High rates of Pap smear screening among Black women have not eliminated the persistent disparity in mortality of Black women from cervical cancer compared to White women [ [1] Farley J. Risinger J.I. Rose G.S. Maxwell G.L. Racial disparities in blacks with gynecologic cancers. Cancer. 2007 Jul 15; 110: 234-243 Crossref PubMed Scopus (62) Google Scholar , [2] https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/cancer-facts-and-figures-for-african-americans-2019-2021.pdf Google Scholar ]. Given the success of prevention strategies when deployed effectively, in this study, Ford et al. sought to elucidate the multi-level factors associated with the barriers to treatment at the individual, health provider, and practice level that could be addressed to achieve more equitable health outcomes [ [3] Ford S. Tarraf W. Williams K.P. Anne Roman L. Leach R. Differences in cervical cancer screening and follow-up for black and white women in the United States. Gynecologic Oncology. 2021; 160: 369-374 Abstract Full Text Full Text PDF Scopus (11) Google Scholar ].

Across the United States, it is now apparent that the COVID-19 virus is exacerbating existing societal biases and longstanding inequities in health care, resulting in an excess of morbidity and mortality in underserved populations. The Society of Gynecologic Oncology (SGO) is committed to eliminating disparities, and increasing awareness of the critical issues that contribute to the differential outcomes experienced by gynecologic oncology patients. Health equity, defined as fairness and justice, exists only when people have an equal opportunity to be healthy. Health inequity, therefore, is the unfair and avoidable difference in health status seen within and between countries [[1]CSDH Closing the gap in a generation: health equity through action on the social determinants of health.in: Final Report of the Commission on Social Determinants of Health. World Health Organization, Geneva2008Google Scholar]. When defined structures or systems limit a person's ability to be healthy, inequities emerge. It is our goal to make gynecologic cancer patients, their caregivers and providers, aware of the issues that have been revealed, and amplified during the current global health crisis. The World Health Organization defines social determinants of health (SDOH) as conditions "in which people are born, grow, live, work and age and the systems put in place to deal with illness" [[1]CSDH Closing the gap in a generation: health equity through action on the social determinants of health.in: Final Report of the Commission on Social Determinants of Health. World Health Organization, Geneva2008Google Scholar]. Unequal SDOH create and sustain most health inequities. Our patients' reality is that their health is directly linked to SDOH including, housing, violence, transportation, food access, neighborhood and community economics [[2]Alcaraz K.I. Wiedt T.L. Daniels E.C. Yabroff K.R. Guerra C.E. Wender R.C. Understanding and addressing social determinants to advance cancer health equity in the United States: a blueprint for practice, research, and policy.CA Cancer J. Clin. 2020; 70 ([Internet]. Jan [cited 2020 Apr 25]. Available from:): 31-46https://onlinelibrary.wiley.com/doi/abs/10.3322/caac.21586Crossref PubMed Scopus (234) Google Scholar]. The current pandemic will impose an additional burden on vulnerable populations that already face barriers predisposing them to worse health outcomes. Preexisting comorbid conditions, economic insecurity, living environment, over representation in lower wage jobs or those requiring contact resulting in a higher risk for COVID-19 exposure, are all factors that adversely influence health outcomes during this pandemic (Fig. 1). As providers for women from diverse socio-economic, geographic, and racial/ethnic backgrounds, we see first-hand how SDOH adversely affect cancer care and delivery [[3]Collins Y. Holcomb K. Chapman-Davis E. Khabele D. Farley J.H. Gynecologic cancer disparities: a report from the Health Disparities Taskforce of the Society of Gynecologic Oncology.Gynecol. Oncol. 2014; 133 ([Internet]. May [cited 2020 Apr 25]. Available from:): 353-361https://linkinghub.elsevier.com/retrieve/pii/S009082581400002XAbstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar]. Implicit bias is the stereotypes, attitudes, beliefs, judgments, prejudices that affect our thinking and behaviors in ways that we do not realize. Implicit biases are an integral part of our news and media platforms, influence our conversations and impact our healthcare and education systems (Fig. 2). These biases, which encompass both favorable and unfavorable assessments, are activated involuntarily and without an individual's awareness or intentional control [[4]Greenwald A.G. Banaji M.R. Implicit social cognition: attitudes, self-esteem, and stereotypes.Psychol. Rev. 1995; 102 ([Internet]. [cited 2020 Apr 25]. Available from:): 4-27http://doi.apa.org/getdoi.cfm?doi=10.1037/0033-295X.102.1.4Crossref PubMed Scopus (4066) Google Scholar]. We bring these unconscious biases to all our interactions including patient care and management decisions. When implicit biases are not addressed, they affect working relationships, trust, work productivity, and healthcare outcomes [[5]Chisolm-Straker M. Straker H. Implicit bias in US medicine: complex findings and incomplete conclusions.Int. J. Hum. Rights Healthc. 2017 Mar 13; 10 ([Internet]. [cited 2020 Apr 25]. Available from:): 43-55https://www.emerald.com/insight/content/doi/10.1108/IJHRH-11-2015-0038/full/htmlCrossref Scopus (5) Google Scholar]. In the healthcare setting, we must address unconscious bias at the individual provider, institutional, and national policy levels in order to promote fair treatment of our patients. A few studies have begun to address biases, both implicit and explicit, of patients towards providers [[6]Whitgob E.E. Blankenburg R.L. Bogetz A.L. The discriminatory patient and family: strategies to address discrimination towards trainees.Acad. Med. J. Assoc. Am. Med. Coll. 2016; 91 (Association of American Medical Colleges Learn Serve Lead: Proceedings of the 55th Annual Research in Medical Education Sessions): S64-S69Crossref Scopus (55) Google Scholar]. Acknowledging bias is the first step towards reducing our reliance on generalizations or stereotypes. In a study of African-American cancer patients, providers scoring high on implicit bias tests were viewed as less supportive and spent less time with their patients than providers with low scores. These patients had more difficulty remembering what their physicians told them, less confidence in their treatment plans, and found it more difficult to follow recommended treatments [[7]Penner L.A. Dovidio J.F. Gonzalez R. Albrecht T.L. Chapman R. Foster T. et al.The effects of oncologist implicit racial bias in racially discordant oncology interactions.J. Clin. Oncol. 2016 Aug 20; 34 ([Internet]. [cited 2020 Apr 25]. Available from:): 2874-2880http://ascopubs.org/doi/10.1200/JCO.2015.66.3658Crossref PubMed Scopus (210) Google Scholar]. Implicit biases worsen in times of stress [[8]DeAngelis T. How does implicit bias by physicians affect patients' healthcare?.Monit. Psychol. 2019 Mar; 50 ([Internet]. Available from:): 22https://www.apa.org/monitor/2019/03/ce-cornerGoogle Scholar]. During this high stress COVID-19 environment, implicit bias may be amplified, affecting health outcomes among many of our patients. Emerging data suggests that the COVID-19 pandemic has disproportionately affected many minority populations in the United States (US) (Fig. 3). For health care disparities experts and those caring for vulnerable populations, this is not surprising [[9]Kendi I. Why Don''t We Know Who the Coronavirus Victims Are?.in: The Atlantic [Internet]. 2020 Apr 1https://www.theatlantic.com/ideas/archive/2020/04/stop-looking-away-race-covid-19-victims/609250/Google Scholar]. While news of the pandemic from other countries focused solely on old age, gender, and comorbid condition, reporting in the US has revealed the COVID-19 impact in our communities by race, ethnicity and socio-economic variables. The trends in disparate infection rates, outcomes, and higher mortality have been reported across the country [[10]Richman T. Maryland hasn''t released racial breakdown of coronavirus cases, despite pressure from black lawmakers.in: The Baltimore Sun [Internet]. 2020 Apr 2https://www.baltimoresun.com/coronavirus/bs-md-pol-race-breakdown-coronavirus-20200402-tlpx4bxx7nd6hd3dv2bnis7x6m-story.htmlGoogle Scholar]. The lack of reporting race and ethnicity data affected the initial COVID-19 narrative. Data from ZIP Codes in many regions began to hint at other important disparities. In late March and early April, data from multiple communities began to emerge. On April 3, 2020, ProPublica reported, initial statistics in Milwaukee County, WI, 81% of the deaths from COVID-19 were among Black residents despite comprising only 26% of that county's population [[11]Blow C. Social distancing is a privilege.Publisher Name: The New York Times: Opinionhttps://www.nytimes.com/2020/04/05/opinion/coronavirus-social-distancing.htmlDate: 2020 Apr 5Google Scholar,[12]Johnson A. Buford T. Early data shows African Americans have contracted and died of coronavirus at an alarming rate.https://www.propublica.org/article/early-data-shows-african-americans-have-contracted-and-died-of-coronavirus-at-an-alarming-rateDate: 2020 Apr 3Google Scholar]. These death rates among Black residents in the county continue to be high, currently accounting for 50% of deaths from COVID-19 [[13]Milwaukee County COVID-19 dashboard.https://county.milwaukee.gov/EN/COVID-19Google Scholar]. The Detroit News reported on April 2 that at least 40% of deaths attributed to COVID-19 in Michigan were Black residents, a percentage that far exceeds the proportion of African Americans in the Detroit region and state [[11]Blow C. Social distancing is a privilege.Publisher Name: The New York Times: Opinionhttps://www.nytimes.com/2020/04/05/opinion/coronavirus-social-distancing.htmlDate: 2020 Apr 5Google Scholar,[14]Mauger C. MacDonald C. Michigan''s COVID-19 cases, deaths hit blacks disproportionately.in: The Detroit News [Internet]. 