did not have a family history that met one of the USPSTF patterns., Conclusions: These results suggest a higher prevalence of women with an increased-risk family history than originally predicted by the USPSTF, and lack of provider recognition and referral for genetic services., Impact: Improvements in healthcare infrastructure and clinician education will be required to realize population level benefits from BRCA genetic counseling and testing.

Background: Preventive health care services, such as cancer screening can be particularly vulnerable to a lack of paid leave from work since care is not being sought for illness or symptoms. We first describe the prevalence of paid sick leave by broad occupational categories and then examine the association between access to paid sick leave and cancer testing and medical care-seeking in the U.S. workforce., Methods: Data from the 2008 National Health Interview survey were analyzed by using paid sick leave status and other health-related factors to describe the proportion of U.S. workers undergoing mammography, Pap testing, endoscopy, fecal occult blood test (FOBT), and medical-care seeking., Results: More than 48 million individuals (38%) in an estimated U.S. working population of 127 million did not have paid sick leave in 2008. The percentage of workers who underwent mammography, Pap test, endoscopy at recommended intervals, had seen a doctor during the previous 12 months or had at least one visit to a health care provider during the previous 12 months was significantly higher among those with paid sick leave compared with those without sick leave after controlling for sociodemographic and health-care-related factors., Conclusions: Lack of paid sick leave appears to be a potential barrier to obtaining preventive medical care and is a societal benefit that is potentially amenable to change.

Objective: To examine the relationship between womens' experiences during mammography and their likelihood of being rescreened after receiving a negative or benign mammogram., Methods: Telephone interview and medical record data were collected from a random sample of enrollees from four states in a national screening program targeting uninsured and underinsured women at least 30 months after they had undergone an index mammogram in 1997. We calculated 30-month rescreening rates by prior mammography characteristics including pain and embarrassment, worry, convenience of appointment time, treatment by staff, and financial considerations., Results: Of the 2,000 women in the sampling frame, 1,895 (93.6%) were located, 1,685 (88.6%) were interviewed and 1,680 provided data required for our analysis. Overall, 81.5% of the women had undergone rescreening. More than 90% of the women reported being 'satisfied' or 'very satisfied' with treatment by facility staff, facility location and wait time during the appointment. Statistically significant decreased rescreening rates were seen for women who reported feeling embarrassed and for women reporting dissatisfaction with ability to schedule a convenient appointment time., Conclusion: These results suggest that providing additional reassurance and privacy may increase rescreening rates.

Background: To locate online health information, Internet users typically use a search engine, such as Yahoo! or Google. We studied Yahoo! search activity related to the 23 most common cancers in the United States., Objective: The objective was to test three potential correlates of Yahoo! cancer search activity--estimated cancer incidence, estimated cancer mortality, and the volume of cancer news coverage--and to study the periodicity of and peaks in Yahoo! cancer search activity., Methods: Yahoo! cancer search activity was obtained from a proprietary database called the Yahoo! Buzz Index. The American Cancer Society's estimates of cancer incidence and mortality were used. News reports associated with specific cancer types were identified using the LexisNexis "US News" database, which includes more than 400 national and regional newspapers and a variety of newswire services., Results: The Yahoo! search activity associated with specific cancers correlated with their estimated incidence (Spearman rank correlation, rho = 0.50, P = .015), estimated mortality (rho = 0.66, P = .001), and volume of related news coverage (rho = 0.88, P < .001). Yahoo! cancer search activity tended to be higher on weekdays and during national cancer awareness months but lower during summer months; cancer news coverage also tended to follow these trends. Sharp increases in Yahoo! search activity scores from one day to the next appeared to be associated with increases in relevant news coverage., Conclusions: Media coverage appears to play a powerful role in prompting online searches for cancer information. Internet search activity offers an innovative tool for passive surveillance of health information-seeking behavior.

As a public health agency within the US Department of Health and Human Services, the Agency for Toxic Substances and Disease Registry (ATSDR) is responsible for implementing the health-related provisions of the Superfund Act. Much of its work is carried out to address health concerns in communities near sources of environmental contamination, usually in consultation with other local, state, and federal agencies. Over the last decade, ATSDR has considered, supported or conducted health investigations in a variety of different communities across the country. Communication with community residents has been an integral part of the process in all of these activities. The approach to communicating results needs to begin early by developing relationships and clarifying expectations, and it needs to remain flexible. Through examples taken from specific situations, we illustrate many of the lessons we have gained from trying to apply the principles of good community involvement to the design and conduct of health investigations and to the communication of study results.

