Ahmedin Jemal

Survival difference between secondary and de novo acute myeloid leukemia by age, antecedent cancer types, and chemotherapy receipt

AbstractBackgroundThis study compared the survival of persons with secondary acute myeloid leukemia (sAML) to those with de novo AML (dnAML) by age at AML diagnosis, chemotherapy receipt, and cancer type preceding sAML diagnosis.MethodsData from Surveillance, Epidemiology, and End Results 17 Registries were used, which included 47,704 individuals diagnosed with AML between 2001 and 2018. Multivariable Cox proportional hazards regression was used to compare AML‐specific survival between sAML and dnAML. Trends in 5‐year age‐standardized relative survival were examined via the Joinpoint survival model.ResultsOverall, individuals with sAML had an 8% higher risk of dying from AML (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.05–1.11) compared to those with dnAML. Disparities widened with younger age at diagnosis, particularly in those who received chemotherapy for AML (HR, 1.14; 95% CI, 1.10–1.19). In persons aged 20–64 years and who received chemotherapy, HRs were greatest for those with antecedent myelodysplastic syndrome (HR, 2.04; 95% CI, 1.83–2.28), ovarian cancer (HR, 1.91; 95% CI, 1.19–3.08), head and neck cancer (HR, 1.55; 95% CI, 1.02–2.36), leukemia (HR, 1.45; 95% CI, 1.12–1.89), and non‐Hodgkin lymphoma (HR, 1.42; 95% CI, 1.20–1.69). Among those aged ≥65 years and who received chemotherapy, HRs were highest for those with antecedent cervical cancer (HR, 2.42; 95% CI, 1.15–5.10) and myelodysplastic syndrome (HR, 1.28; 95% CI, 1.19–1.38). The 5‐year relative survival improved 0.3% per year for sAML slower than 0.86% per year for dnAML. Consequently, the survival gap widened from 7.2% (95% CI, 5.4%–9.0%) during the period 2001–2003 to 14.3% (95% CI, 12.8%–15.8%) during the period 2012–2014.ConclusionsSignificant survival disparities exist between sAML and dnAML on the basis of age at diagnosis, chemotherapy receipt, and antecedent cancer, which highlights opportunities to improve outcomes among those diagnosed with sAML.

Effect of Health Education on Cervical Cancer Screening Uptake and Knowledge among Target Women in Addis Ababa: A Randomized Controlled Trial

Abstract Health education can improve cervical cancer screening uptake; however, evidence from randomized controlled trials in the general population of Addis Ababa is limited. The aim of this study is to assess the effect of health education on screening uptake and knowledge among women aged 30 to 49 years in Addis Ababa, Ethiopia. A randomized controlled trial was conducted involving 1,300 women who had never been screened before. The intervention group received home-based health education about cervical cancer, supplemented by brochures. The χ2 test, independent sample t test, and paired t tests were used to assess pre- and pos-tintervention differences. The impact of the intervention was measured using the differences-in-differences approach. Three months after the intervention, 1,154 (88.8%) were interviewed. Screening uptake was significantly higher in the intervention group, with 241 (41.8%) of women screened compared with 93 (16.1%) in the control group. After the intervention, awareness increased by 42.2%, knowledge of symptoms increased by 23.1%, knowledge of risk factors increased by 15.2%, positive attitudes improved by 26.7%, and overall knowledge increased by 19.5% among the intervention group, indicating that the change is statistically significant. The differences-in-differences analysis indicated that 51% of the change in overall knowledge was due to the intervention. Age, occupation, and income were significantly associated with the uptake of screening, whereas the lack of time was a common barrier. Structured home-based education significantly increases cervical cancer knowledge and screening uptake. Scaling up home-based health education can significantly improve screening uptake. Prevention Relevance: Cervical cancer is the second leading cause of cancer-related morbidity and mortality among women in Ethiopia. Increasing awareness, improving access to screening, and promoting timely preventive interventions are critical to reducing the disease burden and increases life saving among women.

