The timing, location, intensity, and drivers of forest disturbance and recovery are crucial for developing effective management strategies and policies for forest conservation and ecosystem ...resilience. Although many algorithms and improvement methods have been developed, it is still difficult to guarantee the detection accuracy for forest disturbance and recovery patterns in southern China due to the complex climate and topography, faster forest recovery after disturbance, and the low availability of noise-free Landsat images. Here, we improved the LandTrendr parameters for different provinces to detect forest disturbances and recovery trajectories based on the LandTrendr change detection algorithm and time-series Landsat images on the GEE platform, and then applied the secondary random forest classifier to classify the forest disturbance and recovery patterns in southern China during 1990–2020. The accuracy evaluation indicated that our approach and improved parameters of the LandTrendr algorithm can increase the detection accuracy for both the spatiotemporal patterns and multiple events of forest disturbance and recovery, with an overall accuracy greater than 86% and a Kappa coefficient greater than 0.91 for different provinces. The total forest loss area was 1.54 × 105 km2 during 1990–2020 (4931 km2/year); however, most of these disturbed forests were recovered and only 6.39 × 104 km2 was a net loss area (converted to other land cover types). The area with two or more times of disturbance events accounted for 11.50% of the total forest loss area. The total forest gain area (including gain after loss and the afforestation area) was 5.44 × 105 km2, among which, the forest gain area after loss was 8.94 × 104 km2, and the net gain area from afforestation was 4.55 × 105 km2. The timing of the implementation of forestry policies significantly affected the interannual variations in forest disturbance and recovery, with large variations among different provinces. The detected forest loss and gain area was further compared against with inventory and other geospatial products, and proved the effectiveness of our method. Our study suggests that parameter optimization in the LandTrendr algorithm could greatly increase the accuracy for detecting the multiple and lower rate disturbance/recovery events in the fast-regrowing forested areas. Our findings also offer a long-term, moderate spatial resolution, and precise forest dynamic data for achieving sustainable forest management and the carbon neutrality goal in southern China.
Purpose
Non-white cancer patients receive more aggressive care at the end-of-life (EOL). This may indicate low quality EOL care if discordant with patient preferences. We investigated preferred ...potential place of death and preferences regarding use of mechanical ventilation in a cohort of Texas cancer patients.
Methods
A population-based convenience sample of recently diagnosed cancer patients from the Texas Cancer Registry was surveyed using a multi-scale inventory between March 2018 and June 2020. Item responses to questions about preferences regarding location of death and mechanical ventilation were the outcome measures of this investigation. Inverse probability weighting analysis was used to construct multivariable logistic regression examining the associations of covariates.
Results
Of the 1460 respondents, a majority (82%) preferred to die at home compared to 8% who preferred dying at the hospital. In total, 25% of respondents expressed a preference for undergoing mechanical ventilation at the EOL. Adjusted analysis showed increased preference among Black (OR = 1.81; 95% CI: 1.19–2.73) and other non-white, non-Hispanic race individuals (OR = 3.53; 95% CI: 1.99–6.27) for dying at a hospital. Males, married individuals, those of higher education and poor self-reported health showed significantly higher preference for dying at home. Non-white respondents of all races were more likely to prefer mechanical ventilation at the EOL as were individuals who lived with another person at home.
Conclusion
Non-white cancer patients were more likely to express preferences coinciding with aggressive EOL care including dying at the hospital and utilizing mechanical ventilation. These findings were independent of other sociodemographic characteristics, including decisional self-efficacy.
We aimed to explore the differences in immune checkpoint inhibitor (ICI) immunotherapy utilization for advanced melanoma by examining patient and neighborhood characteristics. We performed a ...retrospective cohort study using a deidentified, random sample of SEER-Medicare beneficiaries aged ≥65 years with stage III or stage IV melanoma (2011–2017). Our primary outcome was initiation of ICI immunotherapy (ipilimumab, pembrolizumab, nivolumab, or atezolizumab) after stage III or stage IV melanoma diagnosis. We analyzed ICI usage with multivariable logistic regression. After analyzing the entire 2011–2017 cohort, we conducted a secondary analysis in which we separately analyzed the 2011–2014 and 2015–2017 cohorts to assess possible differences over time. We included 3531 beneficiaries, with mean follow-up of 2.1 (SD = 2.0) years. Higher likelihood of ICI usage was associated with male sex (OR = 1.21, 95% confidence interval = 1.04–1.42) and higher density of medical oncologists (OR = 1.02, 95% confidence interval = 1.01–1.04). Lower likelihood of ICI usage was associated with older age group and Charlson comorbidity score (score ≥2; OR = 0.72, 95% confidence interval = 0.60–0.86). These associations were diminished in more recent years (no association with sex, medical oncologist density, Charlson comorbidity score, and association with only the oldest age group in years 2015–2017). We found significant sex- and age-related differences in initiation among SEER-Medicare beneficiaries with stage III or stage IV melanoma, which appear to be improving over time.
