Keith Naylor

A Resident-Led Quality Improvement Initiative to Improve Obesity Screening

Instruction on quality improvement (QI) methods is required as part of residency education; however, there is limited evidence regarding whether internal medicine residents can improve patient care using these methods. Because obesity screening is not done routinely in clinical practice, residents aimed to improve screening using QI techniques. Residents streamlined body mass index (BMI) documentation, created educational materials about obesity, and launched an obesity screening QI initiative in a residency clinic. Residents designed plan-do-study-act cycles focused on increasing awareness and maintaining improvements in screening over a 1-year period. Documentation rates were collected at baseline, 2 weeks, 6 months, and 1 year post-intervention. At 1 year, obesity treatment rates also were collected. BMI documentation rates after 1 year were higher than baseline (43% vs 4%, P < .0001). In obese patients, BMI documentation was associated with lifestyle counseling (34% vs 14%, P < .01). An internal medicine resident-led QI project targeting obesity can improve screening.

Evaluating screening colonoscopy quality in an uninsured urban population following patient navigation

Patient navigation (PN) increases screening colonoscopy completion in minority and uninsured populations. However, colonoscopy quality is under-reported in the setting of PN and quality indicators have often failed to meet benchmark standards. This study investigated screening colonoscopy quality indicators after year-one of a PN initiative targeting the medically uninsured. This was a retrospective analysis of 296 outpatient screening colonoscopies. Patients were 45 to 75 years of age with no history of bowel cancer, inflammatory bowel disease, or colorectal surgery. The screening colonoscopy quality indicators: adenoma detection rate (ADR), cecal intubation rate (CIR), and bowel preparation quality were compared in 89 uninsured Federally Qualified Health Center (FQHC) patients who received PN and 207 University Hospital patients who received usual care. The FQHC PN and University Hospital cohorts were similar in female sex (69% vs. 70%; p = 0.861) and African American race (61% vs. 61%; p = 0.920). The FQHC PN cohort was younger (57 years vs. 60 years; p < 0.001). There was no difference in ADR (33% vs. 32%; p = 0.971) or CIR (96% vs. 95%; p = 0.900) comparing the FQHC PN and University Hospital cohorts. The FQHC PN patients had a greater likelihood of an optimal bowel preparation on multivariate logistic regression (odds ratio 4.17; 95% confidence interval 1.07 to 16.20). Uninsured FQHC patients who received PN were observed to have intra-procedure quality indicators that exceeded bench-mark standards for high-quality screening colonoscopy and were equivalent to those observed in an insured University Hospital patient population.