Association between racialized economic segregation and stage at diagnosis for 3 screenable cancers in New York City

Abstract Background Racial and economic segregation can create barriers to timely cancer diagnosis and adversely affect survival. This study examines the association between neighborhood-level segregation, measured by the neighborhood-Index of Concentration at Extremes (n-ICE), and stage at diagnosis (advanced [regional/distant] vs localized) for 3 screenable cancers in New York City. Methods We analyzed 98 449 incident cases (breast, 58 970; cervical, 4790; and colorectal, 34 689) using New York State Cancer Registry data (2008-2019). Census tract-level n-ICE measures of racial and/or income-based economic segregation were calculated. Age-adjusted stage-specific incidence rates and advanced-to-localized incidence rate ratios (IRRs) were measured across n-ICE quartiles. Results Advanced-to-localized stage IRRs were significantly higher in the most-deprived and/or non-Hispanic Black (NHB)-concentrated areas (Q1) than the most-affluent and/or most non-Hispanic White (NHW)-concentrated areas (Q4) for breast and cervical cancer (breast: n-ICEIncome, IRRQ1 = 0.71 vs IRRQ4 = 0.48; n-ICENHB, IRRQ1 = 0.75 vs IRRQ4 = 0.53; n-ICENHB+Income, IRRQ1 = 0.74 vs IRRQ4 = 0.47; cervical: n-ICEIncome, IRRQ1 = 1.30 vs IRRQ4 = 0.97; n-ICENHB, IRRQ1 = 1.44 vs IRRQ4 = 0.99; n-ICENHB+Income, IRRQ1 = 1.37 vs IRRQ4 = 0.92) (all P-values < .01). Hispanic concentration alone (n-ICEHispanic) was not associated with disparities; however, its combination with economic deprivation was significant in both cancers (breast: n-ICEHispanic+Income, IRRQ1 = 0.70 vs IRRQ4 = 0.47; cervical: n-ICEHispanic+Income, IRRQ1 = 1.31 vs IRRQ4 = 0.93) (all P-values < .01). All racialized-economic segregation measures (n-ICENHB+Income/n-ICEHispanic+Income) showed increasing IRRs with higher segregation for both cancers (all P-trend < .04). No disparities were observed for colorectal cancer. Conclusions Racialized-economic segregation in New York City was associated with higher advanced-stage diagnoses of breast and cervical cancer but not colorectal cancer. These findings may partially reflect both structural barriers that delay timely diagnosis and the impact of local equity-driven initiatives that broaden colorectal cancer screening access.

Cervical Cancer Screening Uptake and Sociocultural Barriers among Women in Addis Ababa, Ethiopia: Population-Based Study

Abstract Background: Cervical cancer is the second leading cause of cancer death among women in Addis Ababa and other parts of Ethiopia. Yet, there are limited age-eligible city-wide data on cervical cancer screening prevalence in Addis Ababa to inform public policy. Methods: A population-based cross-sectional study was conducted among 1881 screening eligible women aged 30 to 49 years, who were selected from 63 enumeration areas in Addis Ababa based on multistage sampling and proportional sample size allocation. Logistic regression was used to identify barriers to screening. All statistical tests were two-sided, P < 0.05. Results: Overall, 30.8% [95% confidence interval (CI), 28.8%–33.0%] of study participants reported receipt of screening in the past 5 years. Less than half (45.7%) of women reported that they received healthcare provider recommendation for screening, and only 15% of married women reported that they had spousal support for it. In the multivariable adjusted model, the odd of being screened was considerably higher in women with healthcare provider recommendation, with spousal support, and with good cervical cancer screening awareness and knowledge of risk factors for the disease. Factors associated with not seeking screening service included feeling healthy and perception of low risk for cervical cancer. Conclusions: Cervical cancer screening uptake is low in Addis Ababa, and less than half received healthcare provider recommendation. Future studies should identify barriers to provider recommendations. Impact: The findings underscore the need for a coordinated effort to enhance healthcare provider recommendations for cervical cancer screening and to raise awareness about the benefits of screening in the general population.

Association of mental health treatment receipt with cancer screening among US adults with a history of anxiety or depression

Adults with a history of depression or anxiety who lacked mental health treatment in the past year were significantly less likely to be up‐to‐date with breast, cervical, and colorectal cancer than those who received treatment. Concerted efforts to increase mental health treatment receipt among adults with mental illness may reduce disparities in cancer screening and related outcomes in this population.

