74-year-old male with a history of hypertension and smoking, is having dinner with his wife when he develops sudden onset of difficulty speaking, with drooling from the left side of his mouth, and weakness in his left hand. His wife asks him if he is all right and the patient denies any difficulty. His symptoms progress over the next 10 minutes until he cannot lift his arm and has trouble standing. The patient continues to deny any problems. The wife sits the man in a chair and calls 911. The EMS squad arrives within 5 minutes. Upon arrival in the ED, patient‘s blood pressure was 178/94, pulse 78 and regular, PaO2 97% on room air. Neuro exam – Cranial nerves- Mild left facial droop. Motor- Right arm and leg extremity with 5/5 strength. Left arm cannot resist gravity, left leg with mild drift. Sensation intact. Neglect- Mild neglect to left side of body. Language- Expressive and receptive language intact.
Mild to moderate dysarthria. Able to protect airway.
Please do a 1 to 2-page case study analysis. In your Case Study Analysis related to the scenario provided, explain the following:
• Both the neurological and musculoskeletal pathophysiologic processes that would account for the patient presenting these symptoms.
• Any racial/ethnic variables that may impact physiological functioning.
• How these processes interact to affect the patient.
resources
McCance, K. L. & Huether, S. E. (2019). Pathophysiology: the biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier.
Chapter 15: Structure and Function of the Neurologic System
Chapter 16: Pain, Temperature Regulation, Sleep, and Sensory Function (stop at Sleep); Summary Review
Chapter 17: Alterations in Cognitive Systems, Cerebral Hemodynamics, and Motor Function (start at Acute confusional states and delirium) (stop at Alterations in neuromotor functions); (Parkinson’s Disease); Summary Review
Chapter 18: Disorders of the Central and Peripheral Nervous Systems and the Neuromuscular Junction (stop at Degenerative disorders of the spine); (start at Cerebrovascular disorders) (stop at Tumors of the central nervous system); Summary Review
Chapter 44: Structure and Function of the Musculoskeletal System (stop at Components of muscle function); Summary Review
Chapter 45: Alterations of Musculoskeletal Function (stop at Bone tumors); (start at Disorders of joints); Summary Review
Chapter 47: Structure, Function, and Disorders of the Integument (section on Lyme Disease)
Chin, L. S. (2018). Spinal cord injuriesLinks to an external site.. Retrieved from https://emedicine.medscape.com/article/793582-overview#a4
write 200-250 words that respond to the following questions with your thoughts, ideas, and comments. This will be the foundation for future discussions by your classmates. Be substantive and clear, and use examples to reinforce your ideas.
The general manager of a business encounters many different types of business transactions. Provide an example for each of the following transactions that would describe its effect on the accounting equation. Each situation is independent of the other situations.
The transaction would increase an asset account and increase a liability account.
The transaction would decrease an asset account and decrease the owner’s equity account.
The transaction would increase an asset account and increase the owner’s equity account.
The transaction would decrease an asset account and decrease a liability account.
For this writing assignment, let’s focus on developing an essay based on the “five-paragraph” structure. Following that structure means that your paper should include one paragraph for the Introduction, three paragraphs for the Body, and one paragraph for the Conclusion. You do not have to label your paragraphs as Introduction, Body, Conclusion.
Using this structure should allow you to present your position in sufficient depth. Don’t worry if you end up writing six paragraphs. The point here is to give you guidance on the basic structure to be used for this assignment.
Here are some tips to help you set up the formatting for your essay. We recommend you use the Microsoft Word application from your Bellevue University Office 365 account.
Formatting
· Start by putting your name, the course name, and the date in the upper-left corner of the document, as shown above.
· Select the “Layout” option above to set you “Margins” select the 1-inch margins for all sides.
· Select the “Home” button option above and locate the “Line and Paragraph Spacing” button and select “2.0” which is double spacing, this should be set for the entire essay.
· Remember Not to add additional spacing between paragraphs only the double spacing.
