Karen J. Ortiz-Ortiz

Esophageal cancer incidence rates by histological type and overall: Puerto Rico versus the United States Surveillance, Epidemiology, and End Results population, 1992-2005.

OBJECTIVE The aim of our study was to compare the age-standardized incidence of esophageal cancer (EC) in Puerto Ricans (PRs) with that for non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic (USH), groups in the United States (US) as reported by the Surveillance, Epidemiology, and End Results program for the 1992-2005 period. METHODS We computed the age-standardized and age-specific incidence (per 100,000 individuals) of EC during 1992-2005 using the World Standard Population as reference. The percent changes for age-standardized rates (ASR), from 1992-1996 to 2001-2005, were calculated. The relative risks (RR) and the standardized rate ratios (SRR) were estimated, along with 95% confidence intervals (CIs). RESULTS The ASR of adenocarcinomas (AC) showed increases for most racial/ethnic groups from 1992-1996 to 2001-2005. All racial/ethnic groups showed ASR reductions for squamous cell carcinomas (SCC). For both sexes, PRs had lower AC incidences than NHW and USH but higher than NHB. For those younger than 80 years of age, PR men showed higher SCC incidences than NHW but lower than NHB (P < 0.05). The incidence of SCC was about two times higher in PR men than USH men (SRR: 2.16; 95% CI = 1.65-2.88). Among women, the RR for SCC increased with age when comparing PRs to groups in the US. CONCLUSION Incidence disparities were observed between PRs and other racial/ethnic groups in the US. These differences and trends may reflect lifestyles of each racial/ethnic group. Further studies are warranted to explain these disparities.

Effects of Type of Health Insurance Coverage on Colorectal Cancer Survival in Puerto Rico: A Population-Based Study

Colorectal cancer represents a major health problem and an important economic burden in Puerto Rico. In the 1990s, the Commonwealth of Puerto Rico implemented a health care reform through the privatization of the public health system. The goal was to ensure access to health services, eliminate disparities for medically indigent citizens and provide special coverage for high-risk conditions such as cancer. This study estimates the 5-year relative survival rate of colorectal cancer and the relative excess risk of death in Puerto Rico for 2004–2005, by type of health insurance coverage; Government Health Plan vs. Non-Government Health Plan. Colorectal cancer in advanced stages was more common in Government Health Plan patients compared with Non-Government Health Plan patients (44.29% vs. 40.24 had regional extent and 13.58% versus 10.42% had distant involvement, respectively). Government Health Plan patients in the 50–64 (RR = 6.59; CI: 2.85–15.24) and ≥65 (RR = 2.4; CI: 1.72–4.04) age-groups had the greater excess risk of death compared with Non-Government Health Plan patients. Further studies evaluating the interplay of access to health services and the barriers affecting the Government Health Plan population are warranted.

Anal cancer trends in Puerto Rico from 1985 to 2005: the potential impact of the AIDS epidemic.