Background. Screening with low-dose computed tomography scans can reduce lung cancer deaths but uptake remains low. This study examines psychosocial factors associated with obtaining lung cancer ...screening (LCS) among individuals. Methods. This is a secondary analysis of a randomized clinical trial conducted with 13 state quitlines’ clients. Participants who met age and smoking history criteria were enrolled and followed-up for 6 months. Only participants randomized to the intervention group (a patient decision aid) were included in this analysis. A logistic regression was performed to identify determinants of obtaining LCS 6 months after the intervention. Results. There were 204 participants included in this study. Regarding individual attitudes, high and moderate levels of concern about overdiagnosis were associated with a decreased likelihood of obtaining LCS compared with lower levels of concern (high levels of concern, odds ratio OR 0.17, 95% confidence interval CI 0.04–0.65; moderate levels of concern, OR 0.15, 95% CI 0.05–0.53). In contrast, higher levels of anticipated regret about not obtaining LCS and later being diagnosed with lung cancer were associated with an increased likelihood of being screened compared with lower levels of anticipated regret (OR 5.59, 95% CI 1.72–18.10). Other potential harms related to LCS were not significant. Limitations. Follow-up may not have been long enough for all individuals who wished to be screened to complete the scan. Additionally, participants may have been more health motivated due to recruitment via tobacco quitlines. Conclusions. Anticipated regret about not obtaining screening is associated with screening behavior, whereas concern about overdiagnosis is associated with decreased likelihood of LCS. Implications. Decision support research may benefit from further examining anticipated regret in screening decisions. Additional training and information may be helpful to address concerns regarding overdiagnosis.
Introduction: Tumor-related liver failure (TRLF) is the most common cause of death in patients with intrahepatic cholangiocarcinoma (ICC). Though we previously showed that liver radiotherapy (L-RT) ...for locally advanced ICC is associated with less frequent TRLF and longer overall survival (OS), the role of L-RT for patients with extrahepatic metastatic disease (M1) remains undefined. We sought to compare outcomes for M1 ICC patients treated with and without L-RT. Methods: We reviewed ICC patients that found to have M1 disease at initial diagnosis at a single institution between 2010 and 2021 who received L-RT, matching them with an institutional cohort by propensity score and a National Cancer Database (NCDB) cohort by frequency technique. The median biologically effective dose was 97.5 Gy (interquartile range 80.5–97.9 Gy) for L-RT. Patients treated with other local therapies or supportive care alone were excluded. We analyzed survival with Cox proportional hazard modeling. Results: We identified 61 patients who received L-RT and 220 who received chemotherapy alone. At median follow-up of 11 months after diagnosis, median OS was 9 months (95% confidence interval CI 8–11) and 21 months (CI: 17–26) for patients receiving chemotherapy alone and L-RT, respectively. TRLF was the cause of death more often in the patients who received chemotherapy alone compared to those who received L-RT (82% vs. 47%; p = 0.001). On multivariable propensity score-matched analysis, associations with lower risk of death included duration of upfront chemotherapy (hazard ratio HR 0.82; p = 0.005) and receipt of L-RT (HR: 0.40; p = 0.002). The median OS from diagnosis for NCDB chemotherapy alone cohort was shorter than that of the institutional L-RT cohort (9 vs. 22 months; p < 0.001). Conclusion: For M1 ICC, L-RT associated with a lower rate of death due to TRLF and longer OS versus those treated with chemotherapy alone. Prospective studies of L-RT in this setting are warranted.
