Michele Follen

Nativity disparities in late-stage diagnosis and cause-specific survival among Hispanic women with invasive cervical cancer: an analysis of Surveillance, Epidemiology, and End Results data

PurposeWhile cervical cancer screening and risk behaviors have been found to vary among US- and foreign-born Hispanic women, many cancer epidemiology studies have conceptualized Hispanics as a homogenous group. Here, we examine differences in cervical cancer stage at diagnosis and survival among Hispanic women by nativity.MethodsWe use data from the Surveillance, Epidemiology, and End Results program, 1998–2008. Nativity was based on place of birth and was categorized as US versus foreign born. Distant and regional tumors were classified as late stage, while local tumors were classified as early stage.ResultsForty-seven percent of cases of invasive cervical cancer among Hispanics were diagnosed at a late stage, and over half of invasive cervical cancer cases were among foreign-born women. Foreign-born Hispanic women were significantly more likely than US-born Hispanics to have late-stage diagnosis, after adjusting for age at diagnosis and tumor histology (adjusted odds rationxa0=xa01.09, p valuexa0=xa00.003). There was heterogeneity in the association between nativity and survival by stage at diagnosis. Among cases with early-stage diagnosis, survival was poorer among foreign-born versus US-born Hispanics after adjusting for age at diagnosis, histology, and cancer-directed therapy [adjusted hazard ratios (HR)xa0=xa01.31, p valuexa0=xa00.030]. However, among cases with late-stage diagnosis, survival was better among foreign-born Hispanics (adjusted HRxa0=xa00.81, p valuexa0<xa00.001).ConclusionsWe hypothesize that nativity differences in survival may be indicative of diverse risk, screening, and treatment profiles. Given such differences, it may be inappropriate to aggregate Hispanics as a single group for cervical cancer research.

Association of traffic-related hazardous air pollutants and cervical dysplasia in an urban multiethnic population: a cross-sectional study

BackgroundHuman papillomavirus (HPV) infection is a necessary cause in the development of cervical cancer; however, not all women infected with HPV develop cervical cancer indicating that other risk factors are involved. Our objective was to determine the association between exposure to ambient levels of common traffic-related air toxics and cervical dysplasia, a precursor lesion for cervical cancer.MethodsThe study sample consisted of women enrolled in a Phase II clinical trial to evaluate diagnostic techniques for cervical disease in Houston, Texas. The current assessment is a secondary data analysis in which cases were defined as women diagnosed with cervical dysplasia, while those without cervical dysplasia served as controls. Residential census tract-level estimates of ambient benzene, diesel particulate matter (DPM), and polycyclic aromatic hydrocarbons (PAHs) were used to assess exposure. Census tract-level pollutant estimates were obtained from the United States Environmental Protection Agency. Multivariable logistic regression was used to estimate prevalence odds ratios (aOR) and 95% confidence intervals (CI) adjusted for age, race/ethnicity, education, smoking status, and HPV status.ResultsWomen in the highest residential exposure categories for benzene and DPM had an increased prevalence of cervical dysplasia compared to the lowest exposure category (Benzene: aOR [95% CI] for high exposureu2009=u20091.97[1.07-3.62], very high exposureu2009=u20092.30[1.19-4.46]. DPM: aOR [95% CI] for high exposureu2009=u20092.83[1.55-5.16], very high exposureu2009=u20092.10[1.07-4.11]). Similarly, women with high residential exposure to PAHs had an increased prevalence of cervical dysplasia (aOR [95% CI]u2009=u20092.46[1.35-4.48]). The highest PAH exposure category was also positively associated with cervical dysplasia prevalence but was not statistically significant. Assessment of the combined effect of HAP exposure indicates that exposure to high levels of more than one HAP is positively associated with cervical dysplasia prevalence (p for trendu2009=u20090.004).ConclusionsTraffic-related HAPs, such as benzene, DPM, and PAHs, are not as well-regulated and monitored as criteria air pollutants (e.g., ozone), underscoring the need for studies evaluating the role of these toxicants on disease risk. Our results suggest that exposure to traffic-related air toxics may increase cervical dysplasia prevalence.