Dear Editor: Anogenital carcinomas are an uncommon malignancy in Puerto Rico (PR), but its incidence is increasing. In the United States (US), incidence rates of anal squamous cell carcinoma (SCC) from 2004 to 2008 were higher for females (1.8 per 100,000) than for men (1.2 per 100,000).1 As in the US, in PR, age-standardized (US 2000 population) incidence rates are also higher for women than for men (1.55 vs. 1.04 per 100,000). Approximately 84% of anal carcinomas are caused by human papilloma virus (HPV), mostly by oncogenic HPV types 16 and 18.2 Other anal cancer risk factors include history of multiple sexual partners, being a man having sex with men (MSM), receptive anal intercourse, a history of anogenital warts, other anogenital cancers (in women) or sexually transmitted infections (such as HIV), immunosuppression, and current smoking.3–5 A study in the US showed that the progressive increase in male anal cancer rates between 1980–2005 was strongly influenced by the effect of HIV-infected cancer cases, although HIV had little impact on trends among women.6 PR is among the top ten US States and territories with the highest cumulative number of AIDS cases.7 Meanwhile, since 2009, cancer is the leading death cause among the Hispanic/Latinos in US8 Given the limited amount of data for PR on the burden of the HIV epidemic on anal cancer occurrence, we aimed to describe the proportion of anal cancer cases in PR among persons (15+years) living with AIDS (PWA) and the impact of PWA status on anal cancer incidence trends from 1985 to 2005, by sex and age. The PR Central Cancer Registry (PRCCR) and the PR AIDS Surveillance Program databases, both CDC-funded population-based registries, were linked using a probabilistic linkage algorithm with Link Plus v.2.0 software (Release 2.0, CDC. Atlanta, GA). Anal cancers were limited to those invasive primary cancers diagnosed between 1985–2005, and 3 months after an AIDS diagnosis (to establish a risk measure). Anal cancers were defined using the International Classification of Diseases for Oncology, 3rd edition (ICD-O-3), topography codes C210-212, 218 (Anus, Anal Canal, and Anorectum), and excluding hematologic malignancies and Kaposi sarcoma.9 The number of anal cancer cases in the general population, and by PWA status, was summed in categories defined by age (15–19, 20–49, 50–69, and ≥70 years), sex, and histologic subtype [squamous cell carcinoma (SCC), adenocarcinoma, cloacogenic/basaloid, carcinoma NOS, other]. We estimated the following general population incidence rates stratified by age and sex, overall, and excluding PWA. Incidence rates were standardized to the 2000 U.S. population and were calculated per 100,000 persons. Temporal trends were estimated in a log-linear model using Joinpoint (version 4.0.1).10 Annual percent change was defined as 100 * [exp(β)−1], where β is the slope of the trend provided by Joinpoint.10 STATA System release 11.0 (STATA Corp, College Station, Texas) was used for the statistical analysis. The study was approved by the Institutional Review Board of the University of PR Medical Sciences Campus. From 1985 through 2005, a total of 736 cases of anal cancer were diagnosed in PR. Of those, the most common histologic type was SCC (54.2%), followed by cloacogenic/basaloid tumors (20.1%). Most cases (46.88%) occurred among adults aged 50–69 years and a higher proportion of anal cancer cases were females (70.8%). Nonetheless, the proportion of anal cancer cases being PWA was higher among males (n=22, 11.4%) than in females (n=4, 0.77%), and was also higher in the 20–49 year age group (n=20, 20.2%) than in the 50–69 year age-group (n=6, 1.77%) (Table 1). All anal cancer cases among male PWA were in the 20–49 and 50–69 age groups, representing 37% (17/46) and 4.8% (5/105), respectively, of all anal cancer cases in those age groups. In women, the same pattern was observed, with 5.7% (3/53) and 0.4% (n=1/240) of anal cancer cases in those age groups being women PWA (data not shown). Regarding anal cancer incidence trends, in men, incidence increased significantly (p 0.05). In women, anal cancer incidence increased with an APC of 0.97 when PWA cases were considered; whereas the increase was only of 0.85 when these were excluded. Nonetheless, none of the increases in women were statistically significant (p>0.05) (Fig. 1). Meanwhile, among women younger than 50 years, anal cancer incidence increased significantly (p 0.05). On the other hand, in women aged 50 years or older the increase was not statistically significant either when PWA cases were considered or not. In the case of men, the APCs could not be calculated because of small numbers (data not shown). FIG. 1. Age-adjusted incidence rates of anal cancer in Puerto Rico, 1985–2005. Adjusted to the US population; p<0.05. Table 1. Characteristics and Proportion of Anal Cancer Cases in the General Population of Puerto Rico (1985–2005), By People with AIDS (PWA) Statusa Our findings indicate that from 1985 and 2005, increasing trends of anal cancer in men in PR were influenced by the HIV/AIDS epidemic. In women, this pattern was only significant among younger women (<50 years). Our results are similar with the US trends,6 where the HIV epidemic seems to be a stronger predictor of anal cancer occurrence in men than in women. Literature suggests that primary prevention with HPV vaccination11,12 and possibly secondary prevention with anal cytology and high-resolution anoscopy, followed by treatment of anal high-grade squamous intraepithelial lesions, can help in the prevention of anal cancer.9 Our study is limited in statistical power, given the low incidence of PWA/anal cancer cases. In addition, our results are dependent on not having biases and secular trends in the AIDS ascertainment of anal cancer cases; we expect this possibility to be low, given the matching performed of the HIV/AIDS and Cancer Registry databases. Despite these limitations, our results support the need for primary and secondary preventive efforts among PWA, to minimize anal cancer risk in these groups. Future research should assess other factors associated to anal cancer occurrence in this population, particularly among women, as HIV/AIDS does not seem to be a strong predictor of anal cancer occurrence among them. Given that data for this analysis was only available until 2005, future research should contrast our results with trends after this study period, when more potent ART regimens were standard. The effectiveness of anal Pap testing in the prevention of anal malignancies should be assessed. Also, methods to enhance prevention and early detection of anal cancer by using simple screening and molecular methods should be further explored and developed.13,14