2020 Apr 2https://www.detroitnews.com/story/news/local/michigan/2020/04/02/michigans-covid-19-deaths-hit-417-cases-exceed-10-700/5113221002/Google Scholar,[15]Michigan coronavirus database.https://www.michigan.gov/coronavirus/0,9753,7-406-98163_98173---,00.htmlGoogle Scholar]. In addition, more recent reporting in Chelsea, MA, Chicago, IL, and San Francisco, CA, have revealed local hot spots of COVID-19 among Hispanic/Latino and immigrant communities [[16]Garcia M. Chelsea, city of working Latino immigrants, emerges as a COVID-19 hotspot.https://www.bostonglobe.com/2020/04/07/opinion/chelsea-city-working-latino-immigrant-emerges-covid-19-hotspot/Date: 2020 Apr 7Google Scholar,[17]Husain N. Reyes C. Before data showed Chicago blacks dying at higher rates, communities of color knew recovery from COVID-19 would be slow.https://www.chicagotribune.com/coronavirus/ct-coronavirus-chicago-health-disparities-data-20200410-rf7lmmvgurfwxpxiatebsozwsu-story.html#nt=outfit&nt=feed-flex-featureDate: 2020 Apr 10Google Scholar]. Vulnerable populations including those in nursing facilities, prisons and the homeless have unique risks. Homeless populations are among the most vulnerable to infection with COVID-19. They disproportionately suffer from chronic illnesses including cancer, and "social distancing" is also nearly impossible among this population [[18]Ellis EG. For Homeless People, Covid-19 Is Horror on Top of Horror.in: WIRED [Internet]. 2020 Apr 2https://www.wired.com/story/coronavirus-covid-19-homeless/Google Scholar,[19]Bond A. As Covid-19 surges among San Francisco's homeless, doctors face difficult choices.https://www.statnews.com/2020/04/11/coronavirus-san-francisco-homeless-doctors-difficult-choices/Date: 2020 Apr 11Google Scholar]. One model using pre-COVID-19 health data from Los Angeles and New York City assumes potential 40% infection rates among the homeless and estimates that 4.3% of the nationwide homeless population (~21,295) would require hospitalization [[20]Culhane D. Treglia D. Steif K. Kuhn R. Estimated emergency and observational/quarantine capacity need for the US homeless population related to COVID-19 exposure by county; projected hospitalizations, intensive care units and mortality.http://works.bepress.com/dennis_culhane/237/Date: 2020Google Scholar]. COVID-19 challenges for homeless populations throughout the country have only worsened but are difficult to quantify. Shelters are full, closed, or fraught with COVID-19 transmission risk due to crowded conditions. Despite increased demand among those with unstable housing, common places to find safe shelter such as libraries, gyms, and fast food restaurants are also closed. [[18]Ellis EG. For Homeless People, Covid-19 Is Horror on Top of Horror.in: WIRED [Internet]. 2020 Apr 2https://www.wired.com/story/coronavirus-covid-19-homeless/Google Scholar,[19]Bond A. As Covid-19 surges among San Francisco's homeless, doctors face difficult choices.https://www.statnews.com/2020/04/11/coronavirus-san-francisco-homeless-doctors-difficult-choices/Date: 2020 Apr 11Google Scholar]. Data from rural populations has been limited, but concern about health care system capacity has already demonstrated strain in cancer care delivery and will become increasingly relevant [[21]Williams M. Gelay B. Broad L. The covid-19 crisis is going to get much worse when it hits rural areas.in: The Washington Post [Internet]. 2020 Apr 6https://www.washingtonpost.com/opinions/2020/04/06/covid-19-crisis-is-going-get-much-worse-when-it-hits-rural-areas/Google Scholar]. Granular statistics from the front lines of the COVID-19 pandemic in the US are even more concerning. As providers, we must learn from these data and act to protect our vulnerable patients and diverse communities in urban, rural and suburban settings. New York City (NYC) emerged as one of the epicenters of the coronavirus outbreak, with the highest number of COVID-19 cases (138,435) and deaths (9944) nationwide as of April 21, 2020. Data regarding the racial breakdown of NYC COVID-19 demographic data was not initially available, but it was clear by ZIP Code that certain communities were harder hit [[22]Silva D. So many patients dying: Doctors say NYC public hospital reeling from coronavirus cases.in: NBC News [Internet]. 2020 Mar 30https://www.nbcnews.com/news/us-news/so-many-patients-dying-doctors-say-nyc-public-hospitals-reeling-n1172451Google Scholar]. As of April 3, 2020, the highest case counts by ZIP Codes ranged from 409 to 1245 cases and were concentrated in parts of Brooklyn, Queens and the Bronx, specifically in lower income communities of color although actual race data was not reported until April 8. [[23]Mansoor S. Data suggests many New York City neighborhoods hardest hit by COVID-19 are also low-income areas.Publisher Name: Timehttps://time.com/5815820/data-new-york-low-income-neighborhoods-coronavirus/Date: 2020 Apr 5Google Scholar]. As of April 24, 2020, racial disparities were confirmed by NYC COVID-19 mortality rates reported among both Hispanic/Latino (34%) and Black (28%) communities despite only representing 29% and 22% of the NYC population, respectively. Blacks and Hispanics/Latinos were more likely to die of COVID-19 than all other racial groups (Hispanic/Latino 55.3/100,000, Black 64.6/100,000, White 15.6/100,000, and Asian 33.1/100,000) [[24]New York State Department of Health [Internet] https://covid19tracker.health.ny.gov/views/NYS-COVID19-Tracker/NYSDOHCOVID-19Tracker-Fatalities?%3Aembed=yes&%3Atoolbar=no&%3Atabs=n#/views/NYS%2dCOVID19%2dTracker/NYSDOHCOVID%2d19Tracker%2dMap?%253Aembed=yes&%253Atoolbar=noGoogle Scholar]. In NYC, the concept of social distancing and lockdown for many immigrant and underserved communities is not feasible. Many continue to work and are considered "essential" health care workers, city employees and delivery personnel resulting in higher spread and later presentation to hospitals for treatment. In Louisiana, as of April 21, 2020, there have been 24,854 cases of COVID-19 in all 64 parishes with 1405 deaths. Black patients comprise 56.25% of COVID-19 deaths in Louisiana while comprising only 32% of the state's population. Of the COVID-19 deaths in Louisiana, 56% had hypertension, 35% had diabetes, and 8% had cancer [[25]Louisiana Department of Health [Internet] http://ldh.la.gov/CoronavirusGoogle Scholar]. The overlap between these diseases traditionally linked to SDOH and now COVID related mortality is important to recognize. Chicago first reported racial disparities related to COVID-19 on April 8, 2020 with African Americans representing 52% of those with positive tests and 70% of deaths, although only making up 29% of the population [[26]Ramos E. Zamudio M.I. In Chicago, 70% of COVID-19 Deaths Are Black.in: WBEZ [Internet]. 2020 Apr 5https://www.wbez.org/stories/in-chicago-70-of-covid-19-deaths-are-black/dd3f295f-445e-4e38-b37f-a1503782b507Google Scholar,[27]Spielman F. Lightfoot declares 'public health red alarm' about racial disparity in COVID-19 deaths.https://chicago.suntimes.com/coronavirus/2020/4/6/21209848/coronavirus-covid-19-deaths-racial-disparity-life-expectancy-arwady-lightfootDate: 2020 Apr 6Google Scholar]. Most recent data from April 24, 2020, shows that in a city with 16,200 cases, 43% of cases were in Black residents and 28.5% were in Hispanic/Latino residents. Death rates per 100,000 also show striking differences among racial groups (Black 49.7, Asian 20, Hispanic/Latino 17, White 13.7) [[28]Chicago Department of Public Health [Internet] https://www.chicago.gov/city/en/sites/covid-19/home/latest-data.htmlGoogle Scholar]. The importance of reporting race and ethnicity in COVID-19 data is clear. Similar racial disparities in COVID-19 cases and deaths are now being reported throughout the country. Blame for disparities in outcomes from COVID-19 is often shifted to comorbid conditions that are now identified as risk factors including hypertension, asthma, diabetes and obesity. Increased mortality among people with comorbid illnesses is deemed inevitable and there is "nothing to be done." In gynecologic oncology, we are familiar with how comorbid conditions, many of which are related to inequities in SDOH, can adversely affect cancer care irrespective of race/ethnicity. We must apply active management skills to consider how COVID-19 risks can be mitigated for patients instead of accepting these risks as inevitable. While comorbidities are contributory, other structural concerns surrounding COVID-19 are also important. Although current data is lacking on specific demographics of testing, minority groups and marginalized communities may have had less access to initial testing. Health care providers' implicit racial bias could also influence their decision about who receives a diagnostic coronavirus test or triage. Public health and social media messaging about staying home if ill, coupled with longstanding disenfranchisement from health care access, may have resulted in treatment delays leading to worse outcomes [[29]Levitan R. The infection that's silently killing coronavirus patients.in: The New York Times: Opinion [Internet]. 2020 Apr 20https://www.nytimes.com/2020/04/20/opinion/coronavirus-testing-pneumonia.html?auth=login-email&login=emailGoogle Scholar,[30]Winter T. Enright M. Why did so many New Yorkers with COVID-19 wait until it was too late to call an ambulance?.in: NBC News [Internet]. 