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Adverse neighborhood social and natural (greenspace) environments may contribute to prostate cancer (CaP) etiology, but mechanisms are unclear. We examined associations between neighborhood environment and prostate intratumoral inflammation in 967 men diagnosed with CaP with available tissue from 1986-2009 in the Health Professionals Follow-up Study. Exposures were linked to work or residential addresses in 1988. We estimated indices of neighborhood socioeconomic status (nSES) and segregation (Index of Concentration at Extremes (ICE)) using Census tract-level data. Surrounding greenness was estimated using seasonal averaged Normalized Difference Vegetation Index (NDVI). Surgical tissue underwent pathological review for acute and chronic inflammation, corpora amylacea, and focal atrophic lesions. Adjusted odds ratios (aOR) for inflammation (ordinal) and focal atrophy (binary) were estimated using logistic regression. No associations were observed for acute or chronic inflammation. Each IQR increase in NDVI within 1230m (aOR: 0.74, 95% CI: 0.59, 0.93), ICE-income (aOR: 0.79, 95% CI: 0.61, 1.04) and ICE-race/income (aOR: 0.79, 95% CI: 0.63, 0.99) was associated with lower postatrophic hyperplasia. IQR increases in nSES (aOR: 0.76, 95% CI: 0.57, 1.02) and ICE-race/income (aOR: 0.73, 95% CI: 0.54, 0.99) were associated with lower tumor corpora amylacea. Histopathological inflammatory features of prostate tumors may be influenced by neighborhood

In resource-limited settings, augmenting primary care provider (PCP)-based referrals with data-derived algorithms could direct scarce resources towards those patients most likely to have a cancer diagnosis and benefit from early treatment. Using data from Botswana, we compared accuracy of predictions of probable cancer using different approaches for identifying symptomatic cancer at primary clinics. We followed cancer suspects until they entered specialized care for cancer treatment (following pathologically confirmed diagnosis), exited from the study following noncancer diagnosis, or died. Routine symptom and demographic data included baseline cancer probability assessed by the primary care provider (low, intermediate, high), age, sex, performance status, baseline cancer probability by study physician, predominant symptom (lump, bleeding, pain or other) and HIV status. Logistic regression with 10-fold cross-validation was used to evaluate classification by different sets of predictors: (1) PCPs, (2) Algorithm-only, (3) External specialist physician review and (4) Primary clinician augmented by algorithm. Classification accuracy was assessed using c-statistics, sensitivity and specificity. Six hundred and twenty-three adult cancer suspects with complete data were retained, of whom 166 (27%) were diagnosed with cancer. Models using PCP augmented by algorithm (c-statistic: 77.2%, 95% CI: 73.4%, 81.0%) and external study physician assessment (77.6%, 95% CI: 73.6%, 81.7%) performed better than algorithm-only (74.9%, 95% CI: 71.0%, 78.9%) and PCP initial assessment (62.8%, 95% CI: 57.9%, 67.7%) in correctly classifying suspected cancer patients. Sensitivity and specificity statistics from models combining PCP classifications and routine data were comparable to physicians, suggesting that incorporating data-driven algorithms into referral systems could improve efficiency.

Previous studies have examined the association between prenatal nitrogen dioxide (NO2)—a traffic emissions tracer—and fetal growth based on ultrasound measures. Yet, most have used exposure assessment methods with low temporal resolution, which limits the identification of critical exposure windows given that pregnancy is relatively short. Here, we used NO2 data from an ensemble model linked to residential addresses at birth to fit distributed lag models that estimated the association between NO2 exposure (resolved weekly) and ultrasound biometric parameters in a Massachusetts-based cohort of 9,446 singleton births from 2011–2016. Ultrasound biometric parameters examined included biparietal diameter (BPD), head circumference, femur length, and abdominal circumference. All models adjusted for sociodemographic characteristics, time trends, and temperature. We found that higher NO2 was negatively associated with all ultrasound parameters. The critical window differed depending on the parameter and when it was assessed. For example, for BPD measured after week 31, the critical exposure window appeared to be weeks 15–25; 10-parts-per-billion higher NO2 sustained from conception to the time of measurement was associated with a lower mean z score of −0.11 (95% CI: −0.17, −0.05). Our findings indicate that reducing traffic emissions is one potential avenue to improving fetal and offspring health.

BackgroundThe United States Preventive Services Task Force recommended against prostate-specific antigen (PSA) screening in 2012, which was modified in 2018 into shared decision making for men aged 55-70 years with a life expectancy over 10 years. We studied the trends in PSA screening in younger Black and White men with the implementation of the 2012 and 2018 guidelines.MethodsYounger Black and White men (aged 40-54 years) were identified using the Behavioral Risk Factor Surveillance System database biennially from 2012 to 2020. Our primary outcome was PSA screening within 2 years of the survey. An adjusted logistic regression model with 2-way interaction assessment between race and survey year was used to investigate the temporal trend of PSA screening in younger Black and White men.ResultsA total of 142 892 men were included. We saw steadily decreasing odds of PSA screening among both younger Black and White men in 2014, 2016, 2018, and 2020 compared with 2012 (for younger Black men: odds ratio [OR]2014 = 0.77, 95% confidence interval [CI] = 0.62 to 0.96, OR2016 = 0.51, 95% CI = 0.41 to 0.63, OR2018 = 0.33, 95%CI = 0.27 to 0.42, OR2020 = 0.25, 95% CI = 0.18 to 0.32; and for younger White men: OR2014 = 0.81, 95% CI = 0.76 to 0.87, OR2016 = 0.66, 95% CI = 0.61 to 0.71, OR2018 = 0.41, 95%CI = 0.37 to 0.44, OR2020 = 0.36, 95% CI = 0.33 to 0.39). Younger Black men showed a brisker decrease in PSA screening in 2016, 2018, and 2020 compared with younger White men (all P ConclusionsPSA screening among younger men steadily decreased over the past decade since the 2012 United States Preventive Services Task Force guidelines, demonstrating a narrowing racial gap. How such an observed trend translates to long-term clinical outcomes for younger Black men remains to be seen.