ID: 89: RESIDENTIAL SEGREGATION AND SPATIAL CLUSTERING OF COLONOSCOPY RESOURCES WITHIN THE CITY OF CHICAGO

Background In Illinois for the year 2015, colorectal cancer (CRC) is projected to cause 2,090 deaths, making it the leading cause of non-tobacco related cancer mortality. African American or black Illinois residents have an approximately 7% greater incidence and a 30% higher mortality rate when compared to white residents. Guideline consistent CRC screening is known to increase early diagnosis and reduce cancer related death. Colonoscopy is the most commonly performed screening modality and diagnostic colonoscopy is required for follow up of abnormal non-invasive screening tests. The City of Chicago is home to 2.7 million residents, of whom 31% are non-Hispanic white and 37% are non-Hispanic black. Chicago is known to have significant residential racial segregation with 69% of the total non-Hispanic black population living within communities located south of Roosevelt Avenue, on Chicagos south side. Relatively homogenous minority communities, such as Chicagos south side, are prone to the development of healthcare inequities that may result in the development of healthcare disparities. Objective The objective of this study was to use geographic information systems and geospatial analysis to investigate the spatial distribution of healthcare facilities that perform colonoscopy within the City of Chicago. Methods Population demographic data by census block was obtained from the U.S. Census Bureau, 2009–2013 American Community Survey 5-Year Estimates. The locations of facilities performing colonoscopy procedures were identified through internet search; review of Illinois Department of Public Health hospital listings; and ambulatory surgery center (ASC) accreditation listings. Each facility was contacted by phone to confirm performance of on-site colonoscopy and to obtain the number of on-site endoscopy procedure rooms. The addresses of facilities were geocoded using GPS Visualizer. City of Chicago census tract boundaries were mapped using U.S. Census Bureau Tiger Line shapefiles. Maps were created and geospatial analysis was performed using Esri ArcMap version 10.2. Results Within the City of Chicago, a total of 41 facilities were identified that perform on-site colonoscopy. Of the 41 facilities, 26 were hospital-based and 15 were ASC-based. 10 of 26 (38%) Hospital-based colonoscopy sites and 3 of 15 (20%) ASC-based colonoscopy sites were located on Chicagos south side. There were a total of 134 endoscopy procedure rooms reported across the 41 facilities. 30 of the 134 (22%) endoscopy procedure rooms were located on Chicagos south side. Spatial overlap was observed between areas with clustering of endoscopy procedure rooms and census tracts with greater than 80% non-Hispanic white race. Conclusions There is an unequal distribution of colonoscopy facilities and endoscopy procedure rooms across the City of Chicago with geographic clustering of colonoscopy infrastructure observed on Chicagos north side within census tracts comprised of greater than 80% non-Hispanic white race. Census tracts containing high proportions of non-Hispanic black race were clustered on Chicagos south side within areas with a relative paucity of colonoscopy infrastructure. The spatial clustering of colonoscopy procedure rooms represents a healthcare resource inequity that may contribute to the persistence of disparities in CRC related mortality among non-Hispanic black communities in Chicago.

Abstract C79: Use of social network analysis to examine racial disparities in screening colonoscopy referral

Background: In Illinois for the year 2016, colorectal cancer (CRC) is projected to cause 2,030 deaths, making it the leading cause of non-tobacco related cancer mortality. African American (AA) Illinois residents have an approximately 7% greater incidence and a 30% higher mortality rate when compared to white residents. Guideline consistent routine screening is known to reduce death related to CRC. Screening colonoscopy is the most commonly performed CRC screening test. However, African Americans are known to have lower rates of both screening and diagnostic colonoscopy completion compared to whites. Chicago9s South Side includes 34 of the city9s 77 recognized community areas and is home to a combined population of more than 800,000 residents, of whom greater than 75% are African American. The contiguous communities that make up the South Side cover approximately 60% of Chicago9s land area. There are 41 facilities throughout Chicago that perform outpatient screening colonoscopy, of with 13 (32%) are located on Chicago9s South Side. The University of Chicago Medical Center (UCMC) is the largest healthcare provider on the South Side and represents 30% of the local capacity for screening colonoscopy services. Objective: The objectives of this study were to use social network analysis (SNA) to explore the structure of the screening colonoscopy referral network utilized by community-based primary care physicians for colonoscopies that were completed at the UCMC during calendar years 2013 and 2014. Methods: A retrospective chart review was performed for all individuals who completed a screening colonoscopy during years 2013 and 2014 at the UCMC. Screening colonoscopies were identified using CPT codes: G0105 and G0121. For each screening colonoscopy procedure, the referring PCP and colonoscopy provider (colonoscopist) were identified from screening colonoscopy procedure reports. A referral-tie was assigned between a PCP and colonoscopist, if the PCP9s name was listed as the referring physician on the procedure report and the colonoscopist9s name was listed as the performing physician. SNA was performed using UCINet for windows and network mapping was performed using Netdraw. Descriptive statistics were performed using STATA 13.1. Results: 405 outpatient screening colonoscopies were completed during the study interval (mean age, 58.4 ± 10 years; 62% female; 40% AA, 44% white). 60% of patients were privately insured, 31% Medicare, and 10% were public insurance or uninsured. A total of 261 individual community PCPs were identified as referring physicians, with a mean frequency of referrals/PCP of 1.18 ± 0.85 and a range of 1 referral up to 25 referrals. Following a SNA of PCP to colonoscopist referral ties, the resulting referral network exhibited a core/periphery structure. 13 PCPs (5%) belonged to the network core and 248 (95%) belonged to the network periphery. PCPs who belonged to the network core had a greater mean referral rate compared to the periphery (3.77 vs. 1.05 referrals; p Conclusions: The screening colonoscopy referral network at the UCMC exhibits a core/periphery structure. Amongst AA patients, screening colonoscopy referrals were disproportionately clustered within the network core amongst a highly inter-connected group of community-based PCPs. This variation in referral patterns indicates that patient characteristics, such as race, may affect the structure of the screening colonoscopy referral network. These variations in the structure of the referral network may impact PCP referral behavior and subsequently patient recommendation for and utilization of CRC screening. Screening colonoscopy referral networks may represent an under-recognized determinant of racial disparities in CRC screening. Citation Format: Keith B. Naylor, Olufemi Kassim, Karen E. Kim, John Schneider. Use of social network analysis to examine racial disparities in screening colonoscopy referral. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C79.