NCCN guideline–concordant cancer care in sub-Saharan Africa: a population-based multicountry study of 5 cancers

Abstract Background To assess population-based quality of cancer care in sub-Saharan Africa and to identify specific gaps and joint opportunities, we assessed concordance of diagnostics and treatments with National Comprehensive Cancer Network Harmonized Guidelines for leading cancer types in 10 countries. Methods Adult patients with female breast cancer, cervical cancer, colorectal cancer, non-Hodgkin lymphoma, and prostate cancer were randomly drawn from 11 population-based cancer registries. Guideline concordance of diagnostics and treatment was assessed using clinical records. In a subcohort of 906 patients with potentially curable cancer (stage I-III breast cancer, cervical cancer, colorectal cancer, prostate cancer, aggressive non-Hodgkin lymphoma [any stage]) and documentation for more than 1 month after diagnosis, we estimated factors associated with guideline-concordant treatment or minor deviations. Results Diagnostic information based on guidelines was complete for 1030 (31.7%) of a total of 3246 patients included. In the subcohort with curable cancer, guideline-concordant treatment was documented in 374 (41.3%, corresponding to 11.7% of 3246 patients included in the population-based cohort): aggressive non-Hodgkin lymphoma (59.8%/9.1% population based), breast cancer (54.5%/19.0%), prostate cancer (39.0%/6.1%), colorectal cancer (33.9%/9.5%), and cervical cancer (27.8%/11.6%). Guideline-concordant treatment was most frequent in Namibia (73.1% of the curable cancer subcohort/32.8% population based) and lowest in Kampala, Uganda (13.5%/3.1%). Guideline-concordant treatment was negatively associated with poor ECOG-ACRIN performance status, locally advanced disease stage, origin from low Human Development Index countries, and a diagnosis of colorectal cancer or cervical cancer. Conclusions The quality of diagnostic workup and treatment showed major deficits, with considerable disparities among countries and cancer types. Improved diagnostic services are necessary to increase the share of curable cancer in sub-Saharan Africa. Treatment components within National Comprehensive Cancer Network Guidelines for several cancers should be prioritized.

Association between waiting time for radiotherapy initiation and disease progression among women with cervical cancer in Addis Ababa, Ethiopia

AbstractThere is shortage of radiotherapy machines in low‐income countries, including Ethiopia. Data on adverse effects of this on cancer outcomes are limited, however. Herein, we examined the extent of waiting time for radiotherapy and its association with disease progression based on a prospective cohort study of women diagnosed with stage IA‐IVA cervical cancer in Addis Ababa and who were scheduled to receive radiotherapy at Tikur Anbessa Specialized Hospital, the only hospital that provides radiotherapy services in the country. Association was examined using Multivariable mixed effects logistic regression model. Among the 178 women with cervical cancer scheduled for receipt of radiotherapy and with vital status information, 16 deceased (9.0%) while waiting for radiotherapy. For the remaining 162 women who initiated radiotherapy, the median treatment waiting period was 137 days (IQR = 60‐234 days), with 74.1% of women waiting for >60 days. Tumor progressed to higher stage for 44.4% of these women. Compared to those women who initiated radiotherapy ≤60 days after diagnostic confirmation, the odds of tumor progression to higher stage was three times higher in those women who initiated radiotherapy between 120‐179 days (aOR =3.30, 95%CI: 1.18‐9.27) and ≥180 days (aOR =3.06, 95%CI: 1.24‐7.52). Waiting period for receipt of radiotherapy among women with cervical cancer is exceedingly long in Addis Ababa, and it is associated with disease progression to higher stages. These findings reinforce the need to expand radiotherapy infrastructure in order to mitigate the undue high burden of the disease in Ethiopia and other parts of Africa.

Cervical Cancer in Sub-Saharan Africa: A Multinational Population-Based Cohort Study of Care and Guideline Adherence

Abstract Background Cervical cancer (CC) is the most common female cancer in many countries of sub-Saharan Africa (SSA). We assessed treatment guideline adherence and its association with overall survival (OS). Methods Our observational study covered nine population-based cancer registries in eight countries: Benin, Ethiopia, Ivory Coast, Kenya, Mali, Mozambique, Uganda, and Zimbabwe. Random samples of 44–125 patients diagnosed from 2010 to 2016 were selected in each. Cancer-directed therapy (CDT) was evaluated for degree of adherence to National Comprehensive Cancer Network (U.S.) Guidelines. Results Of 632 patients, 15.8% received CDT with curative potential: 5.2% guideline-adherent, 2.4% with minor deviations, and 8.2% with major deviations. CDT was not documented or was without curative potential in 22%; 15.7% were diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IV disease. Adherence was not assessed in 46.9% (no stage or follow-up documented, 11.9%, or records not traced, 35.1%). The largest share of guideline-adherent CDT was observed in Nairobi (49%) and the smallest in Maputo (4%). In patients with FIGO stage I–III disease (n = 190), minor and major guideline deviations were associated with impaired OS (hazard rate ratio [HRR], 1.73; 95% confidence interval [CI], 0.36–8.37; HRR, 1.97; CI, 0.59–6.56, respectively). CDT without curative potential (HRR, 3.88; CI, 1.19–12.71) and no CDT (HRR, 9.43; CI, 3.03–29.33) showed substantially worse survival. Conclusion We found that only one in six patients with cervical cancer in SSA received CDT with curative potential. At least one-fifth and possibly up to two-thirds of women never accessed CDT, despite curable disease, resulting in impaired OS. Investments into more radiotherapy, chemotherapy, and surgical training could change the fatal outcomes of many patients. Implications for Practice Despite evidence-based interventions including guideline-adherent treatment for cervical cancer (CC), there is huge disparity in survival across the globe. This comprehensive multinational population-based registry study aimed to assess the status quo of presentation, treatment guideline adherence, and survival in eight countries. Patients across sub-Saharan Africa present in late stages, and treatment guideline adherence is remarkably low. Both factors were associated with unfavorable survival. This report warns about the inability of most women with cervical cancer in sub-Saharan Africa to access timely and high-quality diagnostic and treatment services, serving as guidance to institutions and policy makers. With regard to clinical practice, there might be cancer-directed treatment options that, although not fully guideline adherent, have relevant survival benefit. Others should perhaps not be chosen even under resource-constrained circumstances.