· Ensure that you indent the first line of each new paragraph ½ inch, this can be done by pressing the “tab” button on your keyboard.
From the “Home” tab in Microsoft Word, select “Times New Roman” as the Font Name and “12” as the Font Size.
Next, go to the “Layout” tab to set up your margins. Under the Margins dropdown, select Normal for 1-inch margins all around.
Introduction
The introduction should be a minimum of three sentences in length. Use the first two sentences to provide the context for your paper. You should clearly state the position you are taking so that you get the reader’s attention and guide them toward your claim. The last sentence of the introduction is the thesis statement (i.e., argument) and it should identify what is going to be discussed in the body of the paper. Because the body is supposed to consist of three paragraphs, it is a good practice to break down your thesis into three main ideas that support your position. See the example below.
Back when my mom did all my laundry, I just threw all my clothes into a pile and didn’t worry about how everything was washed. However, now that I have experience doing my own laundry, I must stress the importance of properly separating clothes into “whites,” “lights,” and “darks” or you will risk ruining your wardrobe. If you do not want ruin your clothes, then you should follow the steps I am about to describe for managing your laundry.
Body
The paragraphs in the body should develop the main ideas of your thesis. Write three paragraphs for the three points or pieces of evidence. The paragraphs should be about 5-8 sentences in length and provide sufficient details that explain what is meant by each of the main ideas in your thesis. Be sure to introduce and summarize each main idea in the individual paragraphs.
Each body paragraph should start with a transition into the topic—words or phrases like “First,” or “Another important point is,” See the example below.
First, I recommend making piles for white, light, and dark clothing. Your white pile should be for articles such as socks, underwear, and t-shirts. (Continue to explain this point in the remaining sentences)
Next, continue separating your colors into piles for light and dark clothing. (Continue to explain this point in the remaining sentences)
Finally, your dark pile should have gray, black, purple, dark blue, and so forth. (Continue to explain this point in the remaining sentences)
Conclusion
The concluding paragraph will recap the thesis and the main ideas presented in the introduction and body of the paper. Briefly restate the main points of your essay and tell the audience why you are right. Tie your topic to a bigger point so that your audience understands the significance of your position.
Remember, you cannot stick a red towel into a load of white laundry without damaging the rest of the clothes in that load. So the next time you set out to do your laundry, make sure you follow the steps outlined above for separating your clothes before washing them. Following these steps might even save you money in the long run because you will not have to buy new clothes to replace the ones that get ruined by improperly separated laundry.
If you use any references or quote another writer, be sure to add a References section at the end of your paper. For each reference, be sure to include the Title, Author, Date, and URL if available. If you have more than one source, be sure to separate them.
Here are a couple examples:
References
Pod, Tide. (2019). The Laundry Separator’s Handbook. Detergent Publishing, Inc.
Shirt, Tee. (2017). Wash Me with My Friends. www.not_a_real_site.com. Accessed on 7/31/2020.
* Feel free to save this document in your personal files for future reference.
