MAMMOGRAPHY

Changes in geographic accessibility to mammography by state and rural-urban status, United States, 2006-2022

A recent study demonstrated that travel time to the nearest mammography facility is long for a significant proportion of women in the United States. The study authors reported that this affects more than 50 percent of women in rural areas in 28 states (J Natl Cancer Inst 2022; doi:10.1093/jnci/djac217). Researchers obtained mammography location data in the contiguous U.S. (District of Columbia and all states except Alaska and Hawaii) in 2006 and 2022 by census tract (73,718). They estimated the number and proportion of women aged 45-84 years who had limited travel time-based geographic accessibility-drive time greater than 20 minutes-to the nearest mammography facility by urban-rural status and state from 2006 to 2022. Associations between limited accessibility and breast cancer screening prevalence by state were then evaluated. Nationwide, the proportion of women with limited access to mammography remains high. While this proportion did not substantially change from 2006 (12.7%) to 2022 (12.2%), the study authors noted that, because of population growth, the estimated number of women with limited accessibility increased from 7.5 million in 2006 to 8.2 million in 2022. The data showed that accessibility to mammography varied by state. In 10 states, more than 26 percent of the female population ages 45-84 years had limited accessibility in 2022, primarily in the Rocky Mountains and Southern regions. The researchers found that this proportion was significantly higher in rural areas versus urban areas. In urban areas, this proportion was less than 5 percent in 35 states. The largest improvements were observed in South Dakota and Mississippi, where limited accessibility declined by 5.1 percent and 4.8 percent, respectively, according to the study authors.

AUTHOR COMMENTARY: "Our findings are concerning. Mammography is widely available in the United States, but barriers, such as long drive times, are likely influencing a woman's decision to get screened," said Daniel Wiese, PhD, Senior Scientist in the Cancer Disparities Research program at the American Cancer Society and lead author of the study. "We need to move forward on programs to remove these barriers so women can access this potentially life-saving screening. The simple answer would be to open more breast cancer screening facilities in sparsely populated areas, but this can be economically and logistically challenging. Providing transportation or promoting the use of mobile screening units may be alternative actions, although further research is needed to improve the effectiveness of mobile screening units in increasing participation in breast cancer screening in rural areas."

CLINICAL TRAINING

Training hematologists/oncologists for the academic-community hybrid: creating a fellowship framework for the future

A group of physicians recently proposed the first-ever training blueprint for oncologists planning careers in a community or academic-community setting (JCO Oncol Pract 2022; doi:10.1200/OP.22.00671). The model would provide an alternative to the traditional oncology training paradigm in which a year of clinical training is followed by 2 years heavily focused on basic or clinical research. Instead, the focus of the latter 2 years of training would focus on areas related to community cancer care, such as equity in care, patient safety, quality improvement, and health policy, while also increasing clinical time in community-based cancer centers. The study authors reviewed current national challenges and changing models of cancer care delivery in the context of the traditional academic training model along with trends in practice patterns for recent hematology/oncology graduates. They defined the Academic-Community hybrid (ACH) and how it supports the evolution in contemporary models of cancer care. "The ACH hematology/oncology fellowship training pathway emphasizes and optimizes professional development domains including clinical care, patient safety and quality improvement, business and operations, cancer care equity and community access, healthy policy and alignment with professional organizations, and medical education," according to the study authors who concluded that this novel training model provides a paradigm for "optimizing preparedness for practice in an increasingly complex cancer care delivery environment while addressing workforce shortages and health disparities."

AUTHOR COMMENTARY: "Over the last 15 years or more, cancer care has become increasingly complex. At the same time, there has been substantial growth in the delivery of care at regional and community centers, with most patients receiving their care in the community. However, the conventional model for training oncologists-fellowships designed to produce clinician scientists/researchers-has been slow to reflect these changes," said first author Daniel Roberts, MD, a medical oncologist and hematologist at Dana-Farber Cancer Institute. "It's also important to acknowledge that many fellowship programs already have a great deal of community-facing work and likely have elements of this in place. What we hope to provide with our proposal is a blueprint for all fellowships across the country to prepare interested trainees to practice in a community-based setting."

LUNG CANCER

KMT2D deficiency drives lung squamous cell carcinoma and hypersensitivity to RTK-RAS inhibition

A team of researchers recently identified a gene that drives development of lung squamous cell carcinoma (LUSC), a major subtype of lung cancer with limited treatment options (Cancer Cell 2022; doi:10.1016/j.ccell.2022.11.015). While KMT2D is one of the most frequently mutated genes in LUSC (>20%), the role in its oncogenesis remains unknown, according to the study authors. Findings from this research showed that deleting KMT2D caused normal lung cells grown in organoids to transform into LUSC cells. "KMT2D loss increases activation of receptor tyrosine kinases (RTKs), EGFR and ERBB2, partly through reprogramming the chromatin landscape to repress the expression of protein tyrosine phosphatases," according to the investigators. Based on these findings, the research team tested a combination of two drugs-SHP2 inhibitor SHP099 and pan-ERBB inhibitor afatinib. They found that the combination slowed lung tumor growth in mice with LUSC that had been engineered to lack KMT2D, as well as in tumors in mice derived from the human LUSC tumors with KMT2D mutations. "Combining SHP2 inhibitor SHP099 and pan-ERBB inhibitor afatinib inhibits lung tumor growth in KMT2D-deficient LUSC murine models and in patient-derived xenografts harboring KMT2D mutations," the study authors concluded. "Our study identifies KMT2D as a pivotal epigenetic modulator for LUSC oncogenesis and suggests that KMT2D loss renders LUSC therapeutically vulnerable to RTK-RAS inhibition."

AUTHOR COMMENTARY: "Our study identifies KMT2D as a pivotal contributor to the development of lung squamous cancers and offers vital clues about how to target KMT2D-deficient LUSC," noted co-corresponding author Kwok Kin-Wong, MD, PhD, Director of the Division of Hematology and Medical Oncology at NYU Langone Health. "The same genetic changes that cause the gene to contribute to cancer also create tumors that are very sensitive to existing drugs that target a related pathway."