2020 Apr 23https://www.nbcnews.com/health/health-care/why-did-so-many-new-yorkers-covid-19-wait-until-n1190111Google Scholar]. In NYC, it became clear that the most vulnerable under-resourced safety-net hospitals serving the most affected communities were quickly overloaded. Factors such as resource allocation, geographic location, and public versus private hospital systems have influenced access to necessary supplies and COVID-19 testing. As a result, state legislation was rapidly implemented to better pool resources to address these disparities [[22]Silva D. So many patients dying: Doctors say NYC public hospital reeling from coronavirus cases.in: NBC News [Internet]. 2020 Mar 30https://www.nbcnews.com/news/us-news/so-many-patients-dying-doctors-say-nyc-public-hospitals-reeling-n1172451Google Scholar,[23]Mansoor S. Data suggests many New York City neighborhoods hardest hit by COVID-19 are also low-income areas.Publisher Name: Timehttps://time.com/5815820/data-new-york-low-income-neighborhoods-coronavirus/Date: 2020 Apr 5Google Scholar,[31]Amid ongoing COVID-19 pandemic Governor Cuomo announces statewide public-private hospital plan to fight COVID-19.Publisher Name: New York State Online Pressroomhttps://www.governor.ny.gov/news/amid-ongoing-covid-19-pandemic-governor-cuomo-announces-new-hospital-network-centralDate: 2020 Mar 30Google Scholar]. The US Department of State Coronavirus Task Force advises, "flattening the curve" through a variety of methods including social distancing. Steps to "flatten the curve" and "shelter in place" come with their own set of inherent racial and economic biases. We must understand that there is a stark difference in who has the "privilege" to stay at home [[11]Blow C. Social distancing is a privilege.Publisher Name: The New York Times: Opinionhttps://www.nytimes.com/2020/04/05/opinion/coronavirus-social-distancing.htmlDate: 2020 Apr 5Google Scholar]. Many white-collar workers have broadband internet and computers, which enable them to easily work from home, while many from poorer neighborhoods do not have this luxury. Only 9.2% of workers in the lowest quartile of the wage distribution can telework, compared with 61.5% of workers in the highest quartile [[11]Blow C. Social distancing is a privilege.Publisher Name: The New York Times: Opinionhttps://www.nytimes.com/2020/04/05/opinion/coronavirus-social-distancing.htmlDate: 2020 Apr 5Google Scholar,[32]Bureau of Labor Statistics Job flexibilities and work schedules — 2017–2018. Data from the American time use survey. [Internet].https://www.bls.gov/news.release/pdf/flex2.pdfDate: 2019 SepGoogle Scholar]. Social distancing is a privilege [[11]Blow C. Social distancing is a privilege.Publisher Name: The New York Times: Opinionhttps://www.nytimes.com/2020/04/05/opinion/coronavirus-social-distancing.htmlDate: 2020 Apr 5Google Scholar]. Those who cannot must make a grave choice between staying at home and risk lost wages or going to work and risk contagion. Minorities also make up a higher percentage of low wage workers who are considered essential and cannot work from home [[33]Fitzhugh E. Florant A. Julien J. Pinder D. Stewart III, S. Wright J. et al.COVID-19: investing in black lives and livelihoods [Internet].Publisher Name: McKinsey & Companyhttps://www.mckinsey.com/industries/public-sector/our-insights/covid-19-investing-in-black-lives-and-livelihoodsDate: 2020Google Scholar]. A recent analysis forecasting COVID-19 effects on Black Americans, revealed that Blacks are overrepresented in all jobs that are considered essential, making up 15% of the entire essential workforce [[33]Fitzhugh E. Florant A. Julien J. Pinder D. Stewart III, S. Wright J. et al.COVID-19: investing in black lives and livelihoods [Internet].Publisher Name: McKinsey & Companyhttps://www.mckinsey.com/industries/public-sector/our-insights/covid-19-investing-in-black-lives-and-livelihoodsDate: 2020Google Scholar]. This includes front-line healthcare occupations, where Blacks make up at least one-third of nursing assistants, orderlies, and psychiatric aides [[33]Fitzhugh E. Florant A. Julien J. Pinder D. Stewart III, S. Wright J. et al.COVID-19: investing in black lives and livelihoods [Internet].Publisher Name: McKinsey & Companyhttps://www.mckinsey.com/industries/public-sector/our-insights/covid-19-investing-in-black-lives-and-livelihoodsDate: 2020Google Scholar]. In the health care sector, many low-wage jobs including environmental services, transport, and food services are positions held by Blacks, Hispanics/Latinos, and Asians. As health care providers for women, it is important to highlight that 1 in 3 women hold jobs defined as essential, with higher rates found among non-white women [[34]Robertson C. Gebeloff R. How Millions of Women Became the Most Essential Workers in America.in: The New York Times [Internet]. 2020 Apr 18https://www.nytimes.com/2020/04/18/us/coronavirus-women-essential-workers.htmlGoogle Scholar]. Poverty, lack of savings, and unstable housing increase vulnerability to COVID-19. Urban low-wage workers must often use crowded mass transportation and risk exposure. We must recognize and empathize with what it is like to be poor in the US: to live in a too-small space with too many people, to not have enough money to stockpile food for a long duration, and to live in a food desert. We must be acutely aware of the role these factors have on our patients and how it impacts their health decisions. Another critical consideration is how the COVID-19 pandemic has affected the diverse Asian and Asian-American communities throughout this country. A rise in the incidence of verbal, physical, and violent attacks against Asian Americans has been reported throughout the US. Promotion of hateful rhetoric like labeling SARS-COV-2 virus the "Chinese Virus" has resulted in increasing anti-Asian sentiments and bigotry [[35]Margolin J. FBI warns of potential surge in hate crimes against Asian Americans amid coronavirus.in: ABC News [Internet]. 2020 Mar 27https://abcnews.go.com/US/fbi-warns-potential-surge-hate-crimes-asianamericans/story?id=69831920Google Scholar]. Americans of Asian descent need to know they will be protected not just from COVID-19 but also from violence, harassment, and discrimination. The Asian-American community is not homogenous and includes many countries of origin including East Asia, Southeast Asia and South Asia. Many subsets of Asian communities also suffer from poverty and face the same health care disparities and SDOH as other minority groups, especially during the COVID-19 crisis. Approximately 20% of the nation's front-line health care workers are immigrants, representing many countries of origin in Asia. In 2019, the Association of American Medical Colleges reported that 17% of doctors practicing in the United States were of Asian descent [[36]American Association of Medical Colleges U.S. physician workforce data. Diversity in medicine: facts and figures 2019 [Internet].https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018Google Scholar]. The virus of hate puts Asians and Asian-American members within our own gynecologic oncology community and the patients they serve in double jeopardy [[37]Zia H. Targeting Asians and Asian Americans will make it harder to stop covid-19.Publisher Name: The Washington Posthttps://www.washingtonpost.com/opinions/2020/04/02/targeting-asians-asian-americans-will-make-it-harder-stop-covid-19/Date: 2020 Apr 2Google Scholar]. This cannot be tolerated. SGO—like many leading medical organizations including the American College of Surgeons—condemns such bias and bigotry and encourages reporting of any such incidences [[38]American College of Surgeons ACS statement on discrimination [Internet].https://www.facs.org/covid-19/discriminationDate: 2020Google Scholar]. The most accurate and salient information on patients' needs comes from patients themselves. In oncology, large and powerful advocacy groups that represent patient perspectives, fund research and set priorities for future knowledge. In clinical research, patient-reported outcome measures of toxicity are incorporated into clinical trial protocols [[39]Basch E. Reeve B.B. Mitchell S.A. Clauser S.B. Minasian L.M. Dueck A.C. et al.Development of the National Cancer Institute's patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE).J. Natl. Cancer Inst. 2014 Sep; 106Crossref Scopus (632) Google Scholar], and in practice, use of patient-reported measures has a survival benefit [[40]Basch E. Deal A.M. Dueck A.C. Scher H.I. Kris M.G. Hudis C. et al.Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment.JAMA. 2017; 318 (11): 197-198Crossref PubMed Scopus (1309) Google Scholar]. Organizations focused on advocacy, cancer navigation, and support, have quickly mobilized to address the psychosocial, health, and financial needs at the national and local level, and through online and media presences. [[39]Basch E. Reeve B.B. Mitchell S.A. Clauser S.B. Minasian L.M. Dueck A.C. et al.Development of the National Cancer Institute's patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE).J. Natl. Cancer Inst. 2014 Sep; 106Crossref Scopus (632) Google Scholar]. A gap remains among organizations specifically serving the marginalized populations in gynecologic oncology. Groups focusing specifically on underserved communities, although limited, are trusted networks that are now mobilizing to address COVID-19 needs [[40]Basch E. Deal A.M. Dueck A.C. Scher H.I. Kris M.G. Hudis C. et al.Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment.JAMA. 2017; 318 (11): 197-198Crossref PubMed Scopus (1309) Google Scholar,[41]Blank S. Frey M. What the COVID-19 crisis means for gynecologic cancer patients [Internet].https://www.foundationforwomenscancer.org/webinar-on-covid-19-and-gyn-cancer-patients/Date: 2020Google Scholar]. The Endometrial Cancer Action Network for African Americans (ECANA) is one organization that started in response to these gaps, and has taken one step in the journey to meaningful national engagement among marginalized communities in gynecological oncology [[42]Endometrial Cancer Action Network for African-Americans [Internet] https://ecanawomen.org/Google Scholar]. ECANA members are experiencing first-hand the statistics reported in this paper including close contacts infected with COVID-19, the inability to socially isolate, and the need to continue working. Yet at the same time, demonstrating the power of the patient voice and community partnership, these women are promoting strong evidence-based public health messaging using both ECANA and personal social media platforms to limit the impact of the pandemic [[42]Endometrial Cancer Action Network for African-Americans [Internet] https://ecanawomen.org/Google Scholar]. They communicated the importance of staying home, social distancing, strategies for self-care, and addressing the frustration, and anger of the racial disparities related to COVID-19. When pandemics such as COVID-19 occur, the marginalized populations will always be at highest risk. Without the power of immediate connection with community-based groups, we as clinicians risk a costly delay in recognizing, assessing, and intervening to mitigate their extra vulnerability. Moving forward we can invest and engage with marginalized communities to provide real-time information and actionable solutions to blunt the impact of structural bias in our healthcare system and society. We conclude this statement with a call to action. SGO advocates for the continued support of all our patients and health care personnel providing cancer care during this turbulent time. SGO and the American Society of Clinical Oncology (ASCO) have published guidelines about adapting oncology care during this pandemic [[43]Gynecologic oncology considerations during the COVID-19 pandemic [Internet].Publisher Name: Society of Gynecologic Oncologyhttps://www.sgo.org/clinical-practice/management/covid-19-resources-for-health-care-practitioners/gyn-onc-considerations-during-covid-19/Date: 2020Google Scholar,[44]COVID-19 patient care information. [Internet].Publisher Name: American Society of Clinical Oncologyhttps://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19Date: 2020Google Scholar]. These recommendations are made to safely care for patients; however, underserved populations face significant barriers to adhering to these guidelines. Creative solutions must be considered to address these barriers; however, identification and acknowledgment that they exist is the first step. These guidelines must be tailored to address the specific needs and resources of our patients and their communities (Fig. 4). Cancer care delivery should be performed without the specter of discrimination, racism, implicit or explicit bias, and should factor in the social determinants of health in order to identify focused solutions. First, to be successful, organizations must acknowledge and know the historical context, cycles, systems, and structures that make minority and underserved communities at risk. Others who are marginalized include people from rural communities, the elderly, people with disabilities, women in prison, and members of the LGBTQ community. These groups also face exacerbated disparities in the COVID-19 era. Creating social capital by training and positioning community advocates and leaders in key positions is necessary to foster meaningful community shared governance to respond to this crisis and promote long-term health equity. Second, we must continue to advocate for policy at the local, state and national levels that increases equitable health care access and quality. Despite the Affordable Care Act's original intent to expand coverage to nearly all Americans, about 3 million remain uninsured [[45]Garfield R. Orgera K. Damico A. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid.in: Kaiser Commission on Medicaid and the Uninsured, The Henry J Kaiser Family Foundation [Internet]. 2020 Jan 14https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/Google Scholar,[46]Grogan C.M. Park S. (Ethan) The racial divide in State Medicaid expansions.J. Health Polit. Policy Law. 2017 Jun; 42 ([Internet]. [cited 2020 Apr 25]. Available from:): 539-572https://read.dukeupress.edu/jhppl/article/42/3/539-572/13927Crossref PubMed Scopus (63) Google Scholar]. In the Medicaid non-expansion states, over half of low-income Americans who were uninsured in 2010 remain without access to affordable coverage. These Americans fall in the so-called coverage gap: they are not poor enough to qualify for traditional Medicaid, and yet do not earn enough to qualify for subsidies on the exchange. We must advocate for closing this loophole in coverage, which disproportionately affects underserved patients. This effort will be even more necessary as more cancer patients are left financially vulnerable, out of work and lacking insurance due to the COVID-19 crisis. As gynecologic oncology practitioners, we should continue to have frank conversations with our patients with regards to COVID-19 symptoms as well as questions about changing financial concerns, safe home environments, access to care, food and housing. Being honest about our individual implicit biases (since we all have them) is critical. Self-evaluation of comfortable and less comfortable spaces/circumstances is important to overcome these biases [[47]Forscher P.S. Mitamura C. Dix E.L. Cox W.T.L. Devine P.G. Breaking the prejudice habit: mechanisms, timecourse, and longevity.J. Exp. Soc. Psychol. 2017 Sep; 72 ([Internet]. [cited 2020 Apr 25]. Available from:): 133-146https://linkinghub.elsevier.com/retrieve/pii/S0022103116306436Crossref PubMed Scopus (130) Google Scholar]. We should collaborate with our medical colleagues to actively manage ongoing comorbid conditions for our patients as these may influence treatment options for cancer during the pandemic and worsen outcomes related to both. As cancer care providers, we see these circumstances daily and often help negotiate our patients through them towards the goal of equitable care. We must continue to work with our colleagues in social work and advocacy organizations, many of which have quickly adapted to the crisis and are providing online resources for groups and individuals. This crisis should create new opportunities for collaborations with community organizations that can be integrated to better serve our patients now and in the future. Many patient advocates are well positioned to help lead these efforts. As our routine workflows have been altered, we must think outside of current care delivery models and be both bold and creative. Finally, both individual physicians and health care systems must prioritize, ensuring cancer health equity and improving social determinants of health. Promoting economic stability, physical environment, education, and access to healthy food that affect our patients' ability to comply with public health recommendations and our recommended treatments, will influence their outcomes from both cancer and COVID-19. Meaningful community engagement at the level of the individual provider and our health care systems should be prioritized as we realize that we must collaborate to understand local needs and address them in sustainable ways. Institutional efforts and interventions can also be effective to address implicit bias. These efforts include conducting climate assessments, using evidence-based questionnaires, giving leaders feedback on that data, and providing ongoing training [[48]Penner L.A. Gaertner S. Dovidio J.F. Hagiwara N. Porcerelli J. Markova T. et al.A social psychological approach to improving the outcomes of racially discordant medical interactions.J. Gen. Intern. Med. 2013 Sep; 28 ([Internet]. [cited 2020 Apr 25]. Available from:): 1143-1149http://link.springer.com/10.1007/s11606-013-2339-yCrossref PubMed Scopus (56) Google Scholar]. It is imperative to harness our energy to research and develop ways to diminish the heightened impact of glaring health care disparities and discrimination the pandemic has brought to the forefront. COVID-19 has exposed the tragic vulnerabilities of many of our patients and communities but has also revealed the depth of resiliency in providers, in community organizations, and in our cancer patients. Our experience addressing COVID-19 disparities in gynecologic cancer patients can translate to a more holistic dialogue about health equity, bringing all stakeholders to the discussion. We all experience a health benefit if the health outcomes of those at the margins improve. John H. Farley: Conceptualization, writing original draft, review and editing. Jeffrey Hines Writing, original draft, review and editing. Nita K. Lee Investigation, writing original draft, review and editing. Sandra E. Brooks: Writing, writing original draft, review, editing, supervision. Navya Nair: Investigation, methodology, writing, original draft, review and editing. Kemi M Doll: Writing original draft. Carol L. Brown: Conceptualization, writing, review and editing. Ellen J. Sullivan: Project administration, review and editing. Eloise Chapman-Davis: Conceptualization, investigation, data curation, writing original draft, visualization, review, editing, supervision. Dr. Brooks reports no conflicts. Dr. Brown is the Associate Cancer Center Director for Diversity & Health Equity at Memorial Sloan Kettering Cancer Center and was Immediate Past-President of the Society of Gynecologic Oncology when the manuscript was being written. Dr. Chapman-Davis reports no conflicts. Dr. Doll reports no conflicts. Dr. Farley reports no conflicts. Dr. Hines reports no conflicts. Dr. Nair reports personal fees from Intellisphere, LLC DBA Targeted Healthcare Communications, outside the submitted work. Dr. Lee reports no conflicts. Ms. Sullivan reports no conflicts.