PurposeIn patients treated with chemoradiation for esophageal cancer (EC), randomized trial data demonstrate that proton beam therapy (PBT) reduces toxicities and postoperative complications (POCs) ...compared with intensity-modulated radiation therapy (IMRT). However, whether radiation therapy modality affects postoperative health care resource utilization remains unknown. Materials and MethodsWe examined 287 patients with EC who received chemoradiation (prescribed 50.4 Gy/GyE) followed by esophagectomy, including a real-world observational cohort of 237 consecutive patients treated from 2007 to 2013 with PBT (n = 81) versus IMRT (n = 156); and an independent, contemporary comparison cohort of 50 patients from a randomized trial treated from 2012 to 2019 with PBT (n = 21) versus IMRT (n = 29). Postoperative complications were abstracted from medical records. Health care charges were obtained from institutional claims and adjusted for inflation (2021 dollars). Charge differences (Δ = $PBT - $IMRT) were compared by treatment using adjusted generalized linear models with the gamma distribution. ResultsBaseline PBT versus IMRT characteristics were not significantly different. In the observational cohort, during the neoadjuvant chemoradiation phase, health care charges were higher for PBT versus IMRT (Δ = +$71,959; 95% confidence interval CI, $62,274-$82,138; P < .001). There was no difference in surgical charges (Δ = -$2234; 95% CI, -$6003 to $1695; P = .26). However, during postoperative hospitalization following esophagectomy, health care charges were lower for PBT versus IMRT (Δ = -$25,115; 95% CI, -$37,625 to -$9776; P = .003). In the comparison cohort, findings were analogous: Charges were higher for PBT versus IMRT during chemoradiation (Δ = +$61,818; 95% CI, $49,435-$75,069; P < .001), not different for surgery (Δ = -$4784; 95% CI, -$6439 to $3487; P = .25), and lower for PBT postoperatively (Δ = -$27,048; 95% CI, -$41,974 to -$5300; P = .02). Lower postoperative charges for PBT were especially seen among patients with any POCs in the contemporary comparison (Δ = -$176,448; 95% CI, -$209,782 to -$78,813; P = .02). ConclusionHigher up-front chemoradiation resource utilization for PBT in patients with EC was partially offset postoperatively, moderated by reduction in POC risks. Results extend existing clinical evidence of toxicity reduction with PBT.
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of advanced melanoma, but racial disparities in melanoma outcomes continue. These inequities are not fully explained by ...individual factors.
To investigate the associations of neighborhood factors with the use of ICIs in metastatic melanoma.
We conducted a retrospective cohort study of commercially insured US adults with metastatic melanoma diagnosed between January 2011 and December 2020. We examined the associations between the county-level percentage of population from racial and ethnic minority groups and the time from metastatic melanoma diagnosis to initiating ICIs using Cox proportional hazards models adjusting for patient characteristics.
We identified 4,052 patients with metastatic melanoma, of which 49% used ICIs. We found that the adoption of ICIs in a county declined with increasing minority quintile (quintile 1: 52.4%, quintile 2: 50.4%, quintile 3: 50.1%, quintile 4: 45.8%, and quintile 5: 44.7%). The delay in ICI initiation also went up as the percentage of minorities in a county increased (log-rank test
= 0.03). Compared with the lowest quintile, the adjusted hazard ratio of ICI initiation of the second, third, fourth, and highest minority quintile was 0.94 (95% CI = 0.81-1.08), 0.88 (95% CI = 0.76-1.02), 0.81 (95% CI = 0.68-0.97), and 0.77 (95% CI = 0.66-0.91), respectively. Secondary analysis revealed that the slower initiation was driven by the counties with the highest percentage of Hispanic population (hazard ratio = 0.74; 95% CI = 0.61-0.89) in both Cox models and sensitivity analyses. High-minority counties correlated with metro areas, higher poverty levels, and a greater number of medical oncologists.
We found that patients with metastatic melanoma living in counties with higher proportion of minorities, particularly of Hispanic origin, are more likely to experience delays in ICI treatment. This study provides important population-level data on neighborhood-level disparity in medication use. More research is needed on the underlying provider- and system-level factors that directly contributed to the lower use of cancer medicines in high-minority areas, which can help inform the development of evidence-based medication use strategies that can improve health outcomes and equity.