Addressing Colorectal Cancer Disparities Among African American Men Beyond Traditional Practice-Based Settings

An introduction is presented in which the author discusses an article in the journal about the MISTER B Trial involving a patient navigator intervention and the goal of increasing colorectal cancer screening rates among African American men, and it mentions barbershops in New Yor, New York.

Abstract B80: Use of geographic information systems to visualize the screening colonoscopy referral network of the University of Chicago Medical Center

Background: In Illinois for the year 2015, colorectal cancer (CRC) is projected to cause 2,090 deaths, making it the leading cause of non-tobacco related cancer mortality. African American Illinois residents have an approximately 7% greater incidence and a 30% higher mortality rate when compared to white residents. Guideline consistent routine screening is known to reduce death due to CRC. Screening colonoscopy is the most commonly performed CRC screening test. However, African Americans are known to have low rates of screening colonoscopy and diagnostic colonoscopy completion compared to whites. Chicago9s South Side includes 34 of the city9s 77 recognized community areas and is home to a combined population of more than 800,000 residents, of whom greater than 75% are African American. The contiguous communities that make up the South Side cover approximately 60% of Chicago9s land area. There are 41 facilities throughout Chicago that perform outpatient screening colonoscopy, of with 13 (32%) are located on Chicago9s South Side. The University of Chicago Medical Center (UCMC) is the largest healthcare provider on the South Side and represents 30% of the local capacity for screening colonoscopy services. Objectives: The objectives of this study were to use geographic information systems (GIS) and geospatial analysis to explore the distribution of patients who completed a screening colonoscopy at the UCMC during calendar year 2014 and to visualize the associated physician referral network. Methods: A retrospective chart review was performed for all individuals who completed a screening colonoscopy during calendar year 2014 at UCMC. Screening colonoscopies were identified through CPT codes: G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) and G0121 (Colorectal cancer screening; colonoscopy on individual no meeting criteria for high risk). Mapping and spatial analysis were performed using ArcMap version 10.1. Descriptive statistics were performed using STATA 13.1. Results: During calendar year 2014, 1632 outpatient screening colonoscopies were completed on 1592 patients (mean age, 59 years; 36% male; 49% AA, 29% white). Of the 1,632 screening colonoscopy procedures, 1,017 (62%) were completed on patients with ZIP codes located within Chicago9s South Side (mean age, 59 years; 33% male; 63%AA, 17% white). Of the 1,017 colonoscopies performed on South Side residents, 102 (10%) were completed as a result of a referral from an external non-UCMC affiliated physician and 915 (90%) were completed as a result of a referral from a UCMC affiliated physician. Conclusions: The majority of patients who completed a screening colonoscopy at UCMC during calendar year 2014 were residents of the South Side. However, only 10% of the screening colonoscopies completed on South Side residents were related to referrals obtained from non-UCMC affiliated physicians. These results may indicate the presence of a weak referral network between the largest local healthcare provider, UCMC, and local South Side physicians for screening colonoscopy. Citation Format: Keith B. Naylor, Olufemi Kassim, Karen E. Kim. Use of geographic information systems to visualize the screening colonoscopy referral network of the University of Chicago Medical Center. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B80.

