Edgar Munoz

Navigating Latinas with breast screen abnormalities to diagnosis: The Six Cities Study

Breast cancer is the leading cause of cancer‐related deaths in Latinas, chiefly because of later diagnosis. The time from screening to diagnosis is critical to optimizing cancer care, yet the efficacy of navigation in reducing it is insufficiently documented. Here, the authors evaluate a culturally sensitive patient navigation program to reduce the time to diagnosis and increase the proportions of women diagnosed within 30 days and 60 days.

Incidence and risk factors for hepatocellular carcinoma in Texas Latinos: implications for prevention research.

Background Hepatocellular carcinoma (HCC) is increasing in the U.S. despite a decline in cancer overall. Latinos have higher rates of HCC than the general population according to the Surveillance, Epidemiology, and End Results (SEER) Program. Not included in SEER, Texas Latinos make up one-fifth of the U.S. Latino population. To determine whether HCC incidence differs among U.S. and Texas Latinos, this descriptive study compares HCC incidence from 1995 through 2006 among three Latino populations: U.S. SEER, Texas overall and a South Texas subset. To identify lines of prevention research, we compare prevalence of known HCC risk factors among these Latino groups. Methods Data were collected from the U.S. SEER Program, Texas Cancer Registry and Texas Department of State Health Services (TDSHS). Annual age-specific and age-adjusted HCC incidence rates, annual percent changes (APCs) and 95% confidence intervals were calculated as well as prevalence of obesity, diabetes, heavy alcohol use and cigarette smoking. Results Of the three Latino groups compared, South Texas Latinos had the highest age-adjusted HCC incidence rates and SEER Latinos had the lowest (10.6/100,000 (10.1–11.1) and 7.5/100,000 (7.2–7.7), respectively). HCC incidence significantly increased over time (APCs>0) among Latinos in all three geographic groups. Between 1995 and 2006, there was an increase in obesity among all three populations, and obesity was highest among South Texas Latinos. Diabetes increased among U.S. Latinos, and Latino women in South Texas had significantly higher diabetes prevalence than U.S. Latino women. Cigarette smoking and heavy alcohol use were similar among groups. Conclusions The incidence of HCC among Latinos in South Texas is higher than elsewhere in the United States. Higher rates of HCC among Texas and South Texas Latinos may be associated with greater prevalence of obesity and diabetes, risk factors for HCC that are amenable to intervention.

Reducing time-to-treatment in underserved Latinas with breast cancer: The Six Cities Study

The interaction of clinical and patient‐level challenges following a breast cancer diagnosis can be a significant source of health care disparities. Failure to address specific cultural features that create or exacerbate barriers can lead to less‐than optimal navigation results, specifically in Hispanic/Latino women.

Time to definitive diagnosis of breast cancer in Latina and non-Hispanic white women: the six cities study

Time delay after an abnormal screening mammogram may have a critical impact on tumor size, stage at diagnosis, treatment, prognosis, and survival of subsequent breast cancer. This study was undertaken to evaluate disparities between Latina and non-Hispanic white (NHW) women in time to definitive diagnosis of breast cancer after an abnormal screening mammogram, as well as factors contributing to such disparities.As part of the activities of the National Cancer Institute (NCI)-funded Redes En Acción research network, clinical records of 186 Latinas and 74 NHWs who received abnormal screening mammogram results were reviewed to determine the time to obtain a definitive diagnosis. Data was obtained from participating clinics in six U.S. cities and included demographics, clinical history, and mammogram characteristics. Kaplan-Meier estimates and Cox proportional hazards models were used to test differences in median time to definitive diagnosis by ethnicity after adjusting for clinic site, demographics, and clinical characteristics.Time-to-event analysis showed that Latinas took 2.2 times longer to reach 50% definitively diagnosed with breast cancer relative to NHWs, and three times longer to reach 80% diagnosed (p=0.001). Latinas’ median time to definitive diagnosis was 60 days compared to 27 for NHWs, a 59% gap in diagnosis rates (adjusted Hazard Ratio [aHR] = 1.59, 95% CI = 1.09, 2.31; p=0.015). BI-RADS-4/5 women’s diagnosis rate was more than twice that of BI-RADS-3 (aHR = 2.11, 95% CI = 1.18, 3.78; p=0.011).Disparities in time between receipt of abnormal screening result and definitive diagnosis adversely affect Latinas compared to NHWs, and remain significant after adjusting for demographic and clinical variables. With cancer now the leading cause of mortality among Latinos, a greater need exists for ethnically and culturally appropriate interventions like patient navigation to facilitate Latinas’ successful entry into, and progression through, the cancer care system.