Racial and ethnic diversity has historically been difficult to achieve in National Cancer Institute-sponsored clinical trials, even while as many as 80% of those trials have faced difficulty in meeting overall recruitment targets. In an attempt to address these issues, NRG Oncology recently convened a comprehensive workshop titled "Clinical Trials Enrollment: Challenges and Opportunities." Discussants at the workshop included representatives of the three legacy groups of the NRG (ie, Gynecologic Oncology Group, National Surgical Adjuvant Breast and Bowel Program, and Radiation Therapy Oncology Group), a minority-based community clinical oncology program, a large integrated health care system, the leadership of the National Cancer Institute, and a large patient advocacy group. This article summarizes the concepts discussed at the workshop, which included: needs assessments, infrastructural support, training of investigators and research staff, specific clinical trial recruitment strategies (both system and community based), and development and mentoring of young investigators. Many new, more specific tactics, including use of diverse cancer care settings, direct-to-consumer communication, and the need for centralized information technology such as the use of software to match trials to special populations, are presented. It was concluded that new, innovative trial designs and the realities of limited funding would require the adoption of effective and efficient recruiting strategies, specialized training, and stakeholder engagement. US clinical research programs must generate and embrace new ideas and pilot test novel recruitment strategies if they are to maintain their historic role as world leaders in cancer care innovation and delivery.

