scholarly journals Urinary polycyclic aromatic hydrocarbon metabolites and mortality in the United States: A prospective analysis

PLoS ONE ◽  
2021 ◽  
Vol 16 (6) ◽  
pp. e0252719
Author(s):  
Achal P. Patel ◽  
Suril S. Mehta ◽  
Alexandra J. White ◽  
Nicole M. Niehoff ◽  
Whitney D. Arroyave ◽  
...  
Keyword(s):  
Proportional Hazards ◽  
Smoking Status ◽  
The United States ◽  
Cox Proportional Hazards ◽  
Spot Urine ◽  
Specific Mortality ◽  
Polycyclic Aromatic ◽  
Pah Exposure ◽  
Race Ethnicity ◽  
The U.S

Background Polycyclic aromatic hydrocarbons (PAHs) are ubiquitous organic compounds associated with chronic disease in epidemiologic studies, though the contribution of PAH exposure on fatal outcomes in the U.S. is largely unknown. Objectives We investigated urinary hydroxylated PAH metabolites (OH-PAHs) with all-cause and cause-specific mortality in a representative sample of the U.S. population. Methods Study participants were ≥20 years old from the National Health and Nutrition Examination Survey 2001–2014. Concentrations (nmol/L) of eight OH-PAHs from four parent PAHs (naphthalene, fluorene, phenanthrene, pyrene) were measured in spot urine samples at examination. We identified all-cause, cancer-specific, and cardiovascular-specific deaths through 2015 using the National Death Index. We used Cox proportional hazards regression to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between ΣOH-PAHs and mortality endpoints. We assessed potential heterogeneity by age, gender, smoking status, poverty, and race/ethnicity. Additionally, we examined the overall mixture effect using quantile g-computation. Results In 9,739 eligible participants, there were 934 all-cause deaths, 159 cancer-specific deaths, and 108 cardiovascular-specific deaths (median 6.75 years follow-up). A log10 increase in ΣOH-PAHs was associated with higher all-cause mortality (HRadj = 1.39 [95%CI: 1.21, 1.61]), and possibly cancer-specific mortality (HRadj = 1.15 [95%CI: 0.79, 1.69]), and cardiovascular-specific mortality (HRadj = 1.49 [95%CI: 0.94, 2.33]). We observed substantial effect modification by age, smoking status, gender, and race/ethnicity across mortality endpoints. Risk of cardiovascular mortality was higher for non-Hispanic blacks and those in poverty, indicating potential disparities. Quantile g-computation joint associations for a simultaneous quartile increase in OH-PAHs were HRadj = 1.15 [95%CI: 1.02, 1.31], HRadj = 1.41 [95%CI: 1.05, 1.90], and HRadj = 0.98 [95%CI: 0.66, 1.47] for all-cause, cancer-specific, and cardiovascular-specific mortalities, respectively. Discussion Our results support a role for total PAH exposure in all-cause and cause-specific mortality in the U.S. population.

scholarly journals Contemporary Associations of Exclusive Cigarette, Cigar, Pipe, and Smokeless Tobacco Use With Overall and Cause-Specific Mortality in the United States

2019 ◽  
Vol 3 (3) ◽  
Author(s):  
Maki Inoue-Choi ◽  
Meredith S Shiels ◽  
Timothy S McNeel ◽  
Barry I Graubard ◽  
Dorothy Hatsukami ◽  
...  
Keyword(s):  
United States ◽  
Tobacco Use ◽  
Smokeless Tobacco ◽  
Proportional Hazards ◽  
The United States ◽  
Cox Proportional Hazards ◽  
Hazard Ratios ◽  
Specific Mortality ◽  
Smokeless Tobacco Use ◽  
Overall Mortality