PURPOSE In sub-Saharan Africa, radiotherapy (RT) utilization and delivery patterns have not been extensively studied in patients with metastatic breast cancer. METHODS A retrospective cohort study of female patients with metastatic breast cancer seen at Parirenyatwa Radiotherapy Centre in Zimbabwe from 2014 to 2018 was conducted. Demographics, pathology, staging, and treatment data were abstracted through chart review. Fisher's exact test and chi-squared test of independence were used to compare proportions, and independent two-sample t-tests were used to compare means. RESULTS Of 351 patients with breast cancer, 152 (43%) had metastatic disease, median age 51 years (interquartile range: 43-61 years). Of those with metastatic disease, 30 patients (20%) received radiation to various metastatic sites: 16 spine; three nonspine bone metastases; six whole brain; and five chest wall or supraclavicular. Patients who received radiation were younger (46 v 52 years; P = .019), but did not differ significantly by performance status than those who did not. The most common dose prescription was 30 Gy in 10 fractions (33%). Five (17%) patients had treatment interruption and two (7%) had treatment noncompletion. Province of origin and clinical tumor stage were significant predictors of RT receipt ( P = .002; and P = .018, respectively). CONCLUSION A minority of patients with metastatic breast cancer received RT (20%), and these were likely to be younger, with advanced tumor stage, and resided in provinces where RT is available. Conventional courses were generally prescribed. There is a need to strongly consider palliative RT as an option for patients with metastatic breast cancer and use of hypofractionated courses (e.g. 8 Gy in one fraction) may support this goal.

BackgroundLeft unabated, rising temperatures pose an escalating threat to human health. The potential effects of hot temperatures on fetal health have been under-explored. Here, we examined the association between prenatal ambient temperature exposure and fetal growth measures in a Massachusetts-based pregnancy cohort.MethodsWe used ultrasound measurements of biparietal diameter (BPD), head circumference (HC), femur length and abdominal circumference (AC), in addition to birthweight (BW), from 9446 births at Beth Israel Deaconess Medical Center from 2011 to 2016. Ultrasound scans were classified into three distinct gestational periods: 16–23 weeks, 24–31 weeks, 32+ weeks; and z-scores were created for each fetal growth measure using the INTERGROWTH-21st standards. We fitted distributed lag models to estimate the time-varying association between weekly temperature and fetal growth, adjusting for sociodemographic characteristics, seasonal and long-term trends, humidity and particulate matter (PM2.5).ResultsHigher ambient temperature was associated with smaller fetal growth measures. The critical window of exposure appeared to be Weeks 1–20 for ultrasound parameters, and high temperatures throughout pregnancy were important for BW. Associations were strongest for head parameters (BPD and HC) in early to mid-pregnancy, AC late in pregnancy and BW. For example, a 5ºC higher cumulative temperature exposure was associated with a lower mean AC z-score of -0.26 (95% CI: -0.48, -0.04) among 24–31-Week scans, and a lower mean BW z-score of -0.32 (95% CI: -0.51, -0.12).ConclusionHigher temperatures were associated with impaired fetal growth. This has major health implications given that extreme temperatures are more common and escalating.

Few sub-Saharan African studies have ascertained utilization for postmastectomy radiation (PMRT) for breast cancer, the second most common cancer among African women. We estimated PMRT utilization and identified predictors of PMRT receipt in Zimbabwe. Retrospective patient cohort included non-metastatic breast cancer patients treated from 2014 to 2019. PMRT eligibility was assigned per NCCN guidelines. Patients receiving chemotherapy for non-metastatic disease were also included. The primary endpoint was receipt of PMRT, defined as chest wall with/without regional nodal radiation. Predictors of receiving PMRT were identified using logistic regression. Model performance was evaluated using the c statistic and Hosmer–Lemeshow test for goodness-of-fit. 201 women with localized disease and median follow-up of 11.4 months (IQR 3.3–17.9) were analyzed. PMRT was indicated in 177 women and utilized in 59(33.3%). Insurance coverage, clinical nodal involvement, higher grade, positive margins, and hormone therapy receipt were associated with higher odds of PMRT receipt. In adjusted models, no hormone therapy (aOR 0.12, 95% CI 0.043, 0.35) and missing grade (aOR 0.07, 95% CI 0.01, 0.38) were associated with lower odds of PMRT receipt. The resulting c statistic was 0.84, with Hosmer–Lemeshow p-value of 0.93 indicating good model fit. PMRT was utilized in 33% of those meeting NCCN criteria. Missing grade and no endocrine therapy receipt were associated with reduced likelihood of PMRT utilization. In addition to practice adjustments such as increasing hypofractionation and increasing patient access to standard oncologic testing at diagnosis could increase postmastectomy utilization.