Dashing to catch a cab at the corner of Sixth and Vine, the account team was exhilarated. After a quick exchange of high fives, three of the four jumped into the backseat of a cab to return to the Manhattan offices of Devereaux-Dering, a global advertising agency with offices in New York, Hong Kong, and Paris. The team couldn’t wait to tell their team leader, Kurt Lansing, that they had won the BMW account that morning. The fourth team member, Brad Fitzgerald, stood apart from the animated group, studying his BlackBerry and then hailing a cab for an afternoon flight out of LaGuardia. After a two-year slump in sales, Devereaux-Dering needed a big score like the BMW account. To drive new business and land high-profile accounts like this one, the company had hired Kurt Lansing, an MBA from Wharton, with prominent status in the advertising industry. His job was to lead a new business team to study the market, develop strategies, and acquire major accounts. Lansing hand-selected four high achievers for his team that represented each area of the business: Brad Fitzgerald, creative director; Trish Roderick, account services; Adrienne Walsh, production manager; and Tyler Green, brand strategy. “That was a shocker!” said Roderick as she scooted across the backseat of the cab to make room for her teammates. “The client didn’t seem too impressed with our presentation until Fitzgerald presented the last set of slides describing the global campaign. They loved it. I think he single-handedly clinched the deal when he presented the tag line for the Asian market,” she said excitedly. “He’s a real whiz, alright,” muttered Green. “The eighth wonder of the world.” Sighing deeply and losing his earlier exuberance, Green said, “We couldn’t have bagged the deal without him, and I know we’ll all get credit. But none of us knew he planned to present that last part of the global campaign. I know he was working on that tag line late last night, but there was plenty of time this morning to get team input on it. I hate surprises in front of a client. I felt like a fool, even if we did win the business.” “He’s a regular white knight,” chuckled Walsh, “riding in at the last minute to save the day. I suppose we should appreciate him, but he’s just so irritating. He snapped at me last week for not telling him about a client who was upset about delays in their ad campaign. I reminded him that I had told him about it in our status meeting, but he wasn’t listening at the time. He was glued to his precious BlackBerry, as usual. Why have team meetings if he isn’t going to participate?” Roderick was surprised by her teammates’ reaction to Fitzgerald. She thought they had been working well together. She was quickly discovering, however, an undercurrent of resentment. This was the first time that she had been exposed to the conflict that was simmering below the surface. No doubt, Fitzgerald did have a strong ego and aggressive personality. A previously successful entrepreneur, Fitzgerald had a track record of success and was very ambitious. However, she did notice that he didn’t show respect for differing opinions or invite collaboration on ideas. She wondered if he was placing his own success above the team’s. But why complain if the team was sharing the credit and earning fat bonuses along with him? She was content to go with the status quo. “You know,” she said, “we’re darn lucky to be on his team.” She stared out the cab window at the passing traffic and listened to her two teammates continue to grouse. “I should have known something was up when I walked past his office last night and saw him working with the new copywriter. They must have been hashing out the new tag line,” smirked Green. “We are a team, aren’t we? The system is bigger than the individual, remember? He doesn’t seem too concerned about the welfare of the team—only his own.” “Well, let’s all have a heart-to-heart with Mr. McWhiz,” said Walsh sarcastically. “I’m sure he’ll see things our way. We’ll give him a brief overview of Teamwork 101. That will go over great!” As the cab pulled to the curb, they tossed the driver a $20 bill and headed to their offices on the 40th floor. They would all stop to see the team leader, Kurt Lansing, first. In the meantime, Lansing smiled broadly when he received Fitzgerald’s text message that they had won the BMW account. Sinking back in his chair, he marveled at the cohesiveness and success of his team. All that time building a shared vision and building trust was starting to pay off.
QUESTIONS
1. What factors do you think are affecting this team’s cohesiveness? Explain.
2. If you were the team leader, what could you do to bring Fitzgerald into the team more and foster better relationships among the team members?
3. As a team member, what would you do? Should the three members of the team confront Fitzgerald with their concerns? Should they inform Kurt Lansing? Explain your answers.
Daft, Richard L.. The Leadership Experience (p. 319).
Daft, Richard L.. The Leadership Experience (p. 320)
Discussion 1 | Episode 1 EPISODE ONE: THE DIFFERENCE BETWEEN US
Should doctors and other health professionals take biological race into account when diagnosing and treating illness? Why? Can you think of a situation where thinking about race as biological might be misleading or have a negative effect? How would considering social race be different?
Tips:
Please start your Discussion with the Question so people know what you are discussing.
Initial Post Due Friday 11:59 pm, Secondary Sunday at 11:59 pm
Look at the rubric below to see what I am looking for.
There is no specific word count, but 200-500 words are probably adequate.