Nativity Differences in Behaviors Associated with High-Risk HPV Infection Among Hispanic Women in Houston, Texas, USA

While Hispanics in the U.S. are a population with significant within-group heterogeneity, epidemiologic studies often aggregate Hispanics into one homogenous group without considering differences by nativity. The objective of this study is to evaluate nativity differences in the risk behavior profile associated with prevalent high risk human papillomavirus (HR-HPV) among U.S.- and foreign-born Hispanic women. Using a clinical trial dataset, we compare risk behavior and HR-HPV infection patterns among U.S.- and foreign-born participants and assess factors associated with infection in each group. While the prevalence of HR-HPV infection was similar among U.S.- and foreign-born participants, U.S.-born cases had a higher HR-HPV risk profile. The similar prevalence of HR-HPV despite foreign-born women’s lower risk profile suggests a role for unmeasured risk factors among foreign-born Hispanics. More importantly, nativity differences in behavioral risk factors associated with HR-HPV suggest the need to further research cervical cancer risk factors among disaggregated Hispanic subgroups.

Fluorescence Visualization and Imaging: A Tool for Improving Patient Outcomes for Oral and (Hopefully) Other Cancers

Improved detection and delineation of pre-invasive and invasive cancers can be effected through recording the changes in optical properties detected by auto-fluorescence imaging, resulting in statistically improved patient outcomes (oral) and improved lesion detection (cervix).

Preinvasive Disease of the Lower Genital Tract

In conclusion, preinvasive disease of the lower genital tract is much more common than often assumed. It affects women of all socioeconomic levels and age groups. All women deserve to have regular genital screening. Although dysplasia is sexually transmitted, it need not and should not be a stigma, since between 50% and 85% of the sexually active population have at one point in their lives been exposed to HPV. It is important to remember that exposure does not mean disease and that dysplasia can regress. This is often true in immunocompromised patients, whose dysplasia will regress once their immune status improves.

Multiple Roles for Autofluorescence (AF) Visualization, Multispectral AF and Reflectance Imaging and AF-OCT for Early Cancer Detection and Management

Fluorescence visualization in a multi-center oral cancer surgical resection guidance trial, multispectral fluorescence/reflectance imaging for cervical screening and multimodal OCT-AF for biopsy guidance of nodules detected by LDCT lung cancer screening are being clinically evaluated.

Abstract A75: Nativity disparities in late-stage diagnosis and cause-specific survival among Hispanic women with invasive cervical cancer: An analysis of Surveillance, Epidemiology, and End Results data.

Introduction: While cervical cancer screening and risk behaviors have been found to vary among U.S.- and foreign-born Hispanic women, many cancer epidemiology studies conceptualize Hispanics as a homogenous group. Here we examine differences in cervical cancer stage at diagnosis and survival among Hispanic women by nativity. Methods: We used data from the Surveillance, Epidemiology, and End Results (SEER) program. Cases were Hispanic women diagnosed with primary invasive cervical cancer between 1988 and 2008. Nativity was based on place of birth and was categorized as U.S.- versus foreign-born. Missing nativity values were imputed using a multiple imputation by logistic regression strategy that has high sensitivity (0.95) and specificity (0.90) for detecting foreign-born status. Distant and regional tumors were classified as late-stage, while local tumors were classified as early-stage. Multivariable logistic regression was used to assess the association between late-stage diagnosis and nativity. Multivariable Cox regression was used to assess the association between cause-specific survival and nativity. Results: Forty seven percent of cases of invasive cervical cancer among Hispanics were diagnosed at a late stage and over half of invasive cervical cancer cases were among foreign-born women. Foreign-born Hispanic women were significantly more likely than U.S.-born Hispanics to have late-stage diagnosis, after adjusting for age at diagnosis and tumor histology (adjusted odds ratio= 1.09, p-value = 0.003). There was heterogeneity in the association between nativity and survival by stage at diagnosis. Among cases with early-stage diagnosis, survival was poorer among foreign-born versus U.S.-born Hispanics after adjusting for age at diagnosis, histology, and cancer-directed therapy (adjusted HR = 1.31, p-value = 0.030). However, among cases with late-stage diagnosis, survival was poorer among U.S.-born Hispanics (adjusted HR = 0.81, p-value Conclusions: The increased prevalence of late-stage diagnosis among foreign-born Hispanic women is likely a reflection of the lower screening rates in this population relative to those born in the U.S. While we expected the increased prevalence of late-stage diagnosis to result in decreased survival among foreign-born cases, we found significant heterogeneity in the association between nativity and survival by stage at diagnosis. Specifically, when cervical cancer is diagnosed at a late stage, foreign-born Hispanic women have improved survival over U.S.-born women. However, for early-stage diagnoses, our results suggest decreased survival among foreign-born versus U.S.-born Hispanics. We hypothesize that nativity differences in survival may be indicative of diverse risk, screening, and treatment profiles. Given such differences, it may be inappropriate to aggregate Hispanics as a single group for cervical cancer research. Citation Format: Jane R. Montealegre, Renke Zhou, E. Susan Amirian, Michele Follen, Michael E. Scheurer. Nativity disparities in late-stage diagnosis and cause-specific survival among Hispanic women with invasive cervical cancer: An analysis of Surveillance, Epidemiology, and End Results data. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A75.