Abstract Background A growing proportion of tobacco users in the United States use non-cigarette products including cigars, pipes, and smokeless tobacco. Studies examining the disease and mortality risks of these products are urgently needed. Methods We harmonized tobacco use data from 165 335 adults in the 1991, 1992, 1998, 2000, 2005, and 2010 National Health Interview Surveys. Hazard ratios (HRs) and 95% confidence intervals (CIs) for overall and cause-specific mortality occurring through December 31, 2015, were estimated by exclusive use of cigarettes, cigars, pipes, or smokeless tobacco using Cox proportional hazards regression with age as the underlying time metric and never tobacco users as the referent group. Results Current use of cigarettes (HR = 2.23, 95% CI = 2.13 to 2.33) and smokeless tobacco (HR = 1.36, 95% CI = 1.17 to 1.59) were each associated with overall mortality. Relative to never tobacco users, higher risks were observed both in daily (HR = 2.34, 95% CI = 2.24 to 2.44) and nondaily (HR = 1.69, 95% CI = 1.54 to 1.86) cigarette smokers, with associations also observed across major smoking-related causes of death. Daily use of smokeless tobacco was also associated with overall mortality (HR = 1.41, 95% CI = 1.20 to 1.66) as was daily use of cigars (HR = 1.52, 95% CI = 1.12 to 2.08). Current smokeless tobacco use was associated with a higher risk of mortality from heart disease and smoking-related cancer, with strong associations observed for cancers of the oral cavity and bladder. Conclusions Exclusive daily use of cigarettes, cigars, and smokeless tobacco was associated with higher mortality risk. Tobacco control efforts should include cigars and smokeless tobacco.

scholarly journals Differences in Cause-Specific Mortality Between Frail Men and Women in the United States

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 271-271
Author(s):  
Matthew Lohman ◽  
Amanda Sonnega ◽  
Amanda Leggett ◽  
Nicholas Resciniti
Keyword(s):  
Older Adults ◽  
Heart Disease ◽  
Causes Of Death ◽  
Proportional Hazards ◽  
Significant Risk ◽  
The United States ◽  
Cox Proportional Hazards ◽  
Frail Older Adults ◽  
Risk Of Death ◽  
Specific Mortality

Abstract While frailty is associated with risk of numerous adverse health outcomes including mortality, little is known about the most common specific causes of death among frail older adults or how these causes might differ by gender. This information may be important to understanding the frailty syndrome and to informing screening and treatment. We used linked data from the Health and Retirement Study (2004 – 2012) and the National Death Index (NDI). We analyzed data from HRS participants age 65 and older who completed a general health interview and physiological measures (n=10,490). Frailty was operationalized using the phenotype criteria – low weight, low energy expenditure, exhaustion, slow gait, and weakness. Causes of death were determined using International Classification of Diseases (v10) codes from death certificates. We used Cox proportional hazards to compare incidence of cause-specific mortality by frailty status and gender. The attributable risk of mortality due to frailty in the sample was 16.6% among women and 17.3% among men. Overall, frail older adults had greater risk of death from heart disease (hazard ratio (HR): 2.97; 95% CI: 2.18, 4.04), cancer (HR: 2.81; 95% CI: 2.01, 3.93), and dementia 2.86 (95% CI: 1.46, 5.58) but not cerebrovascular disease or accidents. Frail women were more approximately 29% more likely to die from heart disease than frail men. Findings suggest that frailty is a significant risk factor for mortality from several different causes, especially among women. Findings may help inform screening and treatment decisions for older adults at risk for frailty.

scholarly journals Investigation of the Obesity Paradox in Chronic Obstructive Pulmonary Disease, According to Smoking Status, in the United States

2019 ◽  
Vol 188 (11) ◽  
pp. 1977-1983 ◽  
Author(s):  
Tianshi David Wu ◽  
Chinedu O Ejike ◽  
Robert A Wise ◽  
Meredith C McCormack ◽  
Emily P Brigham
Keyword(s):  
Chronic Obstructive Pulmonary Disease ◽  
Pulmonary Disease ◽  
Proportional Hazards ◽  
Smoking Status ◽  
Obesity Paradox ◽  
The United States ◽  
Cox Proportional Hazards ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Never Smokers