Rubric:
20 Points possible
4 Points – Displays a great understanding of the concepts in the assignment
4 Points – Utilizes APA formatting
4 Points – Clear and concise writing with no errors in grammar, spelling, or context.
4 Points – Make a timely initial response.
4 Points – Make a timely and appropriate secondary response. (see tips)
2. Create classes with some of the functionality of a bank account. A single account may have (2) one or more joint owners, but one customer can be the owner of only one bank account (for now). Each of the following should be represented by a class that can have data and functions: • Customer class • Account class 3. • Customer should have the following attributes: Account, Full Name, Work Phone, Home (4) Phone, Cell Phone, Address Line 1, Address Line 2, City, Province, Postal Code. • Customer should always have a full name and also has a default empty string for all of the string values. • Customer should have member functions to set/get all of the data members. • Add validation code to ensure the following: – It is optional for a customer to have an account – A customer must have a full name of at least 1 character in length – One of the phone numbers must be set (any one), and additional phone numbers are optional – Address Line 2 can be blank, but the other address lines can not be blank For each of the above items, write a human readable error message to standard error when validation prevents an action from succeeding. For setter functions, return true if the operation succeeded, and return false if the operation failed. 4. • Account should have the following data members: Account Number, status (can only be (3) one of open, closed, frozen), date opened, branch number, subaccounts • Account should have a constructor that sets reasonable defaults for all of the data members. • Account should have member functions to set/get all of the data members where it makes sense to set the value (add inline comments explaining any decisions to omit get/set functions). In the case of subaccounts add member functions to add and/or remove one subaccount at a time. • Add validation code to ensure the following: – The constructor always requires an account number and a Customer – A newly created account is automatically an open account – An open account can be closed or frozen. A closed account can not be opened or frozen. A frozen account can return to open state and it also can be closed without returning to open state first. – Account balance can be both negative or positive, and must be stored as an integer representing a number of pennies (cents) rather than dollars. – Account deposits and withdrawals must be done using number of pennies (cents) rather than dollars. – Deposits and withdrawals must be positive numbers. – Ensure that the balance can never fall outside of the range of a 32 bit signed integer, but permit as much of this range as possible, including negative values. For each of the above items, write a human readable error message to standard error when validation prevents an action from succeeding. For setter functions, return true if the operation succeeded, and return false if the operation failed. 5. Write a test suite for the above functionality. Use the test suite to verify that your classes are (6) implemented correctly. Ensure that I have access to your git repostory. Please post the path of your git repository to the assignment drop box
In the decision-making process, you must take into account several cultural variables. Describe one of the variables associated with risk tolerance and one of the variables associated with internal/external locus of control. Why are these important factors to consider? Your response must be at least 300 words in length.
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Enjoy Please Note-You have come to the most reliable academic writing site that will sort all assignments that that you could be having. We write essays, research papers, term papers, research proposals Gentrification, account several cultural variables
Does Socioeconomic Status Account for Racial and Ethnic
Disparities in Childhood Cancer Survival?
Rebecca D. Kehm, PhD 1; Logan G. Spector, PhD 2; Jenny N. Poynter, PhD 2; David M. Vock, PhD 3;
Sean F. Altekruse, PhD 4,5; and Theresa L. Osypuk, SD 1
BACKGROUND: For many childhood cancers, survival is lower among non-Hispanic blacks and Hispanics in comparison with non- Hispanic whites, and this may be attributed to underlying socioeconomic factors. However, prior childhood cancer survival studies
have not formally tested for mediation by socioeconomic status (SES). This study applied mediation methods to quantify the role of SES in racial/ethnic differences in childhood cancer survival. METHODS: This study used population-based cancer survival data from
the Surveillance, Epidemiology, and End Results 18 database for black, white, and Hispanic children who had been diagnosed at the ages of 0 to 19 years in 2000-2011 (n 531,866). Black-white and Hispanic-white mortality hazard ratios and 95% confidence intervals, adjusted for age, sex, and stage at diagnosis, were estimated. The inverse odds weighting method was used to test for mediation by
SES, which was measured with a validated census-tract composite index. RESULTS: Whites had a significant survival advantage over blacks and Hispanics for several childhood cancers. SES significantly mediated the race/ethnicity–survival association for acute lym-phoblastic leukemia, acute myeloid leukemia, neuroblastoma, and non-Hodgkin lymphoma; SES reduced the original association
between race/ethnicity and survival by 44%, 28%, 49%, and 34%, respectively, for blacks versus whites and by 31%, 73%, 48%, and 28%, respectively, for Hispanics versus whites ((log hazard ratio total effect – log hazard ratio direct effect)/log hazard ratio total
effect). CONCLUSIONS: SES significantly mediates racial/ethnic childhood cancer survival disparities for several cancers. However, the proportion of the total race/ethnicity–survival association explained by SES varies between black-white and Hispanic-white com- parisons for some cancers, and this suggests that mediation by other factors differs across groups.