Placement of pathology and laboratory medicine (PALM) services requires balancing efficiency (maximizing test volume) with equitable urban–rural access. We compared the association between population density (proxy for efficiency) and travel time to the closest facility (proxy for equitable access) across levels of Tanzania’s public sector health system. We linked geospatial data for Tanzania from multiple sources. Data on facility locations and other geographic measures were collected from government and non-governmental databases. We classified facilities assuming increasing PALM availability by tier: (1) dispensaries, (2) health centres, (3) district hospitals and (4) regional/referral hospitals. We used the AccessMod 5 algorithm to estimate travel time to the closest facility for each tier across Tanzania with 500-m resolution. District-level average population density and travel time to the closest facility were calculated and presented using medians and interquartile ranges. Spatial correlations between these variables were estimated using the global Moran’s I and bivariate Local Indicator of Spatial Autocorrelation, specifying a queen’s neighbourhood matrix. Spatial analysis was restricted to 171 contiguous districts. The study included 5406 dispensaries, 675 health centres, 186 district hospitals and 37 regional/referral hospitals. District-level travel times were shortest for Tier 1 (median: [IQR]: 45.4 min [30.0–74.7]) and longest for Tier 4 facilities (160.2 min [107.3–260.0]). There was a weak spatial autocorrelation across tiers (Tier 1: −0.289, Tier 2: −0.292, Tier 3: −0.271 and Tier 4: −0.258) and few districts were classified as significant spatial outliers. Across tiers, geographic patterns of populated districts surrounded by neighbours with short travel time and sparsely populated districts surrounded by neighbours with long travel time were observed. Similar spatial correlation measures across health system levels suggest that Tanzania’s health system reflects equitable urban–rural access to different PALM services. Longer travel times to hospital-based care could be ameliorated by shifting specialized diagnostics to more accessible lower tiers.

Background Breast cancer is the second most common cancer among women in Zimbabwe. Patients face socioeconomic barriers to accessing oncology care, including radiotherapy. We sought to understand patterns of care and adherence for women with breast cancer in sub‐Saharan Africa (SSA) with radiotherapy access. Methods A retrospective cohort was created for women with breast cancer evaluated at the Parirenyatwa Hospital Radiotherapy and Oncology Center (RTC) from 2014 to 2018. Clinical data were collected to define patterns of care. Non‐adherence was modeled as a binary outcome with different criteria for patients with localized versus metastatic disease. Results In total, 351 women presented with breast cancer with median age 51 at diagnosis (IQR: 43–61). Receptor status was missing for 71% (248). 199 (57%) had non‐metastatic disease, and 152 (43%) had metastases. Of women with localized disease, 34% received post‐mastectomy radiation. Of women with metastatic disease, 9.7% received radiotherapy. Metastatic disease and missing HIV status were associated with increased odds of study‐defined non‐adherence (aOR: 1.85, 95% CI: 1.05, 3.28; aOR: 2.13, 95% CI: 1.11, 4.05), while availability of ER/PR status was associated with lower odds of non‐adherence (aOR: 0.18, 95% CI: 0.09, 0.36). Conclusions Radiotherapy is likely underutilized for women with breast cancer, even in a setting with public sector availability. Exploring patient‐level factors that influence adherence to care may provide clinicians with better tools to support adherence and improve survival. Greater investment is needed in multidisciplinary, multimodality care for breast cancer in SSA.

IntroductionWhile travel distance and time are important proxies of physical access to health facilities, obtaining valid measures with an appropriate modelling method remains challenging in many settings. We compared five measures of geographic accessibility in Haiti, producing recommendations that consider available analytic resources and geospatial goals.MethodsEight public hospitals within the ministry of public health and population were included. We estimated distance and time between hospitals and geographic centroids of Haiti’s section communes and population-level accessibility. Geographic feature data were obtained from public administrative databases, academic research databases and government satellites. We used validated geographic information system methods to produce five geographic access measures: (1) Euclidean distance (ED), (2) network distance (ND), (3) network travel time (NTT), (4) AccessMod 5 (AM5) distance (AM5D) and (5) AM5 travel time (AM5TT). Relative ranking of section communes across the measures was assessed using Pearson correlation coefficients, while mean differences were assessed using analysis of variance (ANOVA) and pairwise t-tests.ResultsAll five geographic access measures were highly correlated (range: 0.78–0.99). Of the distance measures, ED values were consistently the shortest, followed by AM5D values, while ND values were the longest. ND values were as high as 2.3 times ED values. NTT models generally produced longer travel time estimates compared with AM5TT models. ED consistently overestimated population coverage within a given threshold compared with ND and AM5D. For example, population-level accessibility within 15 km of the nearest studied hospital in the Center department was estimated at 68% for ED, 50% for AM5D and 34% for ND.ConclusionWhile the access measures were highly correlated, there were significant differences in the absolute measures. Consideration of the benefits and limitations of each geospatial measure together with the intended purpose of the estimates, such as relative proximity of patients or service coverage, are key to guiding appropriate use.

Introduction: Intimate partner violence (IPV) is associated with several adverse public health outcomes and alcohol use is one of its risk factors. Proximity to alcohol selling points could be linked with problem drinking and IPV. We aimed to determine whether proximal location to alcohol and intensity of alcohol consumption are associated with IPV in rural southwest Uganda. Methods: We conducted a cross-sectional study in rural southwest Uganda with structured interviews at household level. We used the alcohol use disorders identification test (AUDIT) and the Conflict Tactics Scale to measure past year alcohol consumption and IPV (perpetration and victimization). We estimated Euclidean distances between participants’ households and nearest alcohol outlets using geographic information systems. We used generalized estimating equation models to calculate adjusted odds ratios (aOR) for the factors associated with IPV. Results: We enrolled 742 participants and median age was 41 years (inter-quartile range or IQR 32-53) and 52.2% of respondents were male. The overall prevalence of IPV in the past year was 52.2%. In a multivariable regression model, women (aOR = 2.24, 95%CI 1.28, 3.91) compared to men, those living proximal to an alcohol selling point (OR = 1.77, 95% CI 1.38, 2.27) were more likely to experience IPV. There was a dose-response relationship between alcohol consumption and IPV. With non-drinkers as the reference category, the aORs were 4.54 (95% CI 2.04, 10.08) for casual drinkers, 10.53 (95% CI 4.15, 26.77) for hazardous drinkers and 15.31 (95% CI 4.73, 49.54) for alcohol dependent drinkers. Conclusion: IPV is very common and has a dose-response relationship with alcohol consumption and drinking outlet proximity. There is an urgent need for IPV and alcohol interventions programs in these rural communities. Policy to restrict proximity of alcohol outlets to residential locations should be examined as an intervention for alcohol consumption and IPV perpetration.