Abstract B77: Knowledge of screening colonoscopy results and follow up recommendations among navigated patients

Purpose: Patient navigation (PN) programs have increased colorectal screening (CRS) rates in uninsured patient populations. The University of Chicago (UC) partnered with the American Cancer Society (ACS) to develop a CRS initiative at the UC to improve CRS outcomes. Unlike many PN programs, the UC ACS program solely utilized community-placed navigators. Along with addressing barriers, navigators provided one-to-one patient education, pre-procedure instructions, scheduling, appointment and bowel prep reminders. Prior to their screening exam, none of the UC navigated patients had ever received care within the UC network. The efficacy of CRS programs depends on patient awareness of results and follow-up recommendations. Currently, the only data on awareness of colonoscopy surveillance recommendations is limited to a predominantly Caucasian insured population with known adenomas. Yet it is unclear what a predominately African- American navigated patient population knows about their colonoscopy results and follow-up recommendations. Therefore, our objectives were to determine UC navigated patients9 knowledge of colonoscopy results and follow-up recommendations compared to non-navigated patients. Methods: Between Jan. to June 2014, 194 patients obtained a screening colonoscopy with one of the physicians, who were also providers for the UC ACS program. Most, 143 patients met inclusion criteria (navigated patients: initial screening colonoscopy, asymptomatic, uninsured, and age > 45 / non-navigated patients: screening colonoscopy, asymptomatic, insured, and age >45). A brief semi-structured telephone survey was utilized to assess patient9s beliefs about CRS, knowledge of their results, and follow-up recommendations. All patients were surveyed between 4-25 weeks post colonoscopy. Statistical analysis included chi-square and logistical regression (p Results: Of the 143 patients meeting inclusion criteria, 97 patients were reached by phone (68%). Only 1 patient refused to complete the survey providing a 98% response rate. Of the 25 ACS patients meeting inclusion criteria, 18 patients completed the survey compared to 78/119 non-navigated patients. Around 90% of the navigated patient population identified as African American (AA), compared to 64% of the non-navigated patients. There were no statistically significance differences between navigated and non-navigated patients for sex, ethnicity, race, and education level. Non-navigated patients were more likely to report a higher income and having a primary care physician (p Approximately 40% of navigated patients said “no” or “unsure” when asked if colon cancer could be prevented compared to 35% of non-navigated patients (p = 0.37). 100% of the navigated patients correctly reported their colonoscopy findings compared to 79.5% of the non-navigated patients (p=0.04). ACS navigation was the only significant variable found on logistical regression. In contrast, only 44.4% of the navigated patients reported the correct follow-up recommendations compared to 70.5% of non-navigated patients (p=0.04). Logistical regression analysis showed that level of patient education (OR=.32; p=0.02) and having an adenoma (OR=4.1; p=0.02) correlated with knowledge of follow-up recommendations. Conclusions: Despite education and access to care, our study highlights the need for continued education around CRS, since less that 40% of both navigated and non-navigated patients reported screening as a colon cancer preventative procedure. Although navigated patients were more aware of their colonoscopy results than non-navigated patients, this patient population was less aware of their follow-up recommendations. Future studies need to focus on minority populations in order to ensure equal benefit from CRS and to reduce disparities from this often-preventable cancer. Citation Format: Cassandra D.L Fritz, Keith Naylor, Karen Kim. Knowledge of screening colonoscopy results and follow up recommendations among navigated patients. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B77.