2018 American Cancer Society .
KEYWORDS: cancer survival, childhood cancer, mediation, racial and ethnic disparities, socioeconomic status.
INTRODUCTION
Despite improvements over the last 4 decades in cancer survival in the US pediatric population, marked racial and ethnic
disparities persist. 1Compared with non-Hispanic white (white) children, non-Hispanic black (black) and Hispanic chil-
dren experience lower survival from many cancers, including leukemias, 2,3 lymphomas, 4,5 central nervous system (CNS)
tumors, 6and extracranial solid tumors. 7-9 The underlying causes of racial/ethnic survival differences are not well under-
stood and may vary by cancer type. As outlined in Figure 1,bothbiologicalandsocioeconomicpathwayshavebeenpro-
posed in the literature. 10,11 Underlying genetic variations associated with ancestry may lead to differences in tumor
biology and pharmacogenetics for some childhood cancers. 10 However, race/ethnicity is a socially constructed taxonomy
that is not synonymous with ancestry. 12 Race/ethnicity is highly correlated with socioeconomic status (SES), especially in
the United States, where embedded, institutionalized racism continues to place racial and ethnic minorities at high risk for
low SES. 13 Because of emerging evidence for a positive association between SES and survival from some childhood can-
cers, 11racial/ethnic survival disparities may also be explained by socioeconomic differences.
Quantifying the relative role of SES in explaining racial/ethnic survival disparities will help to inform practice and
intervention efforts. If SES accounts for racial/ethnic survival differences, then interventions addressing social and eco-
nomic barriers to treatment and care are warranted. However, if SES does not fully account for survival differences by
race/ethnicity, then other social factors (eg, immigration) and biological mechanisms (eg, tumor biology) must be consid-
ered. To date, formal mediation methods have not been used to disentangle racial/ethnic disparities in childhood cancer
Corresponding author: Rebecca D. Kehm, PhD, Division of Epidemiology and Community Health, University of Minnesota School of Public Health, 13,000 South Second Street, West Bank Office Building, Minneapolis, MN 55455; kehmx003@umn.edu
1Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota; 2Division of Epidemiology and Clini- cal Research, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; 3Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, Minnesota; 4National Cancer Institute, Bethesda, Maryland; 5Epidemiology Branch, Prevention and Population Sciences Program, Division of Cardio- vascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland.
Seeeditorialonpages thisissue. Additional supporting information may be found in the online version of this article.
DOI: 10.1002/cncr.31560, Received: December 8, 2017; Revised: January 11, 2018; Accepted: February 2, 2018, Published online Online Library (wileyonlinelibrary.com)
Original Article
Cancer 2018;124:40 –
Cancer October 15, 2018 4090
August 20, 2018 in Wiley
90
4097.
VC
3975-8, survival. Therefore, we conducted a mediation analysis
using population-based data, representative of the US
pediatric cancer population, to measure the role of SES in
racial and ethnic childhood cancer survival disparities. We
assessed survival from several childhood cancers to deter-
mine whether mediation by SES differs across cancer
types.
