Investigators at the American Cancer Society presented results of several studies during poster sessions at the 2022 ASCO Annual Meeting. Summaries of a few of these studies are provided here.
COVID-19 and Cancer Mortality
According to a new study led by researchers at the American Cancer Society, the COVID-19 pandemic increased the number of cancer-related deaths by 3.2% in the United States from 2019 to 2020. Compared with 2019, the monthly cancer-related mortality rate was higher in April 2020, when health-care capacity was most challenged by the pandemic. Higher mortality rates were again observed each month from July to December 2020 compared with 2019. The study was led by Jingxuan Zhao, MPH, Senior Associate Scientist, Health Services Research at the American Cancer Society, Atlanta. The findings were presented at the 2022 ASCO Annual Meeting.1
Jingxuan Zhao, MPH
In the study, researchers used the U.S. 2019–2020 Multiple Cause of Death database from the Centers for Disease Control and Prevention (CDC) WONDER to identify cancer-related deaths, defined as decedents with invasive cancer as a contributing cause of death. (The CDC’s WONDER [Wide-Ranging Online Data for Epidemiologic Research] is an integrated information and communication system of online databases for the analysis of public health data.)
The investigators compared age-standardized cancer-related annual and monthly mortality rates (per 100,000 person-years and person-months, respectively) in January to December 2020 (pandemic) vs January to December 2019 (prepandemic) overall and stratified them by rurality and place of death. Scientists calculated the 2020 excess death by comparing the numbers of observed death with the projected death based on the age-specific cancer-related death rate from 2015 to 2019.
The results showed the number of cancer-related deaths was 686,054 in 2020, up from 664,888 in 2019, with an annual increase of 3.2%.Compared with the number of projected deaths for 2020 (666,286), the number of cancer-related excess deaths was 19,768 in 2020. The annual age-standardized cancer-related mortality rate continuously decreased from 174 in 2015 to 162 in 2019, although it increased to 164 in 2020. The cancer-related monthly mortality rate was higher in April 2020, when health-care facilities were most challenged by COVID-19, and subsequently declined in May and June 2020; higher mortality rates were again observed each month from July to December 2020 compared with 2019.
In large metropolitan areas, the largest increase in cancer-related mortality was observed in April 2020, whereas in nonmetropolitan areas, the largest increases occurred from July to December 2020, coinciding with the time-spatial pattern of the incidence of COVID-19 in the country. Compared with 2019, cancer-related mortality rates were lower from March to December 2020 in medical facilities, hospice facilities, and nursing homes or long-term care settings but higher in decedents’ homes.
Study authors indicated that ongoing evaluation of the spatial-temporal effects of the pandemic on cancer care and outcomes is warranted, especially in relation to patterns in vaccine uptake and COVID-19 hospitalization rates.
Racial Disparities in Care for Patients With Early-Onset Colorectal Cancer
In a large national study, Black patients diagnosed with early-onset colorectal cancer received worse and less timely care than their White counterparts. The study was led by Leticia Nogueira, PhD, MPH, Senior Principal Scientist, Health Services Research, at the American Cancer Society, Atlanta. Differences in health insurance coverage type (a modifiable factor), according to the study findings, accounted for the largest identified contributor to the racial disparities. The results were presented at the 2022 ASCO Annual Meeting.2
Leticia Nogueira, PhD, MPH
In the study, more than 147,000 non-Hispanic Black and White individuals (between the ages of 20 and 49) newly diagnosed with colorectal cancer during 2004 to 2019 were selected from the National Cancer Database. Patients who received all care recommended by the National Comprehensive Cancer Network (staging, surgery, lymph node evaluation, chemotherapy, and radiotherapy) for which they were eligible, according to cancer subsite and clinical and pathologic TNM stage, were considered guideline-concordant.
Demographic characteristics (age and sex), comorbidities, and health insurance coverage type were added sequentially to a series of multivariable models to estimate the contribution to racial disparities in receipt of guideline-concordant care. Racial disparities in the time from diagnosis date among patients with rectal cancer eligible for neoadjuvant chemotherapy, and surgery date among patients with colon cancer eligible for adjuvant chemotherapy, to the date of chemotherapy initiation were evaluated using restricted mean time to treatment.
Of the 84,728 patients with colon cancer and 62,483 patients with rectal cancer included in the study, 20.8% and 14.5% were Black, respectively. Black patients were 18% and 36% less likely to receive guideline-concordant care than White patients diagnosed with colon and rectal cancers, respectively.
Demographic characteristics and comorbidities combined explained less than 5% of the disparity, whereas health insurance coverage type explained 28.6% and 19.4% of the disparity among patients with colon and rectal cancers, respectively. Restricted mean time to chemotherapy was statistically significantly longer among Black patients than White patients for colon cancer (54.0 vs 48.7 days) and rectal cancer (49.6 vs 40.9 days), respectively.
The study authors stressed that improved access to care may help to mitigate disparities in cancer outcomes.
Disparities and Cardiovascular Mortality Among Cancer Survivors
A recent large national study showed the mortality risk from cardiovascular disease differs considerably among cancer survivors by race/ethnicity and cancer types. The findings were presented at the 2022 ASCO Annual Meeting.3
Hyuna Sung, PhD
In this study, lead author Hyuna Sung, PhD, Principal Scientist, Cancer Surveillance Research at the American Cancer Society, Atlanta, and colleagues used data from almost 3 million survivors of the top 23 cancers diagnosed between the ages of 20 and 64 from 2000 to 2018 obtained from 17 Surveillance, Epidemiology, and End Results registries. Risks for cardiovascular disease death among survivors relative to the general population were calculated using standardized mortality ratios in each racial/ethnic group: non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian or Pacific Islander, and non-Hispanic American Indian. Among survivors, the risks were compared by race/ethnicity using cause-specific proportional hazards models for competing risks, controlling for the year of diagnosis, age at diagnosis, sex, stage (when appropriate), and first course of treatment receipt (surgery, radiotherapy, chemotherapy).