Abstract An obesity paradox in chronic obstructive pulmonary disease (COPD), whereby overweight/obese individuals have improved survival, has been well-described. These studies have generally included smokers. It is unknown whether the paradox exists in individuals with COPD arising from factors other than smoking. Nonsmoking COPD is understudied yet represents some 25%–45% of the disease worldwide. To determine whether the obesity paradox differs between ever- and never-smokers with COPD, 1,723 adult participants with this condition were examined from 2 iterations of the National Health and Nutrition Examination Survey (1988–1994, 2007–2010), with mortality outcomes followed through December 2011. Using Cox proportional hazards models, adjusted for sociodemographic factors, lung function, and survey cycle, ever/never-smoking was found to modify the association between body mass index and hazard of death. Compared with normal-weight participants, overweight/obese participants had lower hazard of death among ever-smokers (for overweight, adjusted hazard ratio (aHR) = 0.56, 95% confidence interval (CI): 0.43, 0.74; for obesity, aHR = 0.66, 95% CI: 0.48, 0.92), but never-smokers did not (overweight, aHR = 1.41, 95% CI: 0.66, 3.03; obesity, aHR = 1.29, 95% CI: 0.48, 3.48). An obesity paradox appeared to be absent among never-smokers with COPD. This, to our knowledge, novel finding might be explained by pathophysiological differences between smoking-related and nonsmoking COPD or by smoking-associated methodological biases.

Associations Between Community Income and Cancer Survival in Ontario, Canada, and the United States

1999 ◽  
Vol 17 (7) ◽  
pp. 2244-2244 ◽  
Author(s):  
Chris Boyd ◽  
Jina Y. Zhang-Salomons ◽  
Patti A. Groome ◽  
William J. Mackillop
Keyword(s):  
United States ◽  
Cancer Survival ◽  
Proportional Hazards ◽  
Census Data ◽  
Neck Region ◽  
The United States ◽  
Cox Proportional Hazards ◽  
Risk Of Death ◽  
Significant Survival ◽  
The U.S

PURPOSE: The objectives of this study were as follows: (1) to compare the magnitude of the association between socioeconomic status (SES) and cancer survival in the Canadian province of Ontario with that in the United States (U.S.), and (2) to compare cancer survival in communities with similar SES in Ontario and in the U.S. METHODS: The Ontario Cancer Registry provided information about all cases of invasive cancer diagnosed in Ontario from 1987 to 1992, and the Surveillance, Epidemiology and End Results Registry (SEER) provided information about all cases diagnosed in the SEER regions of the U.S. during the same time period. Census data provided information about SES at the community level. The product-limit method was used to describe cause-specific survival. Cox proportional hazards models were used to describe the association between SES and the risk of death from cancer. RESULTS: There were significant associations between SES and survival for most cancer sites in both the U.S. and Ontario, but the magnitude of the association was usually larger in the U.S. In the poorest communities, there were significant survival advantages in favor of cancer patients in Ontario for many disease groups, including cancers of the lung, head and neck region, cervix, and uterus. However, in upper- and middle-income communities, there were significant survival advantages in favor of the U.S. for all cases combined and for several individual diseases, including cancers of the breast, colon and rectum, prostate, and bladder. CONCLUSION: The association between SES and cancer survival is weaker in Ontario than it is in the U.S. This is due to a combination of better survival among patients in the poorest communities and worse survival among patients in the wealthier communities of Ontario relative to those in the U.S.

scholarly journals Cyclooxygenase inhibitor use is associated with increased COVID-19 severity

2021 ◽  
Author(s):  
Justin Reese ◽  
Ben Coleman ◽  
Lauren Chan ◽  
Tiffany J Callahan ◽  
Luca Cappelletti ◽  
...  
Keyword(s):  
Proportional Hazards ◽  
Smoking Status ◽  
Community Acquired Pneumonia ◽  
Cox Proportional Hazards ◽  
Electronic Health Record Data ◽  
Cox Inhibitors ◽  
Inflammatory Drugs ◽  
Race Ethnicity ◽  
Tract Infections ◽  
Conclusive Data

BACKGROUND Cyclooxygenase (COX) inhibitors including non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to reduce pain, fever, and inflammation but have been associated with complications in community acquired pneumonia and other respiratory tract infections (RTIs). Conclusive data are not available about potential beneficial or adverse effects of COX inhibitors on COVID-19 patients. METHODS We conducted a retrospective, multi-center observational study by leveraging the harmonized, high-granularity electronic health record data of the National COVID Cohort Collaborative (N3C). Potential associations of eight COX inhibitors with COVID-19 severity were assessed using ordinal logistic regression (OLR) on treatment with the medication in question after matching by treatment propensity as predicted by age, race, ethnicity, gender, smoking status, comorbidities, and BMI. Cox proportional hazards analysis was used to estimate the correlation of medication use with morbidity for eight subcohorts defined by common indications for COX inhibitors. RESULTS OLR revealed statistically significant associations between use of any of five COX inhibitors and increased severity of COVID-19. For instance, the odds ratio of aspirin use in the osteoarthritis cohort (n=2266 patients) was 3.25 (95% CI 2.76 - 3.83). Aspirin and acetaminophen were associated with increased mortality. CONCLUSIONS The association between use of COX inhibitors and COVID-19 severity was consistent across five COX inhibitors and multiple indication subcohorts. Our results align with earlier reports associating NSAID use with complications in RTI patients. Further research is needed to characterize the precise risk of individual COX inhibitors in COVID-19 patients.