MATERIALS AND METHODS
Study Population
We obtained population-based cancer registry data from
the Surveillance, Epidemiology, and End Results (SEER)
18 database; the Alaska Native Tumor Registry was
excluded. We restricted the analysis to black, Hispanic,
and white cases aged 0 to 19 years with microscopically
confirmed first primary malignancies. Race was assigned
in SEER through medical record abstraction. 14,15 His-
panic ethnicity was assigned in SEER on the basis of self-
report/guardian report of Spanish origin in the medical
record or by a computer algorithm that searches surnames
and maiden names to determine Spanish origin. 14,16 We
assessed race/ethnicity with mutually exclusive categories
(non-Hispanic white, non-Hispanic black, and Hispanic);
individuals of Spanish origin were categorized as His-
panic, regardless of racial background. SES data were
available in SEER for diagnostic years 2000-2012. There-
fore, we restricted our sample to cases diagnosed in 2000-
2011 and followed through December 31, 2012, to allow
for at least 1 year of follow-up. We excluded 45 cases with
in situ tumors, 707 cases with missing/zero months of
follow-up, and 725 cases missing SES data. We assessed
cancers with 200 cases for each racial/ethnic group; they
were classified with the International Classification of
Childhood Cancer, third edition. 17 Our final analytic
sample consisted of 31,866 cases. This study was
approved by the Surveillance Research Program in the
National Cancer Institute’s Division of Cancer Control
and Population Sciences.
Measures
Overall survival was calculated in SEER as months from
the date of the cancer diagnosis to the date of death from
any cause or was censored at the date of last contact.
SES was measured at the neighborhood level (based
on the residential address at the date of the cancer diagno-
sis) with a validated census-tract composite index. 18 As
described in the prior literature, 19 the index was con-
structed through a factor analysis of nationwide 2000
decennial census data and 2005-2009 American Commu-
nity Survey data. 18 Seven indicators of neighborhood
SES, previously specified by Yost et al, 20 were included in
the index: proportion employed in working-class occupa-
tions, proportion aged 16 years or older and unemployed,
aThe stage at diagnosis is N/A for leukemias.bHigher quintiles represent higher SES (ie, Q1 is the lowest SES quintile, and Q5 is the highest SES quintile).
4093 Cancer October 15, 2018
Mediation of Childhood Cancer Survival/Kehm et al race-survival association if the indirect effect of race on
survival operating through SES was statistically signifi-
cant. SES significantly mediated the black-white survival
disparity for acute lymphoblastic leukemia (ALL;
indirect-effect hazard ratio [iHR], 1.17; 95% confidence
interval [CI], 1.07-1.28; P<.01; 44% reduction from
the total effect to the direct effect of the racial disparity in
mortality), AML (iHR, 1.15; 95% CI, 1.03-1.29;
P 5 .01; 28% reduction), and neuroblastoma (iHR, 1.17;
95% CI, 1.03-1.33; P5 .02; 49% reduction). SES was a
marginally significant mediator of the black-white sur-
vival disparity for non-Hodgkin lymphoma (NHL; iHR,
bly, SES significantly mediated both the racial and ethnic
disparities in survival for the same 4 cancers.
Secondary Analyses
Except for NHL, the mediating effect of tract-level SES
was greater than the mediating effect of health insurance
status among black-white and Hispanic-white compari-
sons (Supporting Table 3). For example, the indirect
effect of tract SES on the black-white mortality disparity
for ALL was 1.22 (95% CI, 1.01-1.48; P5 .04; 44%
reduction), whereas the indirect effect of health insurance
was 1.09 (95% CI, 0.94-1.27; P5 .24; 19% reduction).
Among cancers with significant SES indirect effects, SES
was not associated with the stage at diagnosis (Supporting
Table 4). The exclusion of the stage at diagnosis from
IOW models did not lead to notably stronger indirect
SES effects (Supporting Tables 5 and 6).