The results showed that among 2,806,515 survivors (non-Hispanic White, 68%; non-Hispanic Black, 13%; Hispanic, 12%; non-Hispanic Asian or Pacific Islander, 7%; non-Hispanic American Indian, 0.5%), 57,883 cardiovascular disease deaths occurred during 6.4 person-years of mean follow-up. Cancer survivors overall were at increased risk of cardiovascular disease death compared with the general population, with a standard mortality ratio of 1.76 among non-Hispanic Asian or Pacific Islander; 1.49 among non-Hispanic American Indian; 1.46 among Hispanic; 1.30 among non-Hispanic Black; and 1.13 among non-Hispanic White survivors.
Compared with non-Hispanic White survivors, the adjusted hazard of cardiovascular disease death was statistically significantly higher among non-Hispanic Black survivors for all 23 cancers and among non-Hispanic American Indian survivors for 9 of 18 cancers. The adjusted hazard of cardiovascular disease death was statistically significantly lower among Hispanic survivors for 5 of the 23 cancers and among non-Hispanic Asian or Pacific Islander survivors for 10 of the 23 cancers.
The highest hazard ratios were among non-Hispanic Black survivors of melanoma, breast cancer, pancreatic cancer, and testicular cancer, whereas the lowest hazard ratios were among non-Hispanic Asian or Pacific Islander survivors of head and neck and cervical cancers and Hispanic survivors of cervical cancer.
Study authors highlighted the need for targeted prevention and surveillance in primary care and for future studies to identify factors that contribute to this variation to inform efforts toward mitigating the cardiovascular risk.
Health Insurance and Costs for Genomic Testing
A recent study led by researchers at the American Cancer Society showed that physician, practice, and patient characteristics were associated with oncologists’ ratings of the importance of patient health insurance and out-of-pocket costs for genomic testing in treatment decisions. The findings were presented at the 2022 ASCO Annual Meeting.4
According to the researchers, the use of genomic testing, especially multimarker tumor panels, is increasing in the United States. Not all tests and related treatments are covered by health insurance, which can result in substantial out-of-pocket costs for patients. Although most patients are concerned about out-of-pocket costs, little is known about oncologists’ treatment decisions with respect to patient health insurance coverage and out-of-pocket costs for genomic testing.
Kewei (Sylvia) Shi, MPH
In the study, presented by Kewei (Sylvia) Shi, MPH, Associate Scientist, Health Services Research at the American Cancer Society, New Haven, Connecticut, researchers identified 1,049 oncologists who reported using multimarker tumor panels from the 2017 National Survey of Precision Medicine in Cancer Treatment. Separate multivariable ordinal logistic regression analyses were used to assess the associations of oncologist, practice, and patient characteristics as well as the oncologist ratings of the importance of health insurance coverage and out-of-pocket costs for genomic testing as part of treatment decisions.
The results showed that most oncologists reported patient insurance coverage for genomic testing was very important (47.3%) or somewhat important (32.7%) in treatment decisions. The remainder stated that patient insurance coverage was a little/not important (20.0%). For out-of-pocket costs for genomic testing, many oncologists reported they were very important (56.9%) or somewhat important (28.0%), and fewer stated they were a little/not important (15.2%) in treatment decisions.
In separate adjusted analyses, oncologists who used next-generation gene-sequencing tests were more likely to report patient health insurance and out-of-pocket costs for testing as important in treatment decisions. Oncologists with more years of experience, who treated solid tumors (rather than hematologic cancers alone), worked in practices without molecular tumor boards for genomic tests, and with higher percentages of patients insured by Medicaid or self-paid/uninsured also reported that insurance coverage and out-of-pocket costs for testing were important in treatment decisions.
Study authors stressed identifying factors that influence physicians’ priorities in treatment decisions may inform the development and targeting of interventions to support patient and physician discussions about oncology care.
DISCLOSURE: Dr. Zhao has received research funding from AstraZeneca. Drs. Nogueira, Sung, and Shi reported no conflicts of interest. For full disclosures of all study authors, visit coi.asco.org.
REFERENCES
1. Zhao J, Han X, Miller K, et al: Changes in cancer-related mortality during the COVID-19 pandemic in the United States. 2022 ASCO Annual Meeting Abstract 6581. Poster presented June 6, 2022.
2. Nogueira LM, May F, Yabroff KR, et al: Racial disparities in receipt of guideline-concordant care for early-onset colorectal cancer in the U.S. 2022 ASCO Annual Meeting. Abstract 6544. Presented June 6, 2022.
3. Sung H, Hyun N, Siegel R, et al: Racial differences in cardiovascular disease mortality among cancer survivors. 2022 ASCO Annual Meeting. Abstract 12075. Presented June 6, 2022.
4. Shi K, Yabroff R, Zhao J, et al: Oncologist consideration of patient health insurance coverage and out-of-pocket costs for genomic testing in treatment decision. 2022 ASCO Annual Meeting. Abstract 6600. Presented June 6, 2022.