scholarly journals Functional Movement Assessments Are Not Associated with Risk of Injury During Military Basic Training

2019 ◽  
Vol 184 (11-12) ◽  
pp. e773-e780 ◽  
Author(s):  
Sarah J de la Motte ◽  
Daniel R Clifton ◽  
Timothy C Gribbin ◽  
Anthony I Beutler ◽  
Patricia A Deuster
Keyword(s):  
Military Service ◽  
Injury Risk ◽  
Proportional Hazards ◽  
Smoking Status ◽  
Military Training ◽  
The United States ◽  
Cox Proportional Hazards ◽  
Basic Training ◽  
Balance Test ◽  
Functional Movement

Abstract Introduction Musculoskeletal injuries (MSK-I) in the U.S. military accounted for more than four million medical encounters in 2017. The Military Entrance Processing Screen to Assess Risk of Training (MEPSTART) was created to identify MSK-I risk during the first 180 days of military service. Methods Active duty applicants to the United States Army, Navy, Air Force, and Marine Corps between February 2013 and December 2014 who consented completed a behavioral and injury history questionnaire and the MEPSTART screen [Functional Movement Screen (FMS), Y-Balance Test (YBT), Landing Error Scoring System (LESS), and Overhead Squat assessment (OHS)] the day they shipped to basic training. Male (n = 1,433) and Female (n = 281) applicants were enrolled and MSK-I were tracked for 180 days. Binomial logistic regression and multivariate Cox proportional hazards modeling were used to assess relationships among MEPSTART screens and MSK-I independent of age, BMI, sex, Service, injury history, and smoking status. Analyses were finalized and performed in 2017. Results The only functional screen related to injury was the LESS score. Compared to those with good LESS scores, applicants with poor LESS scores had lower odds of MSK-I (OR = 0.54, 95% CI = 0.30–0.97, p = 0.04), and a lower instantaneous risk of MSK-I during the first 180 d (HR = 0.58, 95%CI = 0.34–0.96, p = 0.04). However, secondary receiver operator characteristic (ROC) analyses revealed poor discriminative value (AUC = 0.49, 95%CI = 0.43–0.54). Conclusions Functional performance did not predict future injury risk during the first 180 days of service. Poor LESS scores were associated with lower injury risk, but ROC analyses revealed little predictive value and limited clinical usefulness. Comprehensive risk reduction strategies may be preferable for mitigating MSK-I in military training populations.

scholarly journals Associations of evolutionary-concordance diet, Mediterranean diet and evolutionary-concordance lifestyle pattern scores with all-cause and cause-specific mortality

2018 ◽  
pp. 1-10 ◽  
Author(s):  
En Cheng ◽  
Caroline Y. Um ◽  
Anna Prizment ◽  
DeAnn Lazovich ◽  
Roberd M. Bostick
Keyword(s):  
Mediterranean Diet ◽  
Proportional Hazards ◽  
Smoking Status ◽  
Cox Proportional Hazards ◽  
Health Study ◽  
Specific Mortality ◽  
Diet Pattern ◽  
Estimated Risk ◽  
Lifestyle Pattern ◽  
Diet Score