DISCUSSION
This is the first study to use formal mediation methods to
unpack childhood cancer survival disparities by race/eth-
nicity, and it generated several findings. We replicated
TABLE 2. Mediation by SES of Racial (Black vs White) Survival Disparities Among Childhood Cancer Cases
Aged 0 to 19 Years and Diagnosed in 2000-2011 in the SEER 18 Registries
Cancer Type
Total Effect of Race on Survival Through All Medi- ating Pathways
Direct Effect of Race on Survival After Blocking SES Pathway
Indirect Effect of Race on Survival OperatingThrough SES Pathway Reduction From Total Effect to Direct Effect, % b MortalityHR a 95% CI P Mortality HR a 95% CI P Mortality HR a 95% CI P
Germ cell tumors 0.98 0.57-1.69 .94 Not applicable c
Abbreviations: b, log hazard ratio; CI, confidence interval; CNS, central nervous system; HR, hazard ratio; SEER, Surveillance, Epidemiology, and End Results; SES, socioeconomic status; STS, soft-tissue sarcomas.aAdjusted for age, sex, and stage at diagnosis (stage not applicable for leukemias). Bootstrapping was used for standard errors.b( btotal –bdirect )/btotal). cDirect and indirect effects were not estimated for cancers with a statistically nonsignificant total effect ( P>.05); bootstrapping was not used.
4094 Cancer October 15, 2018
Original Article results from prior studies showing that whites have a sig-
nificant survival advantage over blacks and Hispanics for
several childhood cancers, including leukemias, 2,3 lym-
rhabdomyosarcoma soft-tissue sarcomas. 9In no instance
was survival among whites significantly worse than that of
either black or Hispanic children. Racial and ethnic sur-
vival differences were not uniform across cancers, and
some variability between black-white and Hispanic-white
comparisons was observed.
We demonstrated that SES significantly mediates
racial/ethnic survival disparities for several childhood can-
cers, including ALL, AML, neuroblastoma, and NHL.
For these cancers, indirect hazard ratios fell within a nar-
row range (1.13-1.17) for both black-white and Hispanic-
white comparisons. This suggests that the association
between SES and survival is not modified by, and may be
shared across, race/ethnicity. Conversely, the proportion
of the overall survival disparity explained by SES (ie, the
percent reduction) did vary by race/ethnicity for some
cancers. For example, among AML cases, SES explained
only 28% of the black-white survival disparity but 73% of
the Hispanic-white disparity. This may suggest a differen-
tial role of other mediating factors across racial/ethnic
groups for some cancers. For example, prior evidence sug-
gests that, among AML cases, a significantly lower pro-
portion of black children have matched family donors
available in comparison with white and Hispanic chil-
dren. 29Among other cancers with significant racial/ethnic
survival disparities (eg, CNS tumors and soft-tissue sarco-
mas), we found no significant evidence of mediation by
SES. Thus, for these cancers in particular, we cannot rule
out mediation by other factors such as differences in
tumor biology, pharmacogenomics, health care quality,
and other social factors not captured by the SES index (eg,
racism). 30
Because SES did not uniformly influence survival
across different types of childhood cancer, the mecha-
nisms through which SES influences survival may be
cancer-specific. For example, the strong association
between SES and ALL survival may be explained by differ-
ences in treatment adherence. 10 Unlike treatments for
other childhood cancers, the treatment of ALL requires a
prolonged maintenance phase composed of the oral
administration of antimetabolites, which may be difficult
for low-SES families to adhere to because of social and
economic constraints. 10 This is supported by prior evi-
dence of lower treatment adherence among children with
ALL living in a single-mother household versus a 2-parent
household. 31 Other cancer-specific mechanisms through
which SES may influence survival are less understood.