ImportanceAmong patients with colorectal liver metastasis (CRLM) who are eligible for curative-intent liver surgical resection, only half undergo liver metastasectomy. It is currently unclear how rates of liver metastasectomy vary geographically in the US. Geographic differences in county-level socioeconomic characteristics may, in part, explain variability in the receipt of liver metastasectomy for CRLM.ObjectiveTo describe county-level variation in the receipt of liver metastasectomy for CRLM in the US and its association with poverty rates.Design, Setting, and ParticipantsThis ecological, cross-sectional, and county-level analysis was conducted using data from the Surveillance, Epidemiology, and End Results Research Plus database. The study included the county-level proportion of patients who had colorectal adenocarcinoma diagnosed between January 1, 2010, and December 31, 2018, underwent primary surgical resection, and had liver metastasis without extrahepatic metastasis. The county-level proportion of patients with stage I colorectal cancer (CRC) was used as a comparator. Data analysis was performed on March 2, 2022.ExposuresCounty-level poverty in 2010 obtained from the US Census (proportion of county population below the federal poverty level).Main Outcomes and MeasuresThe primary outcome was county-level odds of liver metastasectomy for CRLM. The comparator outcome was county-level odds of surgical resection for stage I CRC. Multivariable binomial logistic regression accounting for clustering of outcomes within a county via an overdispersion parameter was used to estimate the county-level odds of receiving a liver metastasectomy for CRLM associated with a 10% increase in poverty rate.ResultsIn the 194 US counties included in this study, there were 11 348 patients. At the county level, the majority of the population was male (mean [SD], 56.9% [10.2%]), White (71.9% [20.0%]), and aged between 50 and 64 (38.1% [11.0%]) or 65 and 79 (33.6% [11.4%]) years. The adjusted odds of undergoing a liver metastasectomy was lower in counties with higher poverty in 2010 (per 10% increase; odds ratio, 0.82 [95% CI, 0.69-0.96]; P = .02). County-level poverty was not associated with receipt of surgery for stage I CRC. Despite the difference in rates of surgery (mean county-level rates were 0.24 for liver metastasectomy for CRLM and 0.75 for surgery for stage I CRC), the variance at the county-level for these 2 surgical procedures was similar (F370, 193 = 0.81; P = .08).Conclusions and RelevanceThe findings of this study suggest that higher poverty was associated with lower receipt of liver metastasectomy among US patients with CRLM. Surgery for a more common and less complex cancer comparator (ie, stage I CRC) was not observed to be associated with county-level poverty rates. However, county-level variation in surgical rates was similar for CRLM and stage I CRC. These findings further suggest that access to surgical care for complex gastrointestinal cancers such as CRLM may be partially influenced by where patients live.

Neighborhood deprivation is linked with inflammation, which may explain poorer health across populations. Behavioral risk factors are assumed to largely mediate these relationships, but few studies have examined this. We examined three neighborhood contextual factors that could exert direct effects on inflammation: (1) neighborhood socioeconomic status, (2) an index of concentration at extremes (that measures segregation), and (3) surrounding vegetation (greenness).Using blood samples and addresses collected from prospective cohorts of 7,930 male (1990-1994) and 16,183 female (1986-1990) health professionals with at least one inflammatory marker, we prospectively linked neighborhood contextual factors to inflammatory biomarkers (adiponectin, C-reactive protein, interleukin-6, soluble tumor necrosis factor receptor-2). Log-transformed, z-scaled component measures were used to calculate an inflammation score. Neighborhood socioeconomic status and index of concentration of extremes were obtained from the 1990 decennial census and linked to participant addresses. Surrounding greenness was assessed from satellite data and focal statistics were applied to generate exposures within 270 m and 1230 m of the participants' address. We fit multiple linear regression models adjusting for demographic, clinical, and behavioral risk factors.Higher neighborhood socioeconomic status was associated with lower inflammation score in women (β for interquartile range increase = -27.7%, 95% CI: -34.9%, -19.8%) and men (β = -21.2%, 95% CI: -31.0%, -10.1%). Similarly, participants in neighborhoods with higher concentrations of high-income households were associated with lower inflammation score in women (β = -27.8%, 95% CI: -35.8%, -18.7%) and men (β = -16.4%, 95% CI: -29.7%, -0.56%). Surrounding greenness within 270 m of each participant's address was associated with lower inflammation score in women (β = -18.9%, 95% CI: -28.9%, -7.4%) but not men. Results were robust to sensitivity analyses to assess unmeasured confounding and selection bias.Our findings support the hypothesis that adverse neighborhood environments may contribute to inflammation through pathways independent of behavioral risk factors, including psychosocial stress and toxic environments.

Systemic inflammation may serve as a biological mechanism linking air pollution to poor health but supporting evidence from studies of long-term pollutant exposure and inflammatory cytokines is inconsistent.We studied associations between multiple particulate matter (PM) and gaseous air pollutants and pro- and anti-inflammatory cytokines within two nationwide cohorts of men and women.Data were obtained from 16,151 women in the Nurses' Health Study and 7,930 men in the Health Professionals' Follow-up Study with at least one measure of circulating adiponectin, C-Reactive Protein (CRP), Interleukin-6 (IL-6) or soluble tumor necrosis-factor receptor-2 (sTNFR-2). Exposure to PM with aerodynamic diameter ≤2.5, 2.5-10, and ≤10 μm (PMIn adjusted models, we observed a 2.72% (95% CI: 0.43%, 5.95%), 3.11% (-0.12%, 6.45%), and 3.67% (0.19%, 7.26%) increase in CRP associated with a 10 μg/mAcross multiple long-term pollutant exposures and inflammatory markers, associations were generally weak. Focusing on specific pollutant-inflammatory mechanisms may clarify pathways.