Abstract
Background
There is a lack of evidence from nationwide samples on the disparity of initiating immune checkpoint inhibitors (ICIs) after metastatic lung cancer diagnosis.
Methods
We ...identified metastatic lung cancer patients diagnosed between 2015 and 2020 from a large, nationwide commercial claims database. We analyzed the time from metastatic lung cancer diagnosis to ICI therapy using Cox proportional hazard models. Independent variables included county-level measures (quintiles of percentage of racialized population, quintiles of percentage of population below poverty, urbanity, and density of medical oncologists) and patient characteristics (age, sex, Charlson comorbidity index, Medicare Advantage, and year of diagnosis). All tests were 2-sided.
Results
A total of 17 022 patients were included. Counties with a larger proportion of racialized population appeared to be more urban, have a greater percentage of its residents in poverty, and have a higher density of medical oncologists. In Cox analysis, the adjusted hazard ratio of the second, third, fourth, and highest quintile of percentage of racialized population were 0.89 (95% confidence interval CI = 0.82 to 0.98), 0.85 (95% CI = 0.78 to 0.93), 0.78 (95% CI = 0.71 to 0.86), and 0.71 (95% CI = 0.62 to 0.81), respectively, compared with counties in the lowest quintile. The slower ICI therapy initiation was driven by counties with the highest percentage of Hispanic population and other non-Black racialized groups.
Conclusions
Commercially insured patients with metastatic lung cancer who lived in counties with greater percentage of racialized population had slower initiation of ICI therapy after lung cancer diagnosis, despite greater density of oncologists in their neighborhood.
Levels of medical mistrust have historically been higher among racial/ethnic minority patients compared with whites, largely owing to societal and health system inequities and history of ...discrimination or experimentation. However, recently trust in physicians has declined in the United States in general. We investigated trust in physicians among a large cohort of cancer patients residing in Texas.
A sample of recently diagnosed cancer patients in Texas were identified from the Texas Cancer Registry with 1344 patients returning surveys between March 2017 and March 2020. The multiscale inventory was mailed to each individual and included the Trust in the Medical Profession Scale which assesses levels of agreement with 11 trust-related statements. Multivariable linear regression models were constructed to assess the adjusted relationship between trust in the medical profession aggregate score and sociodemographic and clinical factors.
A total of 1250 surveys were evaluable for trust in the medical profession. The mean aggregate trust score for all patients was 37.3 (95% confidence interval: 36.8-37.7). Unadjusted trust scores were higher for Hispanic (40.5) and black (38.2) respondents compared with white (36.4) (P<0.001). Multivariable analyses showed white, younger, more-educated, or those with lower levels of self-reported health estimated toward lower adjusted scores for trust in the medical profession.
We observed relatively higher levels of medical mistrust among white, younger, more-educated individuals with cancer or those with poorer health. While the relatively higher trust among minority individuals is encouraging, these findings raise the possibility that recent societal trends toward mistrust in science may have implications for cancer care.
Minority patients receive more aggressive and potentially suboptimal care at the end of life (EOL). We investigated preferences about pharmacologic interventions at the EOL and their potential ...variation by sociodemographic factors among recently diagnosed cancer patients.
A population-based cross-sectional survey of cancer patients identified through the Texas Cancer registry was conducted using a multi-scale inventory between March 2018 and June 2020. Item responses to questions about potential pharmacologic interventions at the EOL were the focus of this investigation. Inverse probability weighted multivariate analysis examined associations of sociodemographic characteristics, health literacy, and trust in medical professionals with pharmacologic preferences.
Of the 1480 included responses, 13.3% stated they would take a medication that may prolong life at the cost of feeling worse. Adjusted analyses showed Black or Hispanic race/ethnicity, living with another person, and having a higher trust score were more likely to express this preference. In contrast, 41–65 years (vs. 21–40 years), living in a rural area, and adequate or unknown health literacy were less likely to express this preference. Overall 16% of respondents were opposed to potentially life shortening palliative drugs. In adjusted analysis Black or Hispanic respondents were more likely to be opposed to potentially life shortening drugs although age 65–79 and ≥college education were associated with a decreased likelihood of opposition to this item.
Black and Hispanic cancer patients were more likely to express preferences toward more aggressive EOL pharmacologic care. These findings were independent of other sociodemographic characteristics, health literacy and trust in the medical profession.
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