Abstract A09: Uncovering nativity disparities in cancer patterns: A multiple imputation strategy to handle missing nativity data in the SEER database.

Introduction: The study of the effects of immigration on cancer patterns has become increasingly important for health disparities research in the U.S. While data on place of birth are routinely collected in the participating Surveillance, Epidemiology, and End Results (SEER) registries, such data are missing for a large proportion of cases. Furthermore, the distribution of missing nativity data is non-random, and thus cannot be managed with simple strategies such as list-wise deletion. Here we present a multiple imputation (MI) strategy that uses variables in the SEER database to impute nativity status for Hispanic patients diagnosed with invasive cervix (CC), prostate (PC), and colorectal cancer (CRC) between 1988 and 2009. We focus on Hispanic patients, as they represent the largest immigrant group in the U.S. Methods: We used the SAS MI procedure to generate nativity values (U.S.- vs. foreign-born) by the logistic regression imputation method. Among those with known nativity status, a model was fitted for nativity using a priori-defined parameters that were clinically-relevant or significantly associated with nativity status. Parameters included age, stage at diagnosis, receipt of cancer-directed surgery and/or radiation, SEER site, and Hispanic origin. To impute missing nativity, a new regression model was simulated in 20 iterations using the posterior predictive distribution of parameters based on the fitted regression coefficients. The imputation strategy was validated in a random sample of 20% of the observed data with known nativity status. Results: Nativity was missing for 31%, 51%, and 37% of CC, PC, and CRC cases, respectively. The imputation strategy performed best for CC and PC. For these cancers, the imputation strategy correctly classified nativity for 93% of cases. The sensitivity and specificity for detecting foreign-born status was high (0.95 and 0.90, respectively, for CC and 0.94 and 0.90, respectively, for PC). For both cancers, there was very good agreement between the true and imputed values (kappa=0.83 and 0.85). While there was high sensitivity, specificity, and agreement for CRC (0.87, 0.91, 0.78, respectively), the imputation strategy misclassified nativity for 11% of cases. Conclusion: MI by logistic regression performed well for imputing nativity status for CC, PC, and CRC cases, with sensitivity ≥ 0.87 and specificity ≥ 0.90 for detecting foreign-born status, with higher sensitivity among CC and PC cases (≥ 0.94). The misclassification error was less than 10% for CC and PC and was only slightly higher for CRC. Another proposed strategy, which imputes nativity based on date of receipt of a social security number (SSN), has a sensitivity of 0.81 and specificity of 0.80 for detecting foreign-born status among Asians with invasive breast cancer. While we did not evaluate the same population, our data suggest that the proposed MI by logistic regression strategy may more accurately impute nativity status among the high proportion of SEER cases missing these data. Additionally, the strategy uses variables available in the SEER database and is thus significantly less labor-intensive than the SSN method, as SSN is not reported in SEER. Use of the MI strategy will allow researchers to disaggregate analyses by nativity and uncover important nativity disparities in regard to cancer diagnosis, treatment, and survival. Citation Format: Jane R. Montealegre, Renke Zhou, E. Susan Amirian, Michele Follen, Michael E. Scheurer. Uncovering nativity disparities in cancer patterns: A multiple imputation strategy to handle missing nativity data in the SEER database. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A09.