Few sub-Saharan African studies have ascertained utilization for postmastectomy radiation (PMRT) for breast cancer, the second most common cancer among African women. We estimated PMRT utilization and identified predictors of PMRT receipt in Zimbabwe.Retrospective patient cohort included non-metastatic breast cancer patients treated from 2014 to 2019. PMRT eligibility was assigned per NCCN guidelines. Patients receiving chemotherapy for non-metastatic disease were also included. The primary endpoint was receipt of PMRT, defined as chest wall with/without regional nodal radiation. Predictors of receiving PMRT were identified using logistic regression. Model performance was evaluated using the c statistic and Hosmer-Lemeshow test for goodness-of-fit.201 women with localized disease and median follow-up of 11.4 months (IQR 3.3-17.9) were analyzed. PMRT was indicated in 177 women and utilized in 59(33.3%). Insurance coverage, clinical nodal involvement, higher grade, positive margins, and hormone therapy receipt were associated with higher odds of PMRT receipt. In adjusted models, no hormone therapy (aOR 0.12, 95% CI 0.043, 0.35) and missing grade (aOR 0.07, 95% CI 0.01, 0.38) were associated with lower odds of PMRT receipt. The resulting c statistic was 0.84, with Hosmer-Lemeshow p-value of 0.93 indicating good model fit.PMRT was utilized in 33% of those meeting NCCN criteria. Missing grade and no endocrine therapy receipt were associated with reduced likelihood of PMRT utilization. In addition to practice adjustments such as increasing hypofractionation and increasing patient access to standard oncologic testing at diagnosis could increase postmastectomy utilization.

Background Reducing disparities in men with prostate cancer (PCa) that may be caused by racial and socioeconomic differences is a major public health priority. Few reports have studied whether these disparities have changed over time. Methods Men diagnosed with PCa from January 1, 2000 to December 31, 2015 were identified from the Massachusetts and Pennsylvania cancer registries. All-cause mortality and PCa and cardiovascular cause-specific mortality were assessed. To estimate neighborhood socioeconomic position (nSEP), a summary score was generated using census tract-level measures of income, wealth, educational attainment, and racial and income segregation. Participants were grouped by diagnosis year (2000-2003, 2004-2007, 2008-2011, or 2012-2015), and changing trends in the mortality rate ratio by race and nSEP were estimated using covariate-adjusted Cox models with follow-up for up to 10 years, until death, or until censoring on January 1, 2018. Results There were 193,883 patients with PCa and 43,661 deaths over 1,404,131 person-years of follow-up. The Black-White adjusted hazard ratio (aHR) from 2000 to 2003 through 2012 to 2015 was stable for all-cause mortality (aHR, 1.14 to 0.97; P for heterogeneity = .42), decreased for PCa-specific mortality (aHR, 1.38 to 0.93; P for heterogeneity = .005), and increased for cardiovascular mortality (aHR, 1.09 to 1.28; P for heterogeneity = .034). The aHR comparing those in the lowest versus the highest nSEP quintile increased significantly for all-cause mortality (aHR, 1.54 to 1.79; P for heterogeneity = .008), but not for PCa-specific mortality (aHR, 1.60 to 1.72; P for heterogeneity = .40) or cardiovascular mortality (aHR, 1.72 to 1.89; P for heterogeneity = .085). Conclusions Although Black-White disparities in prostate mortality declined in Massachusetts and Pennsylvania over the study period, nSEP mortality disparity trends were stagnant or increased, warranting further attention. Lay summary Few reports have examined whether racial and socioeconomic disparities in prostate cancer mortality have widened or narrowed in recent years. Using data from 2 state registries (Massachusetts and Pennsylvania) with differing intensities of government-mandated health insurance, trends in racial and neighborhood socioeconomic disparities were studied among Black and White men diagnosed from 2000 to 2015. Overall, trends in racial disparities were stagnant for all-cause mortality, shrank for prostate mortality, and widened for cardiovascular mortality. Disparities associated with neighborhood socioeconomic status either were stagnant or widened across all mortality end points. In general, disparities were more pronounced in Pennsylvania than in Massachusetts.

BackgroundSouth Africa has the highest number of people living with HIV (PLWH) and one of the largest antiretroviral therapy (ART) programs globally. High rates of substance use comorbidity exist, including speculation of recreational ART use (i.e., mixing ART with other illicit drugs). Recreational ART use may affect viral load among PLWH due to ART nonadherence and/or viral resistance; however, prior quantitative research has not examined rates of recreational ART use, nor associations with HIV treatment outcomes longitudinally.MethodsData were drawn from a prospective, observational cohort study (n = 500) of ART-eligible adults recruited from two HIV voluntary counseling and testing centers in Cape Town, and Johannesburg, South Africa. Multiple logistic regression models assessed recreational ART use as a predictor of ART initiation over six months and viral load suppression over nine months, above and beyond other substance use (binge drinking and illicit drug use).ResultsApproximately 5% (n = 24) reported recreational ART use, which was less frequent in Cape Town compared to Johannesburg (AOR = 0.025; 95%CI: 0.003-0.19; p