Incidence of hepatocellular carcinoma in Texas Latinos, 1995-2010: an update.

Background A previous study showed Hepatocellular Carcinoma (HCC) rates to be higher among Latinos in Texas and highest among South Texas Latinos compared to other non-Hispanic whites (NHW) and other Latinos in the United States (U.S.). We used more recent data to assess trends in HCC among Texas Latinos and to reassess the elevated HCC incidence rate in Texas Latinos. Methods We used data from the U.S. SEER Program and the Texas Cancer Registry to calculate annual and 3-year moving average age-specific and age-adjusted HCC incidence rates, annual percent changes (APCs), and their corresponding 95% confidence intervals for Latinos and NHW in the U.S., Texas and South Texas. Results Texas Latino male and female incidence rates were 3.1 and 4.0 times higher than their NHW counterparts in SEER regions. Latino males and females in South Texas had the highest rates of HCC incidence overall; rate ratios were 3.6 and 4.2 among South Texas Latino males and females compared to SEER NHW counterparts. There are statistically significant increases in HCC incidence rates in all groups (Texas and South Texas Latinos and NHW groups) and across all age groups. The elevated HCC rates in Texas Latinos are consistent over the 1995–2010 period. Conclusions The incidence of HCC among Latinos in South Texas remains higher than elsewhere in the U.S. and warrants closer investigation of potential risk factors related to prevailing conditions unique to the population including higher obesity and diabetes rates, environmental, cultural and socioeconomic factors and possibly genetic predisposition.

Lifestyle and Clinical Correlates of Hepatocellular Carcinoma in South Texas: A Matched Case-control Study

Accepted Manuscript Lifestyle and clinical correlates of hepatocellular carcinoma in South Texas: a matched case-control study Amelie G. Ramirez, Edgar Munoz, Dorothy Long Parma, Joel E. Michalek, Alan E.C. Holden, Timothy D. Phillips, Bradley H. Pollock PII: DOI: Reference: S1542-3565(17)30322-1 10.1016/j.cgh.2017.03.022 YJCGH 55166 To appear in: Clinical Gastroenterology and Hepatology Accepted Date: 18 March 2017 Please cite this article as: Ramirez AG, Munoz E, Parma DL, Michalek JE, Holden AEC, Phillips TD, Pollock BH, Lifestyle and clinical correlates of hepatocellular carcinoma in South Texas: a matched case-control study, Clinical Gastroenterology and Hepatology (2017), doi: 10.1016/j.cgh.2017.03.022. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Empowering Latina breast cancer patients to make informed decisions about clinical trials: a pilot study

Minority representation in clinical trials is vital for researchers to assess differential effects in outcomes of therapies on biological and genetic characteristics among groups. This study assessed the effect of Choices, a bilingual multi-component intervention, on perceived understanding of clinical trials, agreement with stages of decision readiness and consideration of clinical trials as a treatment option, among Latina breast cancer patients. This randomized controlled pilot study compared Choices with a control condition providing general clinical trial information to eligible patients. Seventy-seven Latina breast cancer patients were randomly assigned to either Choices (n = 38) or the control (n = 39). Choices included three components: an educational interactive video, a low-literacy booklet, and care coordination by patient navigation (i.e., educational and psychosocial support, coordinating appointments, translating, interacting with the medical team). Choices was more effective than the control in improving perceived understanding of clinical trials (p = .033) and increasing consideration of clinical trials as a treatment option (p = .008). Additionally, intervention participants showed significant changes between baseline and post-intervention on agreement with stages of decision readiness statements (p < .002) than control participants (p > .05); the percentage of intervention women in agreement with preparation to action statements increased from 52.8% at baseline to 86.1% at post-intervention, and those in agreement with ready to action stages rose from 50.0% to 88.9%. Computer-based videos and care coordination provided by patient navigation-specifically tailored to Latinos-are effective strategies to successfully address awareness, and improved decision-making skills to make informed decisions about clinical trial participation.

