***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The purpose of this study was to examine influencing factors and outcomes of accelerated partial breast irradiation through brachytherapy ( APBIb ) versus whole breast irradiation ( WBI ) for ductal carcinoma in situ ( DCIS ) . From the Surveillance Epidemiology and End Results program of the US National Cancer Institute , we identified 40,749 women who were diagnosed with first primary DCIS between 2002 and 2011 and treated with breast-conserving surgery and radiotherapy .  A multi-level logistic regression analysis was performed to estimate odds ratios of APBIb use . Hazard ratios ( HRs ) of developing ipsilateral breast tumors ( IBTs ) and contralateral breast tumors ( CBTs ) were analyzed in 1962 patients with APBIb and 7203 propensity score-matched patients with WBI  , using Cox proportional hazards regression . Overall , 2212 ( 4.5 % ) of 40,749 women ( the whole cohort ) received APBIb . Factors associated with the increased use of APBIb included older age , non-Hispanic white race/ethnicity , smaller tumor size , hormone receptor positivity , comedo subtypes , and urban residence . During the 46-month follow-up , 74 ( 0.8 % ) and 131 ( 1.4 % ) of 9165 propensity score-matched patients developed IBTs and CBTs , respectively . Compared with WBI , APBIb was associated with a significantly increased risk of IBTs ( HR 1.74 ; 95 % CI 1.06–2.85 ) but not CBTs ( OR 0.91 ; 95 % CI 0.59–1.41 ) . This population -based study suggests that APBIb use for DCIS was influenced by patient and tumor characteristics as well as urbanization of residence . We observed a moderately increased IBT risk associated with APBIb versus WBI , suggesting that APBIb should be used with caution for DCIS before data from r and omized controlled trials with long-term follow-ups are available To examine racial differences in mammography use and its determinants in the City of St. Louis , MO , USA , we recruited women age 40 or older using r and om-digit dialing to ( 1 ) examine the difference in mammography use between white women and African American women and ( 2 ) identify individual- and census-tract-level risk factors of nonadherence to mammography . During telephone interviews , we inquired about mammography use and several demographic , psychosocial , and health behavior variables . We determined the residential census tracts of study subjects using a geographic information system . The rate of mammography use was 68.0 % among white women and 74.7 % among African American women ( P = 0.022 ) . African American women were more likely to have mammograms than white woman ( adjusted odds ratio [ OR ] = 1.71 ; 95 % confidence interval [ CI ] = 1.09–2.69 ) . System-level barriers to mammography and heavy smoking were associated with lower  mammography  use among both white and African American women .  Personal-experience barriers to mammography  and no physician recommendation also were independently associated with mammography use among white women . White women residing within a historic geographic cluster area of late-stage breast cancer were less likely to have mammograms ( adjusted OR = 0.42 , 95 % CI = 0.22–0.80 ) , while African American women residing within a historic geographic cluster area of late-stage breast cancer were equally likely to have mammograms ( adjusted OR = 0.79 , 95 % CI = 0.28–2.24 ) . Neither individual- nor census-tract-level socioeconomic status was associated with  mammography screening . These findings suggest that there may be a greater need for increasing  mammography use among white women , especially in the historic cluster area of late-stage breast cancer in St. Louis Objectives The purpose of this study was to separately examine the impact of neighborhood socioeconomic deprivation and availability of healthcare re sources on prostate cancer risk among African American and Caucasian men . Methods In the large , prospect i ve NIH-AARP Diet and Health Study , we analyzed baseline ( 1995–1996 ) data from adult men , aged 50–71 years . Incident prostate cancer cases ( n = 22,523 ; 1,089 among African Americans ) were identified through December 2006 .  