Objective: To describe the initial outcomes of an incentive driven medical home and navigation program on preventive services among healthcare system employees. Methods: Quasi-experimental design examining participation, use of preventive services and adherence to medical guidelines and emergency room use in a five hospital integrated health system. Employees were required to complete a health risk assessment (HRA), visit a Primary Care Provider (PCP) and submit PCP visit screening and biometric results in order to be eligible for the financial incentives. Subsidized lifestyle change intervention and navigation programs were also offered to participants. Descriptive statistics and Chi Square were used to analyze results for the 5,435 employee participants and 3,623 non-participants during thee 1-year intervention. Results: Preventive care visits for participants increased by 35% compared to an increase of 3% for non-participants. Nonadherence to medical guidelines decreased 7% for participants and increased 18% for non-participants. Inappropriate emergency room use overall decreased from 20% to 14%. Conclusions: One year after introduction of the wellness program, preventive visits increased, compliance with medical care increased and inappropriate emergency room visits were reduced.

PURPOSE:The aim of this study was to identify patient and physician factors related to enrollment onto Gynecologic Oncology Group (GOG) trials. METHODS:Prospective study of women with primary or recurrent cancer of the uterus or cervix treated at a GOG institution from July 2010 to January 2012. Logistic regression examined probability of availability, eligibility and enrollment in a GOG trial. Odds ratios (OR) and 95% confidence intervals (CI) for significant (p<0.05) results reported. RESULTS:Sixty institutions, 781 patients, and 150 physicians participated, 300/780 (38%) had a trial available, 290/300 had known participation status. Of these, 150 women enrolled (59.5%), 102 eligible did not enroll (35%), 38 (13%) were ineligible. Ethnicity and specialty of physician, practice type, data management availability, and patient age were significantly associated with trial availability. Patients with >4 comorbidities (OR 4.5; CI 1.7-11.8) had higher odds of trial ineligibility. Non-White patients (OR 7.9; CI 1.3-46.2) and patients of Black physicians had greater odds of enrolling (OR 56.5; CI 1.1-999.9) in a therapeutic trial. Significant patient therapeutic trial enrollment factors: belief trial may help (OR 76.9; CI 4.9->1000), concern about care if not on trial (OR12.1; CI 2.1-71.4), pressure to enroll (OR .27; CI 0.12-.64), caregiving without pay (OR 0.13; CI .02-.84). Significant physician beliefs were: patients would not do well on standard therapy (OR 3.6; CI 1.6-8.4), and trial would not be time consuming (OR 3.3; CI 1.3-8.1). CONCLUSIONS:Trial availability, patient and physician beliefs were factors identified that if modified could improve enrollment in cancer cooperative group clinical trials.