Satisfaction with cancer care, self-efficacy, and health-related quality of life in Latino cancer survivors

The objective of the current study was to examine how modifiable factors such as satisfaction with cancer care and self‐efficacy impact health‐related quality of life (HRQOL) among Latino cancer survivors.

An anti-inflammatory dietary intervention to reduce breast cancer recurrence risk: Study design and baseline data

U.S. breast cancer survivors (BCSs) are expected to increase to 4 million in the next 5-10years. Cancer recurrence risk is highest among obese survivors. Inflammatory (Pro-I) biomarkers including C-reactive protein (CRP), Interleukins -3, -6, and -8 (IL-3, IL-6, IL-8), and Tumor Necrosis Factor (TNF)-α have been associated with cancer recurrence risk. Nutritional interventions aimed at reducing inflammation (INF) may contribute to reduced cancer recurrence risk, but studies have been limited to animal models. The goals of this one-year, culinary-based, pilot intervention were to: 1) decrease Pro-I biomarkers and increase anti-inflammatory (AI) cytokine, IL-10, by promoting AI food incorporation into BCS diets; and 2) examine intervention effects on cancer risk factors including body mass index (BMI) and circulating adipose stromal cells (ASCs). A total of 153 BCSs were recruited. Overweight and obese women aged 18 or older were randomized into Intervention (IG; n=76) and Control (CG; n=77) groups. CG received monthly nutritional brochures from the American Institute for Cancer Research. IG attended 6 monthly workshops (lectures on AI topics and chef-prepared food demonstrations), and received monthly newsletters and telephone calls incorporating Motivational Interviewing. At baseline, 6- and 12-month assessments, fasting serum was assayed for Pro-I/AI marker and ASC levels. Using R and Stata version 14 (Stata Corp, 2015), no significant differences were found between groups on baseline demographic variables. Correlations between serum cytokine levels, BMI, % body fat, ASCs, and self-reported variables are discussed.

Helicobacter Pylori Infection in Texas Hispanic and Non-Hispanic White Men: Implications for Gastric Cancer Risk Disparities

Chronic Helicobacter pylori (H. pylori) infection is a major gastric adenocarcinoma (GA) risk factor. GA disproportionately affects U.S. Hispanics compared with non-Hispanic Whites (NHWs). Since H. pylori infection studies in Hispanics are few, infection rates in Hispanic and NHW men in Bexar County were compared, and relationships with ethnicity and obesity examined. Age- and zip code-matched participants from a community-dwelling cohort were randomly selected. Sera from 284 men were analyzed by enzyme immunoassay for H. pylori antibodies. Adjusted risk ratio estimation for matched data was conducted to identify differences. Hispanics had a markedly higher prevalence of infection (30.3%) than NHWs (9.2%). Matched risk ratio (mRR) analyses revealed a strong association between H. pylori seropositivity and Hispanic ethnicity (mRR = 3.31; 95% CI [1.91, 5.73], adjusted by BMI, smoking status, and family history of cancer (mRR range = 3.28-3.89). BMI mRRs (range = 1.19-1.22) were significant in all models. In this cohort, Hispanic men had higher H. pylori infection rates than NHWs, and parallel the disproportionately higher rates of GA; obesity contributes to this higher prevalence. Future studies should address country of origin, acculturation, and other factors influencing obesity to further elucidate risk of GA in Hispanic populations.