6555 Background: Socioeconomic and racial disparities in prostate cancer (PCa) can be attributed to patient-level and physician-level factors. However, there is growing interest in investigating the role of the facility of care in driving cancer disparities. Therefore, we sought to examine receipt of guideline-concordant definitive treatment, time to treatment initiation (TTI), and survival for men with PCa receiving care at hospital systems serving health disparity populations (HSDPs). Methods: We conducted a retrospective analysis of the National Cancer Database (2004-2016) among men with intermediate-risk or high-risk PCa eligible for definitive treatment. The primary outcomes were receipt of definitive treatment and TTI within 90 days of diagnosis. The secondary outcome was survival. We defined HSDPs as minority-serving hospitals – facilities in the highest decile of proportion of Non-Hispanic Black (NHB) or Hispanic cancer patients – and/or high-burden safety-net hospitals – facilities in the highest quartile of proportion of underinsured patients. We used mixed-effect models with facility-level random intercept to compare outcomes between HSDPs and non-HSDPs among the entire cohort and among men who received definitive treatment. We evaluated interactions between HSDP status and race for each of the outcomes. Results: The cohort included 821,931 men with intermediate-risk or high-risk PCa. We included 968 non-HSDPs (72.2%) and 373 HSDPs (27.8%) facilities. Treatment at HSDPs was associated with lower odds of receipt of definitive treatment (aOR 0.64; 95% CI 0.57-0.71; p < 0.001), lower odds of TTI within 90 days of diagnosis (aOR 0.74; 95% CI 0.68-0.79; p < 0.001), and worse survival (aHR 1.05; 95% CI 1.02-1.09; p = 0.003). However, no difference was found in survival among patients who received definitive treatment. NHB men at HSDPs had also worse outcomes than NHB men treated at non-HSDPs as well as NHW men treated at HSDPs (Table). Conclusions: Patients treated at HSDPs were less likely to receive timely definitive treatment and had worse survival. NHB men have worse outcomes than NHW at HSDPs. NHB men with PCa remain largely disadvantaged since they are more likely to be treated at hospitals with worse outcomes and have worse outcomes than other patients at those same institutions. [Table: see text]

Background Massachusetts is a northeastern state with universally mandated health insurance since 2006. Although Black men have generally worse prostate cancer outcomes, emerging data suggest that they may experience equivalent outcomes within a fully insured system. In this setting, the authors analyzed treatments and outcomes of non-Hispanic White and Black men in Massachusetts. Methods White and Black men who were 20 years old or older and had been diagnosed with localized intermediate- or high-risk nonmetastatic prostate cancer in 2004-2015 were identified in the Massachusetts Cancer Registry. Adjusted logistic regression models were used to assess predictors of definitive therapy. Adjusted and unadjusted survival models compared cancer-specific mortality. Interaction terms were then used to assess whether the effect of race varied between counties. Results A total of 20,856 men were identified. Of these, 19,287 (92.5%) were White. There were significant county-level differences in the odds of receiving definitive therapy and survival. Survival was worse for those with high-risk cancer (adjusted hazard ratio [HR], 1.50; 95% CI, 1.4-1.60) and those with public insurance (adjusted HR for Medicaid, 1.69; 95% CI, 1.38-2.07; adjusted HR for Medicare, 1.2; 95% CI, 1.14-1.35). Black men were less likely to receive definitive therapy (adjusted odds ratio, 0.78; 95% CI, 0.74-0.83) but had a 17% lower cancer-specific mortality (adjusted HR, 0.83; 95% CI, 0.7-0.99). Conclusions Despite lower odds of definitive treatment, Black men experience decreased cancer-specific mortality in comparison with White men in Massachusetts. These data support the growing body of research showing that Black men may achieve outcomes equivalent to or even better than those of White men within the context of a well-insured population. Lay summary There is a growing body of evidence showing that the excess risk of death among Black men with prostate cancer may be caused by disparities in access to care, with few or no disparities seen in universally insured health systems such as the Veterans Affairs and US Military Health System. Therefore, the authors sought to assess racial disparities in prostate cancer in Massachusetts, which was the earliest US state to mandate universal insurance coverage (in 2006). Despite lower odds of definitive treatment, Black men with prostate cancer experience reduced cancer-specific mortality in comparison with White men in Massachusetts. These data support the growing body of research showing that Black men may achieve outcomes equivalent to or even better than those of White men within the context of a well-insured population.

BackgroundNeighborhood contextual factors are associated with racial disparities among men with prostate cancer (CaP), but studies often separately emphasize socioeconomic status or built environme...

Background Genetic ancestry, a correlate of self-identified race/ethnicity, could be associated with mortality risk, allowing for more targeted treatments for cancer and other chronic diseases. However, associations may be confounded by neighborhood socioeconomic status (nSES). We investigated whether African ancestry and nSES were independently associated with all-cause mortality in a cohort of African American trial participants. Methods We constructed a cohort of American-born participants of African descent from the Prostate, Lung, Colorectal and Ovarian screening trial. Participants were enrolled from 1993-1998 and followed through 2019 or until death, whichever came first. Genetic ancestry (% African) was estimated using a principal components analysis of genome-wide SNP data and validated against European, African, and Asian panels. A nSES index was estimated using principal component analysis of census tract measures of income, housing, and employment. Census tract was assessed in 2012 for residences of living participants. Last known address was assigned to participants who died prior to 2012. We assigned 2000 census data to those who died prior to 2010, and assigned 2006-2010 American Community Survey data to those who were alive after 2010. Hazard ratios for associations between these variables and all-cause mortality were estimated using sequentially adjusted Cox proportional hazards models with sociodemographic, behavioral, and neighborhood contextual covariates. We tested whether mortality associations with ancestry varied by nSES using multiplicative interaction terms. All tests were two-sided with alpha=0.05. Results Among 2239 African American participants, there were 901 deaths over 40,767 person-years of follow-up. Mean baseline age was 61.7, 45% were men, and the mean percentage of African ancestry was 74.3. In unadjusted models, a 10% increase in African ancestry was associated with a 7% higher rate of all-cause mortality (HR: 1.07, 95% CI: 1.02, 1.12), but this attenuated to the null after adjusting for covariates (aHR: 1.01, 95% CI: 0.96, 1.06). Participants in nSES Q5 had 45% lower rate of mortality compared to those in Q1 in unadjusted models (HR: 0.55, 95% CI: 0.44, 0.68, Ptrend Discussion Our findings suggest that nSES is a stronger independent correlate of mortality than genetic ancestry, which was only weakly associated with mortality after accounting for other factors. Larger studies with wider variability in African ancestry and geographic context are needed to confirm these findings. Citation Format: Hari S. Iyer, Scarlett L. Gomez, Iona Cheng, Timothy R. Rebbeck. Is genetic ancestry associated with mortality risk after accounting for neighborhood socioeconomic status? A study of African American men [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 785.