Modelling the effects of quadrivalent Human Papillomavirus (HPV) vaccination in Puerto Rico

Background No study has estimated the potential impact of Human Papillomavirus (HPV) vaccination in Puerto Rico, a population with considerable burden of HPV-related morbidities. We evaluated the health and economic impacts of implementing a vaccination strategy for females and males in Puerto Rico, with the quadrivalent HPV (HPV4) vaccine, under different vaccination scenarios. Methods We adapted a mathematical model which estimates the direct and indirect health benefits and costs of HPV4 vaccination in a dynamic population. The model compared three vaccination scenarios against screening only (no-vaccination) for three doses of HPV4 vaccine among individuals aged 11–15 years in Puerto Rico: 1) 34% for females and 13% for males (34%F/13%M), 2) 50% for females and 40% for males (50%F/40%M), and 3) 80% for female and 64% for male (80%F/64%M). Data specific to Puerto Rico was used. When not available, values from the United States were used. Input data consisted of demographic, behavioral, epidemiological, screening, and economic parameters. Results The model predicted decreases in: 1) HPV infection prevalence for females and males, 2) cervical intraepithelial neoplasia and cervical cancer incidence for females, 3) genital warts incidence for females and males, and 4) cervical cancer deaths among females, when various vaccination program scenarios were considered. In addition, when the vaccination percentage was increased in every scenario, the reduction was greater and began earlier. The analysis also evidenced an incremental cost effectiveness ratio (ICER) of

Emergency Presentation and Short-Term Survival Among Patients With Colorectal Cancer Enrolled in the Government Health Plan of Puerto Rico:

1,964 per quality–adjusted life year gained for the 80%F/64%M uptake scenario. Conclusions HPV vaccine can prove its cost effectiveness and substantially reduce the burden and costs associated to various HPV-related conditions when targeted to the adequate population together with an organized HPV vaccination program.

Correction: Modelling the effects of quadrivalent Human Papillomavirus (HPV) vaccination in Puerto Rico

Objective: In this study, we examine factors associated with the use of the emergency room (ER) as an entry point into the health-care system to initiate a cancer diagnosis among Puerto Rico’s Government Health Plan (GHP) patients and compare the 1-year survival of GHP patients that initiated cancer diagnosis in the emergency room (ER) presentation with those that initiated the diagnosis in a physician’s office. Methods: Data for patients with colorectal cancer (CRC) aged 50 to 64 years and diagnosed in 2012 were obtained from the Puerto Rico Central Cancer Registry and linked to the Puerto Rico Health Insurance Administration database (n = 190). Crude odds ratio, adjusted odds ratio, and their 95% confidence intervals were reported. We used the Kaplan-Meier method to generate survival curves. Multivariate Cox regression analysis was performed to evaluate the association between ER presentation and 1-year cause-specific survival. Results: We found that 37.37% of the study population had an ER presentation. Male patients had a higher occurrence of having an ER presentation (66.20%), while 76.06% of the patients with an ER presentation were diagnosed in late stage. Emergency room presentation was a highly predictive factor for cancer mortality in the year following the diagnosis. These patients had between 3.99 to 4.24 times higher mortality risk than non-ER presentation patients (P < .05). Conclusion: Late presentation for CRC diagnosis through an ER visit is a significant concern that influences negatively on the patient’s outcome. Efforts at increasing primary care visits and routine screening tests among GHP beneficiaries could improve survival.