Objectives: To identify factors related to availability, eligibility, and enrollment in GOG cervical and uterine cancer trials.

Mobile health units are increasingly utilized to address barriers to mammography screening. Despite the existence of mobile mammography outreach throughout the US, there is a paucity of data describing the populations served by mobile units and the ability of these programs to reach underserved populations, address disparities, and report on outcomes of screening performance. To evaluate the association of variables associated with outcomes for women undergoing breast cancer screening and clinical evaluation on a mobile unit. Retrospective analysis of women undergoing mammography screening during the period 2008–2010. Logistic regression was fitted using generalized estimating equations to account for potential repeat annual visits to the mobile unit. In total, 4,543 mammograms and/or clinical breast exams were conducted on 3,923 women with a mean age of 54.6, 29 % of whom had either never been screened or had not had a screening in 5 years. Age < 50 years, lack of insurance, Hispanic ethnicity, current smoking, or having a family relative (<50 years of age) with a diagnosis of cancer were associated with increased odds of a suspicious mammogram finding (BIRADS 4,5,6). Thirty-one breast cancers were detected. The mobile outreach initiative successfully engaged many women who had not had a recent mammogram. Lack of insurance and current smoking were modifiable variables associated with abnormal screens requiring follow up.

More businesses are utilizing employee wellness programs to improve the health of their employees (improve productivity levels, reduce absenteeism and reduce disability claims) while reducing health care costs. The success of any wellness program depends on three main rudiments: 1) identifying factors that driving up the healthcare cost within the organization such as: smoking, diabetes, back pain, or other chronic conditions. 2) Engagement level of employees in the wellness programs 3) Barriers to achieving expected engagement level. The real challenge for any wellness program is to incorporate data from different e.g. Health Risk Assessment (HRA), demographics, medical claims data, and qualitative input to build a comprehensive wellness program which incorporates the needs of the business population. Promoting health and wellness is a process, so it requires ongoing evaluation and monitoring to ensure employee satisfaction, and to ensure it is meeting the needs of employer along with supporting positive health behavior among employees. SAS® Enterprise Guide® is a comprehensive tool for reporting and analyses which aids wellness program development and adaptation. We describe the use of the Enterprise Guide to identify trends in medical conditions and predict future needs of the program.

Abstract Objective: There is much debate regarding the efficacy of mammography screening in women <50. No cost and low cost service providers may be required to target screening to the population at highest risk in order to maximize utility of resources. We sought to describe outcomes of women >40 undergoing mammography screening in underserved areas through a mobile unit and prevention program affiliated with a large network cancer program in Louisville, Kentucky. Methods: We conducted a retrospective review of women undergoing mammography during the period 3/08-6/09. Locations determined to be high risk by GIS analysis, income and cancer incidence. Analyses included: descriptive analyses, calculation of odds ratios and confidence intervals and regression analyses. Results: Of the 1702 women, 735 (43%) were white, 884 (52%) were African American, 54 (3%) other and 236 (14%) Hispanic/Latina. The mean age was 54 (std.dev. 9.4). Twenty-eight percent of the women (471/1702) had either never had a mammogram or not had one in 5 years. Fifty-one percent were uninsured. Of the 1702 women, 662(39%) were between the ages of 40-49 (Group A) and 1040 (61%) were >49 (Group B). The majority of women resided in high risk areas (74% Group A, 51% Group B). Twelve percent (206/1702) of the mammograms were abnormal and required follow up. Women in Group A were 1.4 times more likely than women in Group B to have a screening mammogram classified as abnormal (OR 1.4 95% CI 1.05-1.88). Four women were diagnosed with cancer in group A (0.6%) and 9 in group B (0.8%), P = ns. The median age of women with cancer was 52, mean = 58, range 42-83, (std. dev. 12.5). The overall follow up rate was 92%. All women with cancer received treatment. Logistic regression analysis demonstrated women of African American race and women who had never been screened were more likely to have abnormal results (P < 0.0001 and P = 0.03 respectively). Conclusion: Our targeted approach of community based screening was successful in identifying a subpopulation of women who are not regularly screened and are at risk for abnormal screening mammograms and breast cancer. Further studies are needed to determine if recommendations for screening should be based on factors other than age.

Purpose To determine the prevalence of insulin resistance and other risk factors for cardiovascular disease (CVD) in young adult survivors of childhood acute lymphoblastic leukemia (ALL). Patients and Methods In this cross-sectional evaluation of 118 survivors of childhood ALL (median age, 23.0 years; range, 18 to 37 years), insulin resistance was estimated using the homeostasis model for assessment of insulin resistance (HOMA-IR). Sex-specific comparisons were made with a cohort of 30- to 37-year-old individuals from the same region participating in the Dallas Heart Study (DHS, N = 782). ALL survivors were stratified by treatment with and without cranial radiotherapy (CRT). Results Female ALL survivors had a significantly higher HOMA-IR (CRT, mean 4.6, 95% CI, 3.6 to 5.7; no CRT, mean 3.3, 95% CI, 2.8 to 3.8) in comparison with DHS women (mean 2.4, 95% CI, 2.2 to 2.7). Eighty percent of women treated with CRT had at least three of six CVD risk factors, and they were significantly more likely to have three or more risk factors compared with DHS women (odds ratio [OR], 5.96; 95% CI, 2.15 to 16.47). Male ALL survivors had a significantly higher HOMA-IR (CRT, mean 4.0, 95% CI, 2.8 to 5.6; no CRT, mean 3.4, 95% CI, 2.9 to 3.9) in comparison with DHS men (mean 2.3, 95% CI, 2.1 to 2.6), but were not more likely to have multiple CVD risk factors. Conclusion ALL survivors had an increased prevalence of insulin resistance in comparison with a cohort of older individuals from the same community. Importantly, women treated with CRT seem to have an increased prevalence of multiple CVD risk factors, warranting close monitoring and risk-reducing strategies.

Background: The cancer incidence and mortality rate in Jefferson County is among the highest in the nation and nearly half of women with breast cancer have not had a recent mammogram at the time of diagnosis. Mobile Health Units are in use in a number of communities, however, there is a paucity of data describing the outcomes of women utilizing these units. We sought evaluate the demographics of the population of women utilizing a mobile health unit and the ability of a mobile health unit to reach rarely and never screened, low income women. Methods: We utilized Community Guide recommendations to encourage mammography screening on our Mobile Health Unit equipped with digital mammography and a clinical exam room. Women ≥ 40 without screening in > 1 year were eligible. We screened women in > 50 locations throughout Jefferson county, a county in which 11% overall are uninsured. The general population is 76% Caucasian, 20%African American, 4% other, 3% Hispanic. We utilized telephone reminders, offered no cost mammograms to the uninsured, one on one education and promoted screening via community partners and small media. After 6/08 we instituted a dedicated nurse navigator for follow up. We used geographic information system mapping to define areas of high poverty and high mortality (high need). We conducted a retrospective review of all women undergoing mammography screening on our unit during the period 3/08–10/08. We performed descriptive analysis, McNemar and Chi Square to determine the differences between two groups. Results: Complete data were available for 746 women. The mean age was 53, 48% (359/746) were Caucasian, 47% (352/746) were African American, 5% were other races and 14% (102/746) were Hispanic/Latina. Forty-seven percent were not insured, 34% were privately insured, 14% were covered by Medicare or Medicaid, 5% not recorded. Thirty-one percent had never had a mammogram, or had not had one in > 5 years. Ninety-five women needed diagnostic follow up, 6 were suspicious for malignancy. The mean age of the 4 patients diagnosed with cancer was 51, none of whom initially had insurance. Two of the 4 were rarely/never screened. Adherence to follow-up was 80% before 6/08 and 92% after the navigator intervention. Forty- six percent were screened in a high need area. The rate of rarely/never screened was higher in the high need areas compared to the other screening locations 36% vs. 28%, p Conclusions: We successfully reached a large percentage of rarely and never screened women by deploying a Mobile Health Unit in partnership with community organizations and evidence based interventions. Individual counseling is critical to ensuring follow-up.