Lifestyle and health risk information was ascertained by question naires administered at baseline . Area-level socioeconomic indicators were ascertained by linkage to the US Census and the Area Re source File . Multilevel Cox models were used to estimate hazard ratios ( HRs ) and 95 % confidence intervals ( CIs ) . Results A differential effect among African Americans and Caucasians was observed for neighborhood deprivation ( p-interaction = 0.04 ) , percent uninsured ( p-interaction = 0.02 ) , and urologist density ( p-interaction = 0.01 ) . Compared to men living in counties with the highest density of urologists , those with fewer had a substantially increased risk of developing advanced prostate cancer ( HR = 2.68 , 95 % CI = 1.31 , 5.47 ) among African American . Conclusions Certain socioeconomic indicators were associated with an increased risk of prostate cancer among African American men compared to Caucasians . Minimizing differences in healthcare availability may be a potentially important pathway to minimizing disparities in prostate cancer risk Objective Previous studies have not examined potential interactions between meat intake and characteristics of the local environment on the risk of mortality . This study examined the impact of area socioeconomic deprivation on the association between meat intake and all-cause and cause-specific mortality after accounting for individual-level risk factors . Methods In the prospect i ve NIH-AARP Diet and Health Study , we analyzed data from adults , ages 50–71 years at baseline ( 1995–1996 ) . Individual-level dietary intake and health risk information were linked to the demographic and socioeconomic context of participants ’ local environment based on census tract data . Deaths ( n = 33,831 ) were identified through December 2005 . Multilevel Cox models were used to estimate hazard ratios and 95 % confidence intervals for quintiles of area deprivation scores . Results Associations of red and processed meats with mortality were consistent across deprivation quintiles . Men residing in least-deprived neighborhoods had a stronger protective effect for white meat consumption . No differences by deprivation index were observed for women . Conclusion Red and processed meat intake increases mortality risk regardless of level of deprivation within a given neighborhood suggesting biological mechanisms rather than neighborhood context ual factors may underlie these meat-mortality associations . The effect of white meat intake on cancer mortality was modified by area deprivation among men OBJECTIVES To estimate the frequency of  ambulatory care-sensitive hospitalizations ( ACSHs ) and to compare the risk of ACSH in breast cancer survivors living in high-poverty with that of those in low-poverty areas . DESIGN Prospect i ve , multilevel study . SETTING National , population -based 1991 to 1999 National Cancer Institute Surveillance , Epidemiology , and End Results Program data linked with Medicare cl aims data throughout the United States . PARTICIPANTS Breast cancer survivors aged 66 and older . MEASUREMENTS ACSH was classified according to diagnosis at hospitalization . The percentage of the population living below the U.S. federal poverty line was calculated at the census-tract level . Potential confounders included demographic characteristics , comorbidity , tumor and treatment factors , and availability of medical care . RESULTS Of 47,643 women , 13.3 % had at least one ACSH . Women who lived in high-poverty census tracts ( > or=30 % poverty rate ) were 1.5 times ( 95 % confidence interval (CI)=1.34 - 1.72 ) as likely to have at least one ACSH after diagnosis as women who lived in low-poverty census tracts ( < 10 % poverty rate ) . After adjusting for most confounders , results remained unchanged . After adjustment for comorbidity , the hazard ratio ( HR ) was reduced to 1.34 ( 95 % CI=1.18 - 1.52 ) , but adjusting for all variables did not further reduce the risk of ACSH associated with poverty rate beyond adjustment for comorbidity ( HR=1.37 , 95 % CI=1.19 - 1.58 ) . CONCLUSION Elderly breast cancer survivors who lived in high-poverty census tracts may be at increased risk of reduced posttreatment follow-up care , preventive care , or symptom management as a result of not having adequate , timely , and high- quality ambulatory primary care as suggested by ACSH PURPOSE Hepatocellular carcinoma ( HCC ) incidence rates continue to increase in the United States . Geographic variation in rates suggests a potential contribution of area-based factors , such as neighborhood socioeconomic deprivation , retail alcohol availability , and access to health care . METHODS Using the National Institutes of Health-American Association of Retired Persons Diet and Health Study , we prospect ively examined  area socioeconomic variations in HCC incidence ( n = 434 cases ) and chronic liver disease ( CLD ) mortality ( n = 805 deaths ) and assessed contribution of alcohol outlet density , health care infrastructure , diabetes , obesity , and health behaviors . Hazard ratios ( HRs ) and 95 % confidence intervals ( CIs ) were estimated from hierarchical Cox regression models . RESULTS Area socioeconomic deprivation was associated with increased risk of HCC incidence and CLD mortality ( HR , 1.48 ; 95 % CI , 1.03 - 2.14 and HR , 2.36 ; 95 % CI , 1.79 - 3.11 , respectively ) after accounting for age , sex , and race . After additionally accounting for educational attainment and health risk factors , associations for HCC incidence were no longer significant ; associations for CLD mortality remained significant ( HR , 1.78 ; 95 % CI , 1.34 - 2.36 ) . Socioeconomic status differences in alcohol outlet density and health behaviors explained the largest proportion of socioeconomic status-CLD mortality association , 10 % and 29 % , respectively . No associations with health care infrastructure were observed . CONCLUSIONS Our results suggest a greater effect of area-based factors for CLD than HCC . Personal risk factors accounted for the largest proportion of variance for HCC but not for CLD mortality Background : The effect of neighborhood and healthcare access factors on cancer outcomes among patients enrolled in navigator programs  is not clearly understood . This study assessed associations between : ( i ) neighborhood factors  and diagnostic time to resolution ( TTR ) and ( ii ) geographic access and TTR following an abnormal breast or cervical cancer screening test among women participating in the Ohio Patient Navigator Research Program ( OPNRP ) . Methods : Patient ( demographic , socioeconomic status , home-to-clinic distance ) and neighborhood ( deprivation , racial segregation ) characteristics of 801 women living in one of 285 census tracts ( CT ) in greater Columbus , Ohio were examined . R and omization to receive navigation occurred at the clinic level . Multilevel Cox regression and spatial analysis were used to estimate effects of various factors on TTR and assess model assumptions , respectively . Results : TTR increased as neighborhood deprivation increased . After adjustment for age , friend social support , education , and healthcare status , the TTR among women living in a neighborhood with a moderate median household income ( between $ 36,147 and $ 53,099 ) was shorter compared with women living in low median household income neighborhoods ( < $ 36,147 ; P < 0.05 ) . There is little evidence that unmeasured confounders are geographically patterned . Conclusions : Increased neighborhood socioeconomic deprivation was associated with longer TTR following an abnormal breast or cervical cancer screening test . Impact : These results highlight the need for addressing patient- and neighborhood-level factors to reduce cancer disparities among underserved population s. Cancer Epidemiol Biomarkers Prev ; 23(12 ) ; 2819–28 . © 2014 AACR Using cancer registry data for the population of California women aged 67 + with breast cancers , we estimated r and om intercept logistic models to examine how two socio-ecological predictors ( residential isolation and poverty ) were associated with probability of late-stage diagnosis for breast cancer . Using the multilevel modeling results , we calculated fully adjusted predicted probabilities associated with women in each Medical Service Study Area ( MSSA ) in California and classified the areas into two distinct groups : MSSAs with predicted rates below the 25th percentile ( presumably the better outcome areas ) and MSSAs with predicted rates above the 75th percentile ( presumably the worse outcome areas ) for two minority groups . Some areas had better outcomes for one group but worse outcomes for the other , suggesting that interventions to improve outcomes need different strategies for different groups in the same areas . Using information from geographic risk factors and multilevel modeling , this study informs interventions design ed to reduce disparities in breast cancer outcomes In 2009 in the United States , breast cancer was the most common cancer in women , and colorectal cancer was the third most common cancer in both men and women . Currently , over 40 % of these cancers are diagnosed at an advanced stage , which results in higher morbidity and mortality than would obtain with optimal cancer screening utilization . To provide information that might improve these cancer outcomes we use spatial analysis to answer questions related to both Why and Where disparities in late-stage cancer diagnoses are observed . In examining Why , we include state level characteristics 
    Output:
    
Socioeconomic factors , health care access , racial/ethnic factors , and rural-urban status were the most common context ual factors addressed in multilevel models .