Use of adjuvant chemotherapy in patients with stage III colon cancer in Puerto Rico: A population-based study

[This corrects the article DOI: 10.1371/journal.pone.0184540.].

Abstract B16: Cancer survivorship prevalence: Descriptive analysis of cancer survivors in Puerto Rico

Objective This study aims to examine factors associated with the use of adjuvant chemotherapy and the use of oxaliplatin after curative resection in stage III colon cancer patients and assesses the effect of their use in three-year survival. Methods This retrospective cohort study was conducted using Puerto Rico Central Cancer Registry-Health Insurance Linkage Database. The study cohort consisted of stage III colon cancer patients with a curative surgery in the period 2008–2012. Multivariate logistic regression was used to estimate adjusted odds ratios. Kaplan-Meier methods and Cox proportional hazards models were used to assess the association between adjuvant chemotherapy and oxaliplatin use and overall survival and risk of death, respectively. Results Overall, 75% of the study population received adjuvant chemotherapy during the study period. Factors statistically associated with receiving adjuvant chemotherapy within four months after resection included being married (adjusted odds ratio [AOR] 1.64; 95% CI 1.18–2.28; p = 0.003), and being enrolled in Medicare (AOR 1.68; 95% CI: 1.03–2.75; p = 0.039) or Medicaid and Medicare dual eligible (AOR 1.66; 95% CI: 1.06–2.60; p = 0.028). However, patients aged ≥70 years were less likely to receive adjuvant chemotherapy (AOR 0.22; 95%CI 0.14–0.36; p<0.001). Discussion We observed a significant reduction in mortality in adjuvant chemotherapy treated patients. Similarly, patients <70 years treated with oxaliplatin had significantly lower risk of death than those who did not, although for patients ≥70 years no statistical significance was achieved. Future studies should assess effective interventions to reduce barriers to access guideline-based recommended colon cancer treatment.

Abstract A76: Cervical cancer survival in Puerto Rico: Disparities by health care coverage

Objective: Statistics about cancer survivorship are inexistent for the Puerto Rican population. With this study we intend to address the first objective of the Puerto Rico Cancer Control Plan 2008-2012 of increasing the knowledge and awareness of survivorship among the Puerto Rican community. Thus, this study aimed to estimate the number of cancer survivors living with a history of a primary malignant tumor in Puerto Rico (PR) as of January 1, 2011, through a secondary data analysis of the Puerto Rico Central Cancer Registry and assess cancer survivorship prevalence of the five most incident cancers in Puerto Rico (breast, prostate, colon and rectum, lung and bronchus, and thyroid). Methods: The study population consisted of people in Puerto Rico living with a cancer diagnosis as of January 1, 2011, as documented in the Puerto Rico Central Cancer Registry. We calculated the limited-duration prevalence, which represents the proportion of people alive on a certain day that had a diagnosis of the disease, within 5 years (2005-2010) and with 23 years (1987-2010). Using the limited duration prevalence statistics from 1987-2011, we also calculated the complete prevalence, which represents the proportion of people alive on a certain day that previously had a diagnosis of the disease, regardless of how long ago the diagnosis was made. The limited-duration prevalence statistics were calculated using the Surveillance Epidemiology and End Results (SEER) Stat software and were later imported to SEER9s Complete Prevalence (ComPrev) software to calculate the complete prevalence. Statistics were calculated overall and by sex, age, period of diagnosis and cancer type. Results: For the complete prevalence, we estimated that 61,928 people in Puerto Rico were living with cancer as of January 1, 2011. Of these, 30,108 are men, 31,820 were women and 37,520 were over 65 years of age or older. For the limited-duration prevalence (2005-2010), we estimated that there were 29,057 cancer survivors in Puerto Rico: 16,131 were men, 12,926 were women and 15,922 were over 65 years of age or older. Results show that the prevalence of cancer survivors in Puerto Rico is higher for prostate (n=18,874) and breast cancer (n=13,736), followed by colorectal cancer (n=7,431), lung and bronchus (n=5,115) and thyroid (n=775) cancer. The prevalence of colon and rectum cancer was similar in both genders (n=3,443 were men and n=3,321 were women). However, the prevalence of lung and bronchus cancer was higher in men (n=403 men vs. n=310 women) and the prevalence of thyroid cancer was higher in females (n=3,367 women vs. n=627 men). Discussion: Similar to the US, most cancer survivors in PR are breast and prostate cancer survivors, as well as persons aged 65 years of age or older. Nonetheless, the proportion of cancer survivors in Puerto Rico (1.6%) is smaller when compared to the US population (4.4%). The findings in this report have important implications for public health practice. As cancer survivorship issues are being recognized, it is our goal to support public health9s efforts of improving the lives of cancer survivors, by increasing knowledge on survivorship in the Puerto Rican community. Cancer survivors have particular needs that should be addressed by the public health system. Information generated by this study is important for the development of research, outreach and intervention priorities in this population. Citation Format: Ana Patricia Ortiz-Martinez, Aixa M. Perez-Caraballo, Keyla Gonzalez-Lorenzo, Coral Cotto-Negron, Hilmaris Centeno, Crisanta Serrano-Collazo, Mitchelle Flores-Febo, Carlos Torres, Naydi Perez, Karen Ortiz-Ortiz. Cancer survivorship prevalence: Descriptive analysis of cancer survivors in Puerto Rico. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B16. doi:10.1158/1538-7755.DISP13-B16