Abstract A52: Use of geographic information systems to identify geographic clustering of screening colonoscopy resources with the city of Chicago

Background: In Illinois for the year 2014, colorectal cancer (CRC) is projected to cause 2,190 deaths, making it the leading cause of non-tobacco related cancer mortality. African American Illinois residents have an approximately 7% greater incidence and a 30% higher mortality rate when compared to white residents. Guideline consistent routine screening is known to reduce death due to CRC. However, according to the Centers for Disease Control, Illinois currently ranks in the lowest quartile amongst states for up-to-date screening of adults age 50 to 75 years. Chicago9s South Side includes 34 of the city9s 77 recognized community areas and is home to a combined population of more than 800,000 residents, of whom greater than 75% are African American. The contiguous communities that make up the South Side cover approximately 60% of Chicago9s land area. Relatively homogenous minority communities, such as Chicago9s South Side, are prone to the development of healthcare inequities that may result in the development of healthcare disparities. Objective: The objectives of this study are to use geographic information systems (GIS) and spatial analysis techniques to investigate geographic variations in the distribution of colonoscopy sites within the City of Chicago. Methods: CRC incidence data (1986-2010) by Zip code was obtained from the Illinois State Cancer Registry. Population characteristics by ZIP code (sex, median age, total population, median household income, racial/ethnic makeup) were obtained from the 2010 Census and Demographic Profile. The locations of colonoscopy sites were identified through a combination of internet search; review of Gastroenterology organization membership rosters; and expert opinion. Colonoscopy site addresses were geocoded using GPS Visualizer. Mapping and testing for spatial autocorrelation (global and local) were performed using STATA 13. Results: 55 colonoscopy sites were identified within the City of Chicago. 15 of 55 (27%) colonoscopy sites were located within Chicago9s South Side. The geocoded address of each colonoscopy site was mapped to assess resource distribution. Testing for local spatial autocorrelation of colonoscopy sites by ZIP code identified significant local autocorrelation centered at Zip code 60613 (Moran9s Ii = 131.399, p = 0.046), located within Chicago9s North Side. Testing for global autocorrelation using population characteristics and CRC incidence data by ZIP code revealed evidence of significant global autocorrelation for areas with increased median household income (Moran9s I = 0.532, p Conclusions: There is unequal distribution of colonoscopy sites across the City of Chicago with 15 sites (27%) located on Chicago9s South Side. Testing for local spatial autocorrelation was significant for clustering of colonoscopy sites near the Zip code 60613, located on Chicago9s North Side. Significant global autocorrelation was found related to increasing median household income. The clustering of colonoscopy sites near ZIP codes with increased median household incomes represents a healthcare resource inequity that may lead to persistence of disparities in CRC screening among low-income, medically underserved, and/or minority communities. Citation Format: Keith B. Naylor, Karen E. Kim. Use of geographic information systems to identify geographic clustering of screening colonoscopy resources with the city of Chicago. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr A52.

Abstract A55: Can opposites attract? Developing a multi-institutional, interprofessional, cancer-related disparities curriculum for health professional students

Background: The city of Chicago continues to be plagued with cancer-related health and healthcare disparities. Both the University of Chicago Pritzker School of Medicine (PSOM) and Chicago State University (CSU) are located on Chicago9s Southside. CSU is a designated minority serving institution with a student body composed of 80% African American, 7% Hispanic/Latino, 1% Asian/Pacific Islander and 8% Caucasian; while PSOM9s student body is 47% Caucasian, 27% Asian/Pacific Islander, 13% African American, and 5% Hispanic/Latino. The Chicago Southside Cancer Disparities Initiative (SSCDI) is a partnership between the University of Chicago Comprehensive Cancer Center and CSU for the development of cancer education, training, and outreach. A primary aim of the SSCDI is to create an interprofessional cancer disparities curriculum for PSOM and CSU9s MPH students. Multiple factors are known to impact the formation and effectiveness of interprofessional collaborations including: institutional commitment; administrative support; institutional familiarity; shared goals; as well as sociodemographic factors. The objective of this study is to identify potential facilitators and barriers to the implementation of an interprofessional cancer-related disparities curriculum for both PSOM and CSU MPH students. Methods: Two town hall meetings were hosted at CSU and PSOM to present SSCDI goals, assess interest, and to solicit feedback from their respective faculty and students. Pre and post surveys were administered. Quantitative data was compared using Chi-square and qualitative data was coded to identify overarching themes. Results: 15 students and 16 faculty/health professionals completed the survey at PSOM; 8 students and 5 faculty/health professionals completed the survey at CSU. PSOM students were less likely to: be familiar with (12.5% vs. 73.3%, p=0.005) or to have visited (25% vs. 100%, p Conclusion: Our study identified key barriers and facilitators to the successful implementation of an interprofessional cancer disparities education at PSOM and CSU. Barriers included: (1) Lack of institutional familiarity, (2) Disparate student views regarding cancer related disparities education, and (3) Administrative/Structural challenges. Facilitators included: (1) Shared commitment to the Southside Community and (2) Complementary strengths/weaknesses in research infrastructure and community engagement. These findings serve as the basis of targeted interventions to increase faculty and student participation and preparedness, including joint community grand rounds, campus tours, research seminars, and social functions. We believe this iterative approach to curriculum design will improve student interaction and the co-learning environment. Citation Format: Keith B. Naylor, Fritz Cassandra, Helen Lam, Lisa Hinton, Yashika Watkins, Thomas Britt, Karen Kim. Can opposites attract? Developing a multi-institutional, interprofessional, cancer-related disparities curriculum for health professional students. [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 A55. doi:10.1158/1538-7755.DISP13-A55

