e18639 Background: Lung cancer is the second most common cancer and the leading cause of cancer deaths in both sex in the United States (US). Prostate cancer is the most common in men, while in women being breast cancer. America’s Health Rankings (AHR) is a comprehensive assessment of the nation's health on a state-by-state basis to determine state health rankings annually. We aimed to evaluate the association, which has not been investigated, between state-level health disparity as measured by AHR and lung, breast, and prostate cancer incidence and mortality in the US. Methods: We examined lung, breast and prostate cancer incidence and mortality data for 2015-2019 from the United States Cancer Statistics (USCS) database provided by the Centers for Disease Control and Prevention (CDC). Overall state health rankings were obtained from AHR and calculated by an equation using weighted measures in five different categories: 25% Behaviors, 22.5% Community & Environment, 12.5% Policy, 15% Clinical Care, and 25% Outcomes. We extracted 2015-2019 AHR data and further classified state health rankings into quartiles (1st [the healthiest] = rank 1 to 13; 4th [the least healthy] = rank 38 to 50). Associations of cancer incidence and mortality with overall state health rankings were analyzed by negative binomial regressions. Results: From 2015 to 2019, age-adjusted incidence rate per 100,000 population for lung, breast, and prostate cancer were 56.3, 128.0 and 109.8, respectively. Age-adjusted mortality rate per 100,000 population for lung, breast, and prostate cancer were 36.7, 19.9 and 18.9, respectively. Among 50 states we included for analysis, AHR indicated that Hawaii was the healthiest state (No.1) whereas Mississippi was the least healthy state (No. 50) for overall health rankings. States in the 4th quartile of health ranking were significantly associated with greater lung cancer incidence (Rate Ratio [RR]: 1.34 [95% CI, 1.18-1.52]) and mortality (1.50 [1.32-1.71]) than those in the 1st quartile. This was pronounced for age < 65 (Incidence [I]: 1.63 [1.36-1.96]; Mortality [M]: 1.93 [1.51-2.48]), Male (I: 1.48 [1.30-1.67]); M: 1.66 [1.47-1.87]), and Black (I: 1.43 [1.22-1.66]; M: 1.54 [1.32-1.79]). Black women living in states with worse health rankings had higher relative risks of breast cancer incidence (1.14 [1.03-1.26]) and mortality (1.27 [1.05-1.53]). There was no significant association between state health rankings and prostate cancer incidence and mortality in the US. Conclusions: There are significant differences in lung, breast, and prostate cancer incidence and mortality within the US. States with worse health rankings had higher cancer incidence and mortality, and varied by different demographics. Our findings suggests that advanced cancer screening and targeted public health interventions should be prioritized in areas with health disadvantages to improve cancer disparity.
486 Background: UTUC is less common and associated with poorer stage-for-stage prognosis compared to urothelial bladder cancer. AC is regarded as a standard-of-care in high-risk UTUC based on superior disease-free survival compared to observation in the POUT trial, though fewer than 10% of patients in this trial had lymph node involvement.1 CheckMate 274 revealed lesser magnitude of benefit with adjuvant nivolumab in UTUC compared to bladder cancer on post hoc analysis.2 The preferred sequence of perioperative systemic therapy in node positive UTUC remains unclear. Methods: We queried the National Cancer Database for adult patients with clinically node positive (cTanyN1-3M0) UTUC diagnosed between 2004 and 2018. Patients were divided into two groups based on the perioperative treatment strategy - NAC or AC. Patients who did not undergo RNU were excluded from analyses. Fisher’s exact and Mann Whiney U tests were used to compare frequency distributions. Cox Proportional Hazards regression was employed for multivariate analysis of factors associated with overall survival. Models were adjusted for age, sex, race, income, educational level, clinical T stage, insurance status, and the Charlson Comorbidity Index. Results: A total of 862 patients were identified - 362 (42%) underwent NAC while 500 (58%) received AC. No significant differences were noted between the groups regarding age, sex, or insurance status. Patients with cT1-2 UTUC more often received NAC (27.9% vs 11.8%, P <0.001) while those with cT3-4 disease more frequently received AC (38.9% vs 57.4%, p<0.001). Rates of NAC vs AC were not significantly different based on clinical N stage (P = 0.35). Overall survival in the NAC group was significantly longer than the AC group (median of 47.1 vs. 20.2 months, log-rank P < 0.001). On multivariable analysis, only the sequence of perioperative chemotherapy was independently predictive of overall survival (Hazard Ratio of 1.38 for AC, with 95% CI 1.14-1.68, P = 0.001). Conclusions: In this large retrospective analysis of outcomes among patients with clinically node positive UTUC who underwent RNU, NAC was associated with significantly longer overall survival compared to AC. References: 1) Birtle A, Lancet 2020; 2) Bajorin DF, NEJM 2021.