Abstract B82: Health disparities of esophageal cancer by histological type in Puerto Rico: 2000–2004

Background: Studies have demonstrated that early diagnosis and receiving appropriate treatment may greatly increase the chances of survival of cancer patients. Although sociodemographic factors and the type of insurance status have been shown to be associated to the patient9s survival, fewer studies have considered the joint effects of these variables on disease outcomes, particularly among Hispanics. Studies have shown that access to health insurance influences the quality of the health-care received. To ensure access to health and to eliminate disparities in medical care, the government of Puerto Rico (PR) implemented during the 19909s a Health Care Reform. The PR Government Health Care (GHC) program is available for medically indigent citizens and it covers approximately 40% of the Puerto Rican population. Objective: This study aimed to describe the 3-year relative survival of cervical cancer in PR and evaluate the effect of the type of health insurance coverage (GHC vs. Non-GHC) on patient9s survival. Methods: Women with a diagnosis of cervical cancer reported to the Puerto Rico Central Cancer Registry database from 2004 to 2005 were linked with health insurance claims data from the GHC from the same time period, to identify GHC patients (61.6%) and those without GHC coverage (38.4%). The maximum relative survival ratio was compared by health insurance groups. A Poisson regression model was used to assess relative excess risks of death. Results: In the period 2004–2005, 333 out of the 344 (96.8%) primary cases of invasive cervical cancer reported among residents of PR were eligible for analysis. A higher than expected percent of the cases had GHC (62%) as compared to the general population in PR (40%). The higher percent of cases were among women 35–49 years-old (36%). When the effect of Health Care Plan was analyzed, the overall 3-year relative survival was 65.7% for GHC women and 78.9% for Non-GHC women. Consistent with previous studies, 3-year relative survival decreased with more advanced disease stage: 82% at localized, 62% at regional and 29% at distant. Survival was also lower among cases with GHC (77% at localized, 54% at regional and 25% at distant) than among those with Non-GHC (88% at localized, 78% at regional and 35% at distant), at all cancer stages. Analyses of the excess of risk showed that the GHC patients had a 2.1 (p=0.004) increased risk of death than Non-GHC patients, after adjusting for age and stage. Conclusions: Three-year relative survival is lower among women in PR with cervical cancer who have GHC as compared to their counterparts. This study shows disparities related to health care coverage among a United States (US) Hispanic population living outside the US that warrants further research. This study will help to formulate strategies to improve cervical cancer survival and to reduce inequalities in cancer care. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A76.