Implementation of Brachytherapy for Patients With Cervical Cancer in Ethiopia: A 3-Year Practice Report

PURPOSE Although cervical cancer is the second most commonly diagnosed cancer in Ethiopia, brachytherapy (BT) was not a component in patient treatment until 2015. The purpose of this study was to identify the patterns of utilization as well as to describe the practice of BT in Ethiopia. MATERIALS AND METHODS A retrospective descriptive data analysis of 138 patients with cervical cancer treated with a curative potential using BT from 2015 to 2018 at Tikur Anbassa Specialized Hospital, which housed the only BT facility in Ethiopia during the study period. RESULTS During the first 3-year period of BT service commencement, each year n = 37, n = 36, and n = 65 patients with cervical cancer were treated, respectively, with curative intention treatment. The median age of these 138 patients was 50 years (range, 22-75). All the patients were in International Federation of Gynecology and Obstetrics stage Ib–IIIb group, and stage IIb (66.4%) was the predominant. Majority (79%) of the patients were treated primarily with radiotherapy (RT), while 21% received RT after surgery. More than half of these patients (62%) received a total RT dose of 82 Gy in equivalent dose in 2 Gy fractions (EQD2), while the rest received a dose ranging from 76 to 86 Gy. Concurrent cisplatin with RT was given only for 36% of the patients for undocumented reasons. The overall treatment time including both external-beam RT and BT was greater than 8 weeks in 21% of the patients. CONCLUSION The utilization of BT service increased gradually and BT enabled the delivery of a higher RT dose to patients with cervical cancer (mostly stage IIB). However, there was protracted treatment duration and low concurrent chemotherapy utilization.

Factors contributing to differences in cervical cancer screening in rural and urban community health centers

AbstractIntroductionCommunity health centers (CHCs) provide historically marginalized populations with primary care, including cancer screening. Previous studies have reported that women living in rural areas are less likely to be up to date with cervical cancer screening than women living in urban areas. However, little is known about rural–urban differences in cervical cancer screening in CHCs and the contributing factors, and whether such differences changed during the COVID‐19 pandemic.MethodsUsing 8‐year pooled Uniform Data System (2014‐2021) data and Oaxaca‐Blinder decomposition, the extent to which CHC‐ and catchment area–level characteristics explained rural‐urban differences in up‐to‐date cervical cancer screening was estimated.ResultsUp‐to‐date cervical cancer screening was lower in rural CHCs than urban CHCs (38.2% vs 43.0% during 2014–2019), and this difference increased during the pandemic (43.5% vs 49.0%). The rural–urban difference in cervical cancer screening in 2014–2019 was mostly explained by differences in CHC‐level proportions of patients with limited English proficiency (55.9%) or income below the poverty level (12.3%) and females aged 21 to 64 years (9.8%), and catchment area–level’s unemployment (3.4%) and primary care physician density (3.2%). However, Medicaid (–48.5%) or no insurance (–19.6%) counterbalanced the differences between rural–urban CHCs. The contribution of these factors to rural–urban differences in cervical cancer screening generally increased in 2020–2021.ConclusionsRural–urban differences in cervical cancer screening were mostly explained by multiple CHC‐level and catchment area–level characteristics. The findings call for tailored interventions, such as providing resources and language services, to improve cancer screening utilization among uninsured, Medicaid, and patients with limited English proficiency in rural CHCs.