Secondary findings from this study suggest that factors
beyond health insurance status and stage at diagnosis con-
tribute to the SES-survival association, at least for some
TABLE 3. Mediation by SES of Ethnic (Hispanic vs White) Survival Disparities Among Childhood Cancer
Cases Aged 0 to 19 Years and Diagnosed in 2000-2011 in the SEER 18 Registries
Cancer Type
Total Effect of Ethnicity on Survival Through All Medi- ating Pathways
Direct Effect of Ethnicity on Survival After Blocking SES Pathway
Indirect Effect of Ethnicity on Survival OperatingThrough SES Pathway Reduction From Total Effect to Direct Effect, % b MortalityHR a 95% CI P Mortality HR a 95% CI P Mortality HR a 95% CI P
Abbreviations: b, log hazard ratio; CI, confidence interval; CNS, central nervous system; HR, hazard ratio; SEER, Surveillance, Epidemiology, and End Results; SES, socioeconomic status; STS, soft-tissue sarcoma.aAdjusted for age, sex, and stage at diagnosis (stage not applicable for leukemias).b( btotal –bdirect )/btotal). cDirect and indirect effects were not estimated for cancers with a statistically nonsignificant total effect ( P>.05); bootstrapping was not used.
4095 Cancer October 15, 2018
Mediation of Childhood Cancer Survival/Kehm et al childhood cancers. Additional research is needed to fur-
ther unpack the association between SES and childhood
cancer survival.
Limitations
We relied on an area-based variable as our primary measure
of SES because of the lack of individual-level SES measures
in SEER data; moreover, we selected an SES index to oper-
ationalize the SES construct over a meaningful period of
time. Although this improves upon many prior
population-based cancer studies that lacked any measures
of SES or relied on county-level measures, tract-level SES is
still a proxy for individual-level SES in this study because
we could not comprehensively control for SES at the indi-
vidual level. 32,33 Furthermore, we used a fairly crude mea-
sure of individual-level health insurance status (private vs
otherwise) in our secondary analysis. Because the tract-level
SES index was available in SEER only for the years 2000-
2012, the sample size and the follow-up time were limited.
This prevented us from testing more homogenized cancer
and racial/ethnic subgroups or stratifying by age. Addi-
tional research is thus needed for other smaller populations
of racial and ethnic groups not considered in this analysis
because of the rarity of childhood cancer, which limited
power. We also lacked geographic variables to explore
potential spatial variations in survival. Furthermore, the
lack of clinical data in SEER limited our ability to account
for diagnostic, therapeutic, and biological factors, such as
cytogenetic or molecular features. Finally, there is the
potential for differential loss to follow-up by race and SES.
In conclusion, through the application of formal
mediation methods, we have demonstrated that SES signif-
icantly contributes to racial and ethnic survival disparities
for several childhood cancers, including ALL, AML, neuro-
blastoma, and NHL. Thus, for these cancers in particular,
racial/ethnic survival disparities could theoretically be
addressed through initiatives that reduce social and eco-
nomic barriers to effective care. Such efforts may include
expanded health insurance coverage, improved patient care
coordination, increased health literacy, and supplementa-
tion of transportation and childcare costs during treatment.
However, because SES did not fully account for survival
disparities, we cannot rule out the potential role of other
mediating pathways, including tumor biology, pharmaco-
multipronged intervention approach that both addresses
socioeconomic barriers to care and invests in personalized
treatment regimens may ultimately be needed to fully elim-
inate childhood cancer survival disparities.
FUNDING SUPPORT
This work was supported by a National Institutes of Health
Translational Pediatric Cancer Epidemiology Training Grant
(T32CA099936).
CONFLICT OF INTEREST DISCLOSURES
The authors made no disclosures.
AUTHOR CONTRIBUTIONS
Rebecca D. Kehm : Conceptualization, data curation, formal anal-
ysis, methodology, writing–original draft, and writing–review and
editing. Logan G. Spector : Conceptualization, methodology, and
writing–review and editing. Jenny N. Poynter : Conceptualization,
methodology, and writing–review and editing. David M. Vock :
Conceptualization, methodology, and writing–review and editing.
Sean F. Altekruse : Conceptualization, methodology, and writing–
review and editing. Theresa L. Osypuk : Conceptualization, meth-
odology, and writing–review and editing.
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