Abstract Various individual diet and lifestyle factors are associated with mortality. Investigating these factors collectively may help clarify whether dietary and lifestyle patterns contribute to life expectancy. We investigated the association of previously described evolutionary-concordance and Mediterranean diet pattern scores and a novel evolutionary-concordance lifestyle pattern score with all-cause and cause-specific mortality in the prospective Iowa Women’s Health Study (1986–2012). We created the diet pattern scores from Willett FFQ responses, and the lifestyle pattern score from self-reported physical activity, BMI and smoking status, and assessed their associations with mortality, using multivariable Cox proportional hazards regression. Of the 35 221 55- to 69-year-old cancer-free women at baseline, 18 687 died during follow-up. The adjusted hazard ratios (HR) and 95 % CI for all-cause, all CVD, and all-cancer mortality among participants in the highest relative to the lowest quintile of the evolutionary-concordance lifestyle score were, respectively, 0·52 (95 % CI 0·50, 0·55), 0·53 (95 % CI 0·49, 0·57) and 0·51 (95 % CI 0·46, 0·57). The corresponding findings for the Mediterranean diet score were HR 0·85 (95 % CI 0·82, 0·90), 0·83 (95 % CI 0·76, 0·90) and 0·93 (95 % CI 0·84, 1·03), and for the evolutionary-concordance diet score they were close to null and not statistically significant. The lowest estimated risk was among those in the highest joint quintile of the lifestyle score and either diet score (both Pinteraction <0·01). Our findings suggest that (1) a more Mediterranean-like diet pattern and (2) a more evolutionary-concordant lifestyle pattern, alone and in interaction with a more evolutionary-concordant or Mediterranean diet pattern, may be inversely associated with mortality.

scholarly journals Gut Microbiota Metabolites of Dietary Lignans and Risk of All-Cause and Cause-Specific Mortality in Adults

2020 ◽  
Vol 4 (Supplement_2) ◽  
pp. 1439-1439 ◽  
Author(s):  
Buyun Liu ◽  
Shuang Rong ◽  
Yangbo Sun ◽  
Robert Wallace ◽  
Linda Snetselaar ◽  
...  
Keyword(s):  
Cancer Mortality ◽  
Proportional Hazards ◽  
The United States ◽  
Epidemiological Studies ◽  
Biological Properties ◽  
Cox Proportional Hazards ◽  
Mortality Data ◽  
All Cause Mortality ◽  
Race Ethnicity ◽  
Cvd Mortality

Abstract Objectives Lignans are bioactive compounds exhibiting various biological properties, including anti-inflammatory, antioxidant and antitumor activities. Epidemiological studies regarding long-term health effects of lignans are sparse. In humans, most lignans in plant-based foods are converted by the intestinal microbiota to enterolactone and enterodiol after ingestion. We examined the association of urinary levels of enterolactone and enterodiol with the risk of mortality among adults in the United States. Methods This is a prospective cohort study including 6262 adults aged 40 years or older who participated in the National Health and Nutrition Examination Survey 1999–2010. These participants were linked to mortality data through December 31, 2015. We used Cox proportional hazards regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association of urinary enterolactone and enterodiol levels with mortality from all causes, cardiovascular disease (CVD), and cancer. Results During on average 9.3 years (maximum 16.8 years) of observation, 1456 death occurred including 329 death from CVD, and 330 death from cancer. After adjustment for age, sex, race/ethnicity, socioeconomic status, dietary and lifestyle factors, and urinary creatinine levels, the HRs (95% CIs) of all-cause mortality across increasing quartiles of urinary enterolactone levels were 1.00 (reference), 0.90 (0.77–1.05), 0.83 (0.71–0.97), and 0.81 (0.66–0.99), respectively (P for trend 0.02). We did not observe significant associations of urinary enterolactone levels with CVD mortality (HR for the highest vs. lowest quartiles 1.17, 95% CI 0.71–1.91) or cancer mortality (HR 0.82, 95% CI 0.55–1.21). For enterodiol, the HRs (95% CIs) of all-cause mortality, CVD mortality, and cancer mortality comparing the highest with lowest quartile of urinary enterodiol levels were 1.17 (0.94–1.45), 1.23 (0.83–1.81), and 1.05 (0.69–1.58), respectively. There was no significant interaction effects by sex and race/ethnicity for the observed associations. Conclusions In this nationally representative sample of US adults, urinary enterolactone levels was inversely associated with all-cause mortality. Further studies are needed to replicate the findings and determine the underlying mechanisms. Funding Sources N/A.

scholarly journals High School Quality and 56-Year All-Cause Mortality Risk Across Race and Ethnicity