Abstract A49: From community-based participatory research to community-based participatory education: The implementation of community participation in cancer disparities curriculum development

Background: The Chicago South Side Cancer Disparities Initiative is a partnership between the University of Chicago and Chicago State University with the primary aim of developing a multi-faceted approach to cancer disparities education, training, and outreach. The current literature on direct community participation in curriculum development is minimal. Therefore, we developed a community-based participatory education (CPBE) model to provide community appropriate solutions to reduce local cancer disparities. In this study, CBPE was applied to develop a cancer-related health disparities curriculum for medical and public health students. Objective: To use CBPE to develop a community-oriented cancer disparities curriculum that is specifically designed to assess the following content areas: 1) Are local communities interested in participating in curriculum design? 2) What should we teach students about disparities in their community? 3) How should community members be involved in the design and implementation of the curriculum? 4) What topics do community members think we should address? Methods: A community town hall format was used to seek answers to the four content areas. Eighty-six community members from 19 different zip code areas of Chicago attended the town hall meeting. Participants were 14% men, 86% women with an average age of 51.7 years. An electronic Audience Response System (ARS) was used for the anonymous rapid collection of community response data. Using a mixed method approach, 4 quantitative and 3 qualitative survey questions were analyzed. Results: 80% of community members heard of health disparities, 93% thought community members should be involved in cancer disparities curriculum development, 85% want to be involved in designing a cancer disparities curriculum and 81% reported an interest in taking the cancer disparities course. Categorical themes were derived from the analysis of open-ended survey responses to potential curricular skills, knowledge and content. General questions followed by categorical themes are listed below: 1) What should students know to successfully interact with your community? a) Importance of Community Empowerment b) Root Causes and Solutions of Disparities c) Knowledge specific to local community needs 2) How should community members be involved in curriculum design? a) Student experiences in community engagement b) Community perspectives on experience with disparities 3) What are the topics the disparities curriculum should address? a) Root cause of Cancer Disparities b) Solutions-“Prescription for Change” c) Development of diverse relationships and interactions Conclusion: The goal of Community Based Participatory Education (CBPE) is to directly involve community in health professional curriculum development. In this study, we outline the active role of the local community in creating an integrated cancer disparities curriculum for both health professionals and the community. The multiple themes identified will be used to prioritize and develop the curriculum. CBPE will provide the infrastructure for community appropriate solutions to reduce the number of health disparities plaguing the south-side Chicago community. Citation Format: Cassandra D.L Fritz, Keith Naylor, Yashika Watkins, Thomas Britt, Lisa Hinton, Jennifer Jones, Gina Curry, Helen Lam, Karen Kim. From community-based participatory research to community-based participatory education: The implementation of community participation in cancer disparities curriculum development. [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 A49. doi:10.1158/1538-7755.DISP13-A49