OBJECTIVE: Failure to initiate antiretroviral therapy (ART) and achieve virologic suppression are significant barriers to the United Nations 90–90–90 goals. Identifying resilience resources, or modifiable strength-based factors, among people living with HIV is critical for successful HIV treatment and prevention. DESIGN: Prospective cohort study. METHODS: From July 2014 to July 2015, 500 adults presenting for voluntary counseling and HIV testing who were diagnosed with HIV and were ART-eligible in South Africa (Soweto and Gugulethu) were enrolled and surveyed. Logistic regression models assessed resilience-related predictors of ART initiation within 6 months of voluntary counseling and HIV testing for HIV, and HIV-1 plasma RNA suppression within 9 months, adjusting for sociodemographic factors. RESULTS: Within 6 months, 62% initiated ART, and within 9 months, 25% had evidence of an undetectable HIV-1 plasma RNA (

Purpose Men in Botswana present with more advanced cancer than women, leading to poorer outcomes. We sought to explain sex-specific differences in time to and stage at treatment initiation. Methods Cancer patients who initiated oncology treatment between October 2010 and June 2017 were recruited at four oncology centers in Botswana. Primary outcomes were time from first visit with cancer symptom to treatment initiation, and advanced cancer (stage III/IV). Sociodemographic and clinical covariates were obtained retrospectively through interviews and medical record review. We used accelerated failure time and logistic models to estimate standardized sex differences in treatment initiation time and risk differences for presentation with advanced stage. Results were stratified by cancer type (breast, cervix, non-Hodgkin’s lymphoma, anogenital, head and neck, esophageal, other). Results 1886 participants (70% female) were included. After covariate adjustment, men experienced longer excess time from first presentation to treatment initiation (8.4 months) than women (7.0 months) for all cancers combined (1.4 months, 95% CI: 0.30, 2.5). In analysis stratified by cancer type, we only found evidence of a sex disparity (Men: 8.2; Women: 6.8 months) among patients with other, non-common cancers (1.4 months, 95% CI: 0.01, 2.8). Men experienced an increased risk of advanced stage (Men: 67%; Women: 60%; aRD: 6.7%, 95% CI: -1.7%, 15.1%) for all cancers combined, but this disparity was only statistically significant among patients with anogenital cancers (Men: 72%; Women: 50%; aRD: 22.0%, 95% CI: 0.5%, 43.5%). Conclusions Accounting for the types of cancers experienced by men and women strongly attenuated disparities in time to treatment initiation and stage. Higher incidence of rarer cancers among men could explain these disparities.

Doctoral students in high- and low-income countries pursuing careers in global health face gaps in their training that could be readily filled through structured peer-learning activities with students based at partnering institutions in complimentary settings. We share lessons learned from the Global Cohort of Doctoral Students, a community of doctoral students based at the Harvard T. H. Chan School of Public Health, Haramaya University. University of Gondar, University of Botswana, and University of Rwanda College of Medicine and Health Sciences. Students in the Global Cohort program engage in collaborative research, forums for constructive feedback, and professional development activities. We describe the motivation for the program, core activities, and early successes. This work was funded by the Rose Traveling Fellowship and Deborah Rose Service Learning Fellowship at the Harvard T. H. Chan School of Public Health. The funding sources had no role in the writing of the manuscript or decision to submit it for publication. Iyer, HS (corresponding author), Harvard TH Chan Sch Publ Hlth, Dept Epidemiol, Boston, MA 02115 USA. Hari_Iyer@dfci.harvard.edu

A health system improvement program combining facility readiness support, clinical training/mentoring, and improvement collaboratives increased quality improvement capacity, improved maternal and newborn quality of care, and reduced neonatal mortality. These results can be used to inform system improvement approach design to transform quality of care and outcomes for newborns., Key Findings A district-wide health system improvement program combining facility readiness support, clinical training/mentoring, and district-wide improvement collaboratives increased quality improvement capacity, improved maternal and newborn quality of care, and reduced neonatal mortality by approximately 35% overall and 49% among high-risk preterm/low birth weight infants.This improvement in mortality was not seen during the same time period in the rest of rural Rwanda. Key Implications Policy makers should consider adopting components of the All Babies Count program into the design of system improvement approaches to transform quality of care and outcomes for newborns.Embedding the design into existing health system structures could help structure improvement in other clinical domains., Introduction: Poor-quality care contributes to a significant portion of neonatal deaths globally. The All Babies Count (ABC) initiative was an 18-month district-wide approach designed to improve clinical and system performance across 2 rural Rwandan districts. Methods: This pre-post intervention study measured change in maternal and newborn health (MNH) quality of care and neonatal mortality. Data from the facility and community health management information system and newly introduced indicators were extracted from facility registers. Medians and interquartile ranges were calculated for the health facility to assess changes over time, and a mixed-effects logistic regression model was created for neonatal mortality. A difference-in-differences analysis was conducted to compare the change in district neonatal mortality with the rest of rural Rwanda. Results: Improvements were seen in multiple measures of facility readiness and MNH quality of care, including antenatal care coverage, preterm labor management, and postnatal care quality. District hospital case fatality decreased, with a statistically significant reduction in district neonatal mortality (odds ratio [OR]=0.54; 95% confidence interval [CI]=0.36, 0.83) and among preterm/low birth weight neonates (OR=0.47; 95% CI=0.25, 0.90). Neonatal mortality was reduced from 30.1 to 19.6 deaths/1,000 live births in the intervention districts and remained relatively stable in the rest of rural Rwanda (difference in differences −12.9). Conclusion: The ABC initiative contributed to improved MNH quality of care and outcomes in rural Rwanda. A combined clinical and health system improvement approach could be an effective strategy to improve quality and reduce neonatal mortality.