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 505-506
Author(s):  
Dominika Seblova ◽  
Kelly Peters ◽  
Susan Lapham ◽  
Laura Zahodne ◽  
Tara Gruenewald ◽  
...  
Keyword(s):  
High School ◽  
Mortality Risk ◽  
Race And Ethnicity ◽  
Proportional Hazards ◽  
School Quality ◽  
Cox Proportional Hazards ◽  
School Level ◽  
Lower Mortality ◽  
All Cause Mortality ◽  
Race Ethnicity

Abstract Having more years of education is independently associated with lower mortality, but it is unclear whether other attributes of schooling matter. We examined the association of high school quality and all-cause mortality across race/ethnicity. In 1960, about 5% of US high schools participated in Project Talent (PT), which collected information about students and their schools. Over 21,000 PT respondents were followed for mortality into their eighth decade of life using the National Death Index. A school quality factor, capturing term length, class size, and teacher qualifications, was used as the main predictor. First, we estimated overall and sex-stratified Cox proportional hazards models with standard errors clustered at the school level, adjusting for age, sex, composite measure of parental socioeconomic status, and 1960 cognitive ability. Second, we added an interaction between school quality and race/ethnicity. Among this diverse cohort (60% non-Hispanic Whites, 23% non-Hispanic Blacks, 7% Hispanics, 10% classified as another race/s) there were 3,476 deaths (16.5%). School quality was highest for Hispanic respondents and lowest for non-Hispanic Blacks. Non-Hispanic Blacks also had the highest mortality risk. In the whole sample, school quality was not associated with mortality risk. However, higher school quality was associated with lower mortality among those classified as another race/s (HR 0.75, 95% CI: 0.56-0.99). For non-Hispanic Blacks and Whites, the HR point estimates were unreliable, but suggest that higher school quality is associated with increased mortality. Future work will disentangle these differences in association of school quality across race/ethnicity and examine cause-specific mortality.

scholarly journals Health Care Access Measures and Palliative Care Use by Race/Ethnicity among Metastatic Gynecological Cancer Patients in the United States

2021 ◽  
Vol 18 (11) ◽  
pp. 6040
Author(s):  
Jessica Y. Islam ◽  
Veeral Saraiya ◽  
Rebecca A. Previs ◽  
Tomi Akinyemiju
Keyword(s):  
Palliative Care ◽  
Cancer Patients ◽  
Gynecological Cancer ◽  
The United States ◽  
Care Utilization ◽  
Treatment Facility ◽  
Facility Type ◽  
Race Ethnicity ◽  
Distance To Care ◽  
The U.S

Palliative care improves quality-of-life and extends survival, however, is underutilized among gynecological cancer patients in the United States (U.S.). Our objective was to evaluate associations between healthcare access (HCA) measures and palliative care utilization among U.S. gynecological cancer patients overall and by race/ethnicity. We used 2004–2016 data from the U.S. National Cancer Database and included patients with metastatic (stage III–IV at-diagnosis) ovarian, cervical, and uterine cancer (n = 176,899). Palliative care was defined as non-curative treatment and could include surgery, radiation, chemotherapy, and pain management, or any combination. HCA measures included insurance type, area-level socioeconomic measures, distance-to-care, and cancer treatment facility type. We evaluated associations of HCA measures with palliative care use overall and by race/ethnicity using multivariable logistic regression. Our population was mostly non-Hispanic White (72%), had ovarian cancer (72%), and 24% survived <6 months. Five percent of metastatic gynecological cancer patients utilized palliative care. Compared to those with private insurance, uninsured patients with ovarian (aOR: 1.80,95% CI: 1.53–2.12), and cervical (aOR: 1.45,95% CI: 1.26–1.67) cancer were more likely to use palliative care. Patients with ovarian (aOR: 0.58,95% CI: 0.48–0.70) or cervical cancer (aOR: 0.74,95% CI: 0.60–0.88) who reside >45 miles from their provider were less likely to utilize palliative care than those within <2 miles. Ovarian cancer patients treated at academic/research programs were less likely to utilize palliative care compared to those treated at community cancer programs (aOR: 0.70, 95%CI: 0.58–0.84). Associations between HCA measures and palliative care utilization were largely consistent across U.S. racial-ethnic groups. Insurance type, cancer treatment facility type, and distance-to-care may influence palliative care use among metastatic gynecological cancer patients in the U.S.

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