343 Background: The population of prostate cancer (PCa) survivors has grown over the recent decades, with many reporting long-term treatment-related physical, emotional, and financial adverse effects resulting in greater psychological distress compared to males without a history of PCa. This study analyzes the prevalence of psychological distress among PCa survivors and its impact on emergency room (ER) utilization and overall survival. Methods: We identified a cohort of 3,453 PCa survivors from the 2000-2018 National Health Interview Survey (NHIS) linked to the National Death Index Mortality Files through Dec 31, 2019. Deaths that occurred during the first two years of follow-up were excluded from analyses to minimize the likelihood of reverse causation. The Kessler Psychological Distress Scale (K6) was used to quantify psychological distress. Severe, moderate, and none/low mental distress have been validated for thresholds K6≥13, 13> K6 ≥5, and 5> K6 ≥0. Its association with self-reported ER utilization during the 12 months preceding the survey and all-cause mortality was estimated using weighted multivariable logistic regression and Cox proportional hazards regression, respectively. Models were adjusted for age, sex, race, educational attainment, comorbidities, region, year of survey, smoking status, health insurance, functional limitations, and time since cancer diagnosis. Results: Among the 3,453 PCa survivors (mean [SD] age 68.5 [7.2] years; 2479 (77.9%] non-Hispanic White, 655 (14.1%) non-Hispanic Black; median time since cancer diagnosis:5 years), 435 (11.3%) and 96 (2.4%) reported moderate and severe psychological distress respectively. PCa survivors with psychological distress tend to be younger, less educated, single, and with multiple comorbid conditions, and functional limitations. 812(22.8%) of PCa survivors visited the ER during 12 months preceding the survey. During a median follow-up of 81 months, 937(25.5%) of survivors died of all causes. After adjusting for covariates, PCa survivors with severe psychological distress were at a higher risk of ER utilization and all-cause mortality than those with moderate or no distress. Conclusions: Psychological distress was associated with increased risk of ER utilization and all-cause mortality among PCa survivors. Greater efforts are needed to understand, recognize, and alleviate such distress, as well as to enhance social and mental/physical health support in this rapidly growing community of vulnerable cancer survivors. [Table: see text]
476 Background: Small cell bladder cancer is a rare and aggressive histological variant with a paucity of data to guide the optimal management strategy in non-metastatic disease. NAC-RC and TMT (maximal transurethral resection of bladder tumor + chemoradiation) have been variably employed based on institutional preferences, and we aim to compare outcomes between these two approaches. Methods: We queried the National Cancer Database for adult patients with small cell bladder cancer diagnosed during the years 2004 to 2018. Patients with small cell histology and early-stage clinically node-negative bladder cancer (cT1-4N0M0) were included and divided into two groups based on the treatment strategy employed – NAC-RC or TMT. Patients who did not receive any definitive local therapy and those who received chemotherapy or radiation in the adjuvant setting were excluded. Fisher’s exact and Mann Whiney U tests were used to compare frequency distributions. Cox Proportional Hazards regression was employed for multivariate analysis of factors associated with overall survival. Models were adjusted for age, sex, race, income, educational level, clinical T stage, insurance status, and the Charlson Comorbidity Index. Results: A total of 1262 patients were identified – 629 (49.8%) underwent NAC-RC while 633 (50.2%) received TMT. Patients in the NAC-RC group were younger (median 67 vs. 74 years, P <0.001) and more frequently Males (81% vs 76%, p = 0.02). Clinical T stage was comparable between the groups (P = 0.38). Patients with private insurance (P < 0.001) and higher income tiers (P = 0.04) were more likely to receive NAC-RC in lieu of TMT. Overall survival in the NAC-RC group was significantly longer than the TMT group (median of 41.3 vs. 25.4 months, log-rank P < 0.001). On multivariable analysis, only the type of treatment modality employed was independently predictive of overall survival (Hazard Ratio of 1.22 for TMT, with 95% CI 1.05-1.43, P = 0.01). Conclusions: In early-stage clinically node-negative small cell bladder cancer, NAC-RC was associated with significantly longer overall survival compared to TMT.
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