PURPOSE Increasing noncommunicable disease burden in sub-Saharan Africa requires the urgent scale-up of pathology and laboratory medicine (PALM) services. To identify service gaps at the district level, we studied geographic variation in the correlation between travel time to health facilities and population density. METHODS We linked geospatial data for Tanzania from multiple sources. Facility locations were extracted from a comprehensive facility list in Africa. Data on geographic factors, demographics, and roads were collected from government and nonprofit databases. We classified facilities assuming increasing PALM service readiness by level: dispensaries, health centers, district hospitals, and regional/referral hospitals. We input these data into the AccessMod 5 algorithm to estimate travel time across Tanzania with 1-km resolution for each PALM classification. We then calculated district-level averages of population and travel time for each PALM category. Associations between these variables were estimated using a bivariable local indicator of spatial autocorrelation, specifying immediate contiguity neighborhood definition. Spatial analysis was restricted to 172 contiguous districts (islands not included). Significance tests were two sided, with an α of .05. RESULTS Analysis included 5,342 dispensaries, 667 health centers, 185 district hospitals, and 34 regional/referral hospitals. Maps revealed clusters of estimated travel time in excess of 6 hours in less populated western and southern districts. More districts reported an average travel time of less than 1 hour to the nearest dispensary (69%) than to regional/referral hospitals (16%). Bivariable local indicators of spatial autocorrelation revealed few significant clusters of spatial correlations; however, significant correlations between low population density and longer travel times in neighboring districts were obtained for 13%, 16%, 15%, and 13% of districts for dispensaries, health centers, district hospitals, and regional/referral hospitals, respectively. CONCLUSION Limited variability of district-level spatial correlations suggests somewhat equitable geographic allocation of PALM services in Tanzania, with small areas of low population density and long travel times that demand additional intervention. Limitations include a lack of ascertainment of specific PALM services.

Supplemental Digital Content is available in the text., Background: Growing evidence suggests that neighborhood contextual environment could influence risk factors and, therefore, incidence of lethal prostate cancer. We studied the association between neighborhood greenness and lethal prostate cancer incidence and assessed mediation by vigorous physical activity. Methods: A total of 47,958 participants were followed in the Health Professionals Follow-up Study from 1986 to 2014. Neighborhood greenness exposure was estimated using normalized difference vegetation index (NDVI) with 1 km resolution, assigned to home or work addresses at start of follow-up. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) were estimated using sequentially adjusted Cox models with individual and contextual prostate cancer risk factors as covariates. Analyses were compared among those whose addresses were constant over follow-up and stratified by population density and address type. Results: We observed 898 cases over 1,054,743 person-years. An interquartile range increase in NDVI was associated with 5% lower rate of lethal prostate cancer (aHR = 0.95, 95% CI = 0.88, 1.03), with stronger associations in nonmovers (aHR = 0.92, 95% CI = 0.85, 1.01). Inverse associations were observed among men in high (aHR = 0.90, 95% CI = 0.82, 0.99) but not low (aHR = 1.11, 95% CI = 0.95, 1.29, Phet = 0.086) population density areas, and those reporting from work (aHR = 0.87, 95% CI = 0.75, 1.01) but not home (aHR = 1.04, 95% CI = 0.91, 1.17, Phet = 0.10) addresses. There was no evidence of mediation by vigorous physical activity. Conclusion: We report inverse associations between neighborhood greenness and lethal prostate cancer when restricting to nonmovers and in high population density areas. Replication could confirm findings and clarify mechanisms.

Background: Black men with prostate cancer (CaP) experience excess mortality compared with White men. Residential greenness, a health promoting contextual factor, could explain racial disparities in mortality among men with CaP. Methods: We identified Pennsylvania Cancer Registry cases diagnosed between January 2000 and December 2015. Totally, 128,568 participants were followed until death or 1 January 2018, whichever occurred first. Residential exposure at diagnosis was characterized using the Normalized Difference Vegetation Index (NDVI) with 250 m resolution. We estimated hazard ratios (HRs) using Cox models, adjusting for area-level socioeconomic status, geographic healthcare access, and segregation. To determine whether increasing residential greenness could reduce racial disparities, we compared standardized 10-year mortality Black-White risk differences under a hypothetical intervention fixing NDVI to the 75th percentile of NDVI experienced by White men. Results: We observed 29,978 deaths over 916,590 person-years. Comparing men in the highest to lowest NDVI quintile, all-cause (adjusted HR [aHR]: 0.88, 95% confidence interval [CI]: 0.84, 0.92, Ptrend < 0.0001), prostate-specific (aHR: 0.88, 95% CI: 0.80, 0.99, Ptrend= 0.0021), and cardiovascular-specific (aHR: 0.82, 95% CI: 0.74, 0.90, Ptrend < 0.0001) mortality were lower. Inverse associations between an interquartile range increase in NDVI and cardiovascular-specific mortality were observed in White (aHR: 0.90, 95% CI: 0.86, 0.93) but not Black men (aHR: 0.97, 95% CI: 0.89, 1.06; Phet = 0.067). Hypothetical interventions to increase NDVI led to nonsignificant reductions in all-cause (−5.3%) and prostate-specific (−23.2%), but not cardiovascular-specific mortality disparities (+50.5%). Discussion: Residential greenness was associated with lower mortality among men with CaP, but findings suggest that increasing residential greenness would have limited impact on racial disparities in mortality.