OBJECTIVE: This study was undertaken to compare toxicity and outcomes from cisplatin-based combination chemotherapy for black and white women with advanced/recurrent cervical cancer.STUDY DESIGN: Frequencies of grade 3 and 4 toxicities, response, and survival were compared by race using data from 3 Gynecologic Oncology Group studies.RESULTS: Black women experienced significantly less grade 3 and 4 neutropenia (63% vs 82%), leukopenia (58% vs 79%), thrombocytopenia (10% vs 23%), and adverse events of any nature (84% vs 93%) compared with white women. Black patients were not at increased risk of disease progression (adjusted relative risk, 1.11; 95% confidence interval, 0.88-1.38; P = .382) or death (adjusted relative risk, 1.02; 95% confidence interval, 0.82-1.26; P = .893).CONCLUSION: Cisplatin-based chemotherapy delivered in a protocol setting for advanced/recurrent carcinoma of the cervix appears better tolerated by black women.

Context: Survivors of childhood acute lymphoblastic leukemia ( ALL) become obese, and are at increased risk for morbidity and mortality post therapy.Objective: We determined the association of cranial radiotherapy ( CRT) and/or sex with levels of total, regional, and ectopic fat storage, metabolic risk, IGF-I, and leptin in adult ALL survivors.Design, Setting, Patients: A cross-sectional analysis of 52 male ( 15 CRT treated) and 62 female ( 24 CRT treated) young adult ALL survivors was conducted.Main Outcomes: We assessed levels of visceral fat, sc abdominal and thigh fat, and liver and muscle fat using computed tomography, total fat and lean body mass using dual-energy x-ray absorptiometry, and IGF-I and leptin levels by radioimmunoassay.Results: Controlled for age and race, ALL survivors treated with CRT had higher levels of abdominal and visceral fat, body fat percentage, metabolic risk ( insulin resistance and dyslipidemia), and leptin but lower lean mass and IGF-I levels than non-CRT survivors ( P <= 0.05 for each). Levels of IGF-I were inversely associated with total, abdominal, and visceral fat in both sexes ( P <= 0.05 for each). Female ALL survivors had less lean mass and visceral fat but higher total and sc abdominal fat than males ( P < 0.05 for each). Neither sex nor CRT was associated with muscle and/ or liver fat content ( P > 0.1).Conclusion: Among young adult ALL survivors, CRT is a risk factor for elevated total, abdominal, and visceral adiposity, a reduced fat-free mass, elevated metabolic risk, and altered IGF-I and leptin levels.

BACKGROUND:The objective of this study was to provide a detailed description of comprehensive long-term follow-up (LTFU) programs for pediatric cancer survivors.METHODS:Program directors from 24 comprehensive LTFU programs in the U.S. and Canada completed a 6-page survey that provided details in 5 categories: description of the program, perceived benefits and strengths of the program, barriers to the development and use of the program, methods to improve the program, and an ideal model of care for pediatric cancer survivors.RESULTS:Participants identified the following primary benefits to health care delivered to survivors through LTFU programs: health care delivered by clinicians familiar with long-term risks of survivors, provision of risk-based screening and surveillance for late effects, and targeted education for risk reduction and healthy lifestyles. Key barriers to the functioning of LTFU programs included system-driven and patient/survivor-driven factors. System-driven factors included inadequate resources and finances to sustain programs, low institutional commitment toward the provision of survivorship care, lack of capacity to care for the growing population of survivors, and difficulties with ongoing communication with community physicians. Survivor-driven barriers included lack of interest and lack of awareness of cancer-related risks.CONCLUSIONS:This report describes the frequency, content, and setting of follow-up care delivered by pediatric comprehensive LTFU programs. Critical challenges as survivorship care evolves will include integrating a structured process of program evaluation and building capacity for care.

The unequal burden of cancer in minority and underserved communities nationally and in Maryland is a compelling crisis. The Maryland Special Populations Cancer Research Network (MSPN) developed an infrastructure covering Maryland's 23 jurisdictions and Baltimore City through formal partnerships between the University of Maryland School of Medicine, University of Maryland Statewide Health Network, University of Maryland Eastern Shore, and community partners in Baltimore City, rural Eastern Shore, rural Western Maryland, rural Southern Maryland, and Piscataway Conoy Tribe and statewide American Indians. Guided by the community-based participatory framework, the MSPN undertook a comprehensive assessment (of needs, strengths, and resources available) that laid the foundation for programmatic efforts in community-initiated cancer awareness and education, research, and training. The MSPN infrastructure was used to implement successful and innovative community-based cancer education interventions and technological solutions; conduct education and promotion of clinical trials, cancer health disparities research, and minority faculty cancer research career development; and leverage additional resources for sustainability. MSPN engaged in informed advocacy among decision- and policyrnakers at state and national levels, and its community-based clinical trials program was recognized by the U.S. Department of Health and Human Services as a Best Practice Award. The solutions to reduce and eliminate cancer health disparities are complex and require comprehensive and focused multidisciplinary cancer health disparities research, training, and education strategies implemented through robust community-academic partnerships.

Restricted accessAbstractFirst published January 2006The Impact of Psychosocial Factors on Access to Care in Adult Minority Survivors of Childhood Cancer: A Childhood Cancer Survivor StudyJ. Casillas, S. Brooks, […], A. Mertens, M. Hudson, L. Robison, and K Oeffinger+3-3View all authors and affiliationsVolume 54, Issue 1_supplhttps://doi.org/10.1177/108155890605401S26

While ovarian tumors demonstrate considerable amount of biologic and histologic diversity, there is considerable overlap in their radiologic appearance, making their distinction difficult on radiologic or gross examination alone. The patient's age, family history, the presence of bilateral masses and the presence or absence of elevated tumor markers may narrow the differential diagnosis. In the following article, we will review the epidemiologic, clinical, and prognostic factors associated with the most common ovarian neoplasms.