Mining, handling, processing, and personal or commercial use of asbestos-contaminated vermiculite have led to widespread contamination of the Libby, Montana, area. We initiated a medical testing program in response to reports of respiratory illness in the community. The purpose of this analysis was to identify and quantify asbestos-related radiographic abnormalities among persons exposed to vermiculite in Libby and to examine associations between these outcomes and participants' self-reported exposures. A cross-sectional interview and medical testing were conducted in Libby from July through November 2000 and from July through September 2001. A total of 7,307 persons who had lived, worked, or played in Libby for at least 6 months before 31 December 1990 completed the interview. Of those, 6,668 participants > or = 18 years of age received chest radiographs to assess the prevalence of pleural and interstitial abnormalities. We observed pleural abnormalities in 17.8% of participants and interstitial abnormalities in < 1% of participants undergoing chest radiography. We examined 29 occupational, recreational, household, and other exposure pathways in the analysis. The prevalence of pleural abnormalities increased with increasing number of exposure pathways, ranging from 6.7% for those who reported no apparent exposures to 34.6% for those who reported > or = 12 pathways. The factors most strongly associated with pleural abnormalities were being a former W.R. Grace worker, being older, having been a household contact of a W.R. Grace worker, and being a male. In addition to being a former W.R. Grace worker, environmental exposures and other nonoccupational risk factors were also important predictors of asbestos-related radiographic abnormalities.

In May and June 1999, an outbreak of acute gastrointestinal illness occurred among long-distance hikers on the Appalachian Trail between Catawba and Troutville, Virginia. An investigation found that 45 out of 70 hikers had become ill within two days of arriving in Catawba, Virginia. Water samples were collected from a general store frequented by the hikers and from several nearby buildings and a popular all-you-can-eat restaurant. Symptoms were consistent with those caused by Norwalk-like viruses, and laboratory diagnosis detected Norwalk-like viruses in stool and serum specimens. People who consumed food items prepared at the general store were almost twice as likely to become ill as persons who did not consume those foods. Environmental sampling of water from the taps inside and outside the general store and from several surrounding establishments in Catawba found contamination by fecal coliform bacteria but not by Norwalk-like virus. Since several hikers reported illness prior to arriving at Catawba, person-to-person transmission of a highly contagious agent such as Norwalk-like virus could not be ruled out. Poor sanitation, scarce water supplies, and crowding can increase the risk of gastrointestinal illness among long-distance hikers.

Objectives: This study examined the mortality experience of 50,000 nurses using the National Occupational Mortality Surveillance database of death certificates., Methods: Proportionate mortality ratios adjusted by race (White, Black, or other) and 5-year age groups were calculated for selected causes of death among female nurses vs all workers and white-collar workers., Results: Excess deaths among nurses less than 65 years of age were seen in both comparison groups for viral hepatitis, cancer of the nasal cavities, accidental falls, suicide, and drug-related deaths. Among nurses 65 years old or older, deaths due to chronic myeloid leukemia were in excess. Proportionate mortality ratios for breast and colon cancers, diabetes, and heart disease varied by occupational comparison group., Conclusions: These findings confirm results of previous studies and identify new associations. Redoubled efforts are called for in overcoming obstacles to reducing workplace hazards.

Evidence suggests a role for reproductive and hormonal factors in the etiology of colorectal cancer. Investigation of adenomas, the presumed precursors of cancer, and reproductive characteristics may place such associations within a particular stage of carcinogenesis. We examined parity, age at first birth, age at menopause, and age at menarche as well as contraceptive and noncontraceptive hormone use in a case-control study of 347 women (115 cases with adenomas and 232 controls) conducted in North Carolina. Using unconditional logistic regression analysis, increasing age at menopause was found to be associated with a reduction in the risk of adenomas [odds ratio (OR), 0.26; 95% confidence interval (CI), 0.10-0.68]. An increased risk for adenomas was found for women undergoing surgical menopause as compared with women undergoing natural menopause (OR, 2.10; 95% CI, 1.05-4.21). Our results suggest a reduced risk of adenomas associated with noncontraceptive hormone use that was limited to a subgroup of women with natural menopause or bilateral oophorectomy (OR, 0.39; 95% CI, 0.15-0.97). No associations were seen between other reproductive characteristics and adenomas. These results suggest protective effects for both endogenous and exogenous female hormones that operate early in the process of carcinogenesis. Alternatively, lifestyle factors or other correlates of exogenous hormone use and delayed menopause could